Outreach to the Veterans Crisis Line During the COVID-19 Pandemic: A Mixed-Methods Analysis

After the onset of the COVID-19 pandemic in March 2020, mass shutdowns across the United States disrupted most areas of public life, with detrimental impacts on income, employment, housing, education, and access to medical care. Disruptions to health services continued to affect 90% of countries well into 2021 (1) and particularly affected U.S. health care (2). The Veterans Health Administration (VHA), the country’s largest health care organization, also anticipated challenges to service continuity and delivery during the pandemic and implemented a COVID-19 response plan in preparation to these challenges

While many health services were reduced because of necessary closures and shutdowns, impacts on individual mental health because of social isolation and pandemic-related anxieties highlighted the importance of the continued availability of psychological support services (3–5). Preexisting remotely accessible services, including crisis hotlines and text or chat supports, took a central role in delivering mental health and social services during that time (6). For U.S. veterans and military service members, the Veterans Crisis Line (VCL; https://www.veteranscrisisline.net), a free 24/7 hotline providing support and crisis intervention to any veteran for any reason, offers veterans and military service members emotional support and timely urgent care.

Despite having many strengths and resources, veterans face vulnerabilities due to homelessness, income instability, and potentially traumatic events (e.g., intimate partner violence) (7–9). Additionally, many veterans experience depression, posttraumatic stress disorder (PTSD), substance use disorders, suicidal ideation, suicide attempt, and death by suicide (10–12). A national survey of U.S. military veterans with preexisting psychiatric conditions reported that more severe prepandemic psychiatric symptoms were associated with increased odds of experiencing suicidal ideation during the pandemic (3).

Veterans’ experiences and suicide risk differ also by gender: female veterans are more likely to experience suicidal ideation and attempts, depression, and interpersonal violence (13–16), whereas male veterans are more likely to die by suicide. Moreover, gender-based inequities may be exacerbated during the pandemic (17), prompting a recent call to action to understand women’s experiences and suicide risk during the pandemic (18). Given the current lack of knowledge of veterans’ experiences during the pandemic, we used a mixed-methods analysis to examine characteristics of veteran outreach to the VCL through calls, texts, and some chat functions (referred to hereafter as “calls”) during the first year of the COVID-19 pandemic. We quantitatively examined the reasons for contacts that were flagged as related to COVID-19 in 12,869 VCL call records during the same period. To further explore the thematic concerns of veterans during this time, we conducted a qualitative analysis of 360 unique call synopsis notes from call records with a COVID-19 flag.

Methods

Data Source and Sample

This study was part of an ongoing project that was reviewed and approved by an internal review board at the U.S. Department of Veterans Affairs, Corporal Michael J. Crescenz VA Medical Center, on February 12, 2021, and is set to conclude on June 30, 2023. Using a standardized database, the VCL collects information on each call or text, including caller gender, reason for call, suicide risk factors, and open-text call synopsis, completed by the VCL responder. Details on caller age, location, and other sociodemographic factors, including race or ethnicity, are not consistently available in the database. In April 2020, the VCL added a “special event” field to identify calls related to the COVID-19 pandemic, as assessed by the VCL responder (referred to hereinafter as “COVID-19 flag”). From 509,854 total calls made to the VCL between April and December 2020, we examined calls from veterans calling on their own behalf with gender identified (N=342,248). Prank calls, as identified by VCL responders, were excluded.

Variables

Caller gender.

When a veteran provides identifying information (e.g., name and date of birth) and is enrolled in the VHA, the veteran’s gender is identified from the VHA medical record. Otherwise, the gender field is completed by the VCL responder on the basis of information the responder receives from, or assumptions the responder makes about, the caller. During the data observation period, VCL gender categories were limited to “man” or “woman” (labeled as “male” or “female”).

COVID-19 flag.

VCL responders were instructed to select “COVID-19” to flag calls that included content pertaining to the COVID-19 pandemic, as stated by the caller. VCL responders received standardized training on how to use this flag. This field’s default was null because this variable was utilized only when relevant.

Reason for call.

The reason-for-call field is a 35-option check box entry where the responder can select option(s) relating to what concern(s) the veteran expressed during the call (e.g., suicidal crisis or thoughts, mental health concerns, or relationship problems). Typically, multiple reasons are expressed in a call; thus, the responder can select as many options as necessary.

Suicide screen.

VCL responders are mandated to ask callers three suicide screening questions, regardless of the stated call reason: Are you currently thinking of suicide? Have you thought of suicide in the past 2 months? and Have you ever attempted to end your life? Responses are recorded as yes or no. We created a composite variable to identify any responses of yes to any of the three questions versus responses of no to all questions.

Call synopsis.

Call synopsis is an unlimited text box that allows responders to provide a brief description of call details from their perspective. These notes were used for our qualitative analysis.

Analysis

We used a complementary mixed-methods approach (19) to assess the characteristics of calls related to COVID-19, drawing on both the coded (quantitative) and open-ended (qualitative) data from VCL call records. We compared the top five most frequent reasons for call and suicide risk screen responses among calls with and without the COVID-19 flag. Given gender differences in call volume and the impact of the COVID-19 pandemic and suicide risk, we conducted gender-stratified analyses. Following a grounded theory approach to thematic content analysis (20), we conducted a qualitative analysis of the call synopsis notes that had a COVID-19 flag between October and December of 2020. In total, 360 randomly selected, gender-stratified (evenly distributed) VCL calls were sampled. Two coders (L.S.K., A.A.) individually reviewed the first 180 call synopsis notes and met as needed to review and discuss recurring themes and questions for a draft codebook. The codebook was organized by general categories such as material impacts and then further ordered by subthemes, for example, job loss. The remaining 180 synopses were divided among the research team and coded by using the codebook. The data were entered into Excel with a unique ID and synopsis content per row and themes or content per column, with two tabs differentiating gender. The research team met throughout the analysis stage to ensure coding consistency and group consensus. (See an online supplement to this article for the coding scheme).

Results

COVID-19–Flagged Calls to VCL: Reasons for the Call and Suicide Risks

Among 342,248 contacts with VCL (291,516 by men and 50,732 by women) by veterans calling on their own behalf, with gender identified during this period, the COVID-19 flag was applied to 2,254 (4.4%) calls by women and 10,615 (3.6%) by men (Table 1). The top five most frequently recorded call reasons among both women and men were mental health concerns, loneliness, medical issues or physical illness, relationship problems, and suicidal crisis or thoughts (Figure 1). For each of the top five reasons for the call, the proportion of calls identified with those reasons was higher among contacts with the COVID-19 flag for both women and men. In particular, loneliness was indicated as a reason in 37% of calls by both female (N=834) and male veterans (N=3,928) with the COVID-19 flag versus 16% of calls (N=7,514 women and N=44,944 men) without the COVID-19 flag.

Suicide risk was higher among women and men whose calls had the COVID-19 flag, compared with those without the flag. As shown in Figure 2, calls flagged as being related to COVID-19 had higher frequencies of all three suicide risk variables, compared with the non–COVID-19 contacts, including for current thoughts of suicide, thoughts of suicide over the past 2 months, and past suicide attempts. Two-thirds (66.1%, N=1,490) of female veterans and more than half (55.4%, N=5,881) of male veterans whose call had the COVID-19 flag responded yes to at least one of the suicide risk screening questions, compared with just over half (53.7%, N=26,033) of female veterans and 49.2.% (N=138,339) of male veterans without the COVID-19 flag.

Concerns of Callers to VCL With the COVID-19 Flag

Themes from 360 individual call synopsis notes, randomly sampled from the 12,869 callers with the COVID-19 flag, were identified. We organized themes into the following categories: material stressors due to the pandemic, including negative impacts on finances and housing; mental health impacts and disrupted access to resources for coping with mental health concerns, including disruptions to health care, group support, socializing, gym, and religious institutions; and COVID-19–specific concerns or questions, such as vaccine availability and where to get tested. We did not observe gender differences in these categories, and the narratives described below emerged as the primary concerns of veteran callers with the COVID-19 flag, regardless of gender. In the following, we describe the most salient themes.

Material impacts and stressors.

Within our sample, veterans who expressed concerns related to housing shared distress due to potentially becoming homeless. In multiple cases, concerns and fears of becoming homeless were directly related to recent job and income losses because of the pandemic and the inability to secure new employment during this time. For some, the economic instability of sudden unemployment forced them to drain their savings. One VCL responder wrote that a caller had been “out of work for 4.5 months, and as a result, has had to ‘blow’ through his savings. . . . He only has enough money for about 4 months of expenses.” Veterans with such financial concerns explained to responders that their new economic strain had depleted financial safety nets and savings, causing them to live “paycheck to paycheck” and fall behind on bills. Another veteran explained that he was having a hard time after being let go from his job and that he was “receiving calls for his car payment” and visits from his landlord, all while struggling to cover basic amenities such as toilet paper and water.

Impacts on mental health and disrupted ability to cope.

A recurring theme about mental health concerns was a general lack of adequate mental health support, irrespective of pandemic-related changes in access to mental health services, including ambivalence about or dissatisfaction with telehealth options. For veterans reporting a lack of support, the inability to schedule in-person appointments or medication access was a primary concern. Additionally, some veterans felt negatively affected by changes to their mental health support systems and routines, such as not being able to attend group therapy or go to the gym or church. These changes in support and routines sometimes coincided with feelings of loneliness and social isolation. Some veterans described their dissatisfaction with telehealth, citing a desire to meet face to face with a therapist or counselor: “Talking to someone over the telephone does not serve [the veteran] well.” One veteran expressed the need for in-person interactions due to lack of privacy in her nursing facility residence. VCL responders consistently reported that veteran callers with mental health concerns felt an overwhelming sense that their underlying health problems—commonly anxiety, insomnia, depression, PTSD, or any combination of these challenges—were exacerbated by the pandemic. As one responder noted, the COVID-19 crisis had contributed to increased panic attacks and triggered the veteran’s PTSD.

Related to concerns about mental health were issues regarding the inability to access necessary resources for coping productively with these mental health stressors, with some of these stressors being exacerbated by the pandemic. As in-person services were forced to close, many veterans expressed to VCL responders how being separated from these relied-upon resources, such as support groups and gyms, had negatively affected their overall well-being. Similarly, veterans mentioned new fears surrounding activities that had once been helpful for relieving stress, such as exercising, going to churches and meetings, or taking classes.

For veterans with past substance use disorders who were unable to attend substance use recovery programs such as Alcoholics Anonymous without an adequate substitute, substance use began to reoccur. Multiple callers expressed that they began drinking or using substances again to cope with pandemic stress; as stated in one responder note, “Veteran shared that he started back drinking alcohol as a way to cope.” Another responder noted, “Veteran shared that the [COVID-19] pandemic has cut him off from people and from his coping skills—such as fishing, swimming, and AA meetings, as well as volunteering with other veterans.” Another responder noted, “[Veteran] reported that she was having issues with her VA and needed to get assistance with alcohol abuse. She reported that right now they are not doing medical detox at the VA due to the COVID-19, and she does not know when things will get back to normal.”

COVID-19–specific concerns.

Expressing concerns and questions related to COVID-19, including the availability of testing and vaccination, was another theme among VCL contacts with the COVID-19 flag. Veterans shared feeling anxious about the medical impacts of the pandemic. For example, some veterans with underlying medical issues voiced fears about being exposed to the virus as well as concerns about their ability to be tested quickly. Additionally, veterans who explicitly told the VCL responder about their anxiety relating to a COVID-19–specific medical concern also reported having a diagnosis of depression, anxiety, or PTSD; preexisting symptoms were exacerbated by COVID-19–related concerns: “Veteran recently started experiencing symptoms of anxiety and worry about her family due to [the] pandemic and stuff she sees on social media and deleted her social media account as a result. Having a difficult time with coping with pandemic.”

Some veterans with the COVID-19 flag contacted the VCL to discuss current events and share their opinions regarding COVID-19. As one responder noted, “Veteran reports that not only is she frustrated with politics but [also with] the COVID-19 virus, race issues, the Supreme Court, and the number of people who have died from COVID-19.” Some issues that surfaced in these calls included worries surrounding vaccines, including whether they were safe, whether they would be available, and whether vaccination would be mandated. In one instance, the responder indicated, “Veteran asked if [COVID-19] vaccinations will be required for veterans families and reported he is concerned about the virus. Veteran reported he receives services at the VA, and it is going well. Veteran reported he is worried his children will not be able to afford the vaccine and feels the country should pay for family members of veterans.”

Discussion

The economic and mental health impacts of the COVID-19 pandemic have been widely felt in the United States, including within the veteran community. Although initial data do not suggest increased suicide risk among the national veteran population during the pandemic (21), research has revealed an elevated risk for substance use, depression, and loneliness among veterans during the pandemic. Given the greater frequency of suicidal ideation and past suicide attempt among the calls to VCL with the COVID-19 flag, our findings suggest that veterans calling VCL with concerns related to COVID-19 may be at increased risk for suicidal ideation, suicide attempt, or both. The quantitative findings suggest that mental health, loneliness, general medical concerns, relationship problems, and suicidal thoughts or crises were salient concerns among callers referring to COVID-19 in their VCL calls.

Our qualitative findings from the call synopsis records of veterans with the COVID-19 flag provide insight into the struggles experienced by veterans who accessed VCL in the first year of the pandemic. These findings included concerns related to COVID-19 and anxieties about the virus, as well as a variety of stressors stemming from or exacerbated by the pandemic, including financial, housing, and mental health concerns, as well as loneliness. Consistent with emerging research in this area (22), we found that preexisting mental health concerns, including depression and PTSD, were exacerbated by pandemic-related stress. Our results extend those of previous research among treatment-seeking veterans in the United Kingdom, indicating robust associations between pandemic stress and mental health symptom severity, including alcohol misuse (23). Additionally, disrupted access to in-person mental health services and reduced ability to cope with stress through typical coping methods (e.g., exercising at a gym or attending church) presented new challenges to veterans’ mental health. Some callers described coping with these stressors through substance use, a known risk factor for suicide (24). Our findings suggest the importance of risk mitigation plans for veterans, such as those provided by the VCL. Our qualitative findings also highlight the clinical value in offering training in and education about coping skills and stress management to veterans experiencing pandemic-related distress because of limited coping resources, many of which were formerly available in person or social in nature.

Our study had some limitations. Data were limited to calls, texts, and some chat content within the VCL’s research database and might not have included contacts to VCL recorded elsewhere. Our analysis excluded veterans who may have contacted the VCL through other chat options. Because of the lack of demographic information on callers, the data did not include comprehensive information on characteristics such as age, race, or other socioeconomic factors that may have affected our findings. Furthermore, caller gender was limited to a male-female binary categorization and was subject to potential misgendering in cases when caller gender was assumed by the responder or when gender was indicated incorrectly in the caller’s medical record. One major limitation of the data was that they comprised information on what the individual VCL responder captured in both the call synopsis text and in other areas open to some interpretation, such as the reason for the call. VCL responders were trained to apply the COVID-19 flag to calls in which the veteran referred to the pandemic; thus, some calls that might have been related to COVID-19 would not have been captured with this flag if not specified by the caller. The data also did not include information regarding individual VCL responders, and we recognize that the type and amount of information that responders included in their synopses were variable.

Conclusions

We found that veterans continued to reach out to the VCL during the COVID-19 pandemic and that callers with COVID-19–related mental health concerns also had higher suicide risk according to their responses to the suicide screening questions. It is possible that those with increased levels of distress were more likely to voice concerns related to COVID-19 and that these specific concerns may also have exacerbated mental distress. From the qualitative data, it was particularly evident that the VCL offered callers with COVID-19–related mental health concerns and anxieties the opportunity to talk through these concerns. Additionally, our quantitative data revealed that veterans struggled with loneliness, and the qualitative data revealed the various ways that callers contacted the VCL for social support. Our findings illustrate the utility of qualitative data for understanding the nuances of veterans’ experiences, particularly in the context of coping with the pandemic. As the pandemic has continued well beyond 2020, additional research is needed to examine whether and how the needs of veterans, including those served by the VCL, change over time. Such research may inform enhancements to the VCL and other health services that play a key role in supporting the health and well-being of our nation’s veterans.