Pringle & Moore | 61-68

Positive Approaches Journal - Volume 2 Title

Volume 12 ► Issue 3 ► November 2023

The Role of the Gatekeeper in Reducing Veteran Suicide

Dr. Janice L. Pringle and Dr. Debra W. Moore

In 2020, the University of Pittsburgh School of Pharmacy’s Program Evaluation and Research Unit (PERU) and Janice Pringle, Ph.D., received $3,500,000 in funding from the U.S. Centers for Disease Control and Prevention’s (CDC) new Comprehensive Suicide Prevention Program for Veteran suicide prevention in Northwest Pennsylvania. PERU’s Northwest Pennsylvania Veteran Suicide Prevention Program (NW PA VSPP) is a collaborative effort between healthcare partners, community organizations, and Veterans groups to create significant and lasting change in the 15-county region. The program aims to reduce veteran suicide attempts, injuries, and deaths by 10 percent (on average) over five years using the principles of the Zero Suicide framework and the Zero Suicide in Health and Behavioral Health Care model. Primary goals are improving access to treatment and support services, increasing awareness of suicide risk, and targeted suicide prevention activities and training opportunities.


Grounded in the Zero Suicide Model

Suicide is a growing public health crisis that took more than 48,000 lives in the United States in 2021, according to the CDC. In Pennsylvania alone, the rate of suicide deaths in 2020 was 13.25 per 100,000, compared to the national rate of 13.96 per 100,000.1 The Zero Suicide framework is based on the realization that people experiencing suicidal thoughts and urges often do not receive the care they need from a sometimes fragmented and distracted healthcare system. Studies have shown that most people who died by suicide saw a health care provider in the year before their deaths.2 This information presents an opportunity for healthcare systems to make a real difference by transforming patient screening processes and the care they receive. Throughout all 50 states and internationally, health and behavioral health systems implementing Zero Suicide have found success by adapting the model through the lenses of their care offerings and cultural considerations.


The Role of the Gatekeeper in Reducing Veteran Suicide

Suicide is an important problem affecting military service members and Veterans. Recent estimates suggest that 17 Veterans may die by suicide each day.3 To address this serious problem, the U.S. Department of Defense and the U.S. Department of Veterans Affairs have implemented comprehensive suicide prevention programs that reduce the negative attitudes and stigma associated with mental health care. Stigma poses a significant barrier to seeking help, engaging in care, and completing psychological health treatment. Mental health stigma in the military is strongly grounded in military culture and is linked to a desire to handle problems independently. As a result, Veterans often refrain from seeking mental health services due to the stigma attached, which can lead to extreme and life-threatening consequences, including depression, substance use disorder, and suicide.

In 2004, the Garrett Lee Smith Memorial Act prioritized training suicide prevention gatekeepers. These training programs are designed to improve knowledge, skills, and motivation to prevent suicide. A gatekeeper is an individual who can recognize a crisis and the warning signs of someone possibly contemplating suicide. Gatekeepers come from all walks of life and do not require any prior training or education. Clinical providers and nonclinical individuals interacting with Veterans and their families are natural gatekeepers to identifying and referring Veterans at risk for suicide. Gatekeeper training programs have improved knowledge and self-efficacy, especially among non-clinicians4, and can help reduce the stigma associated with mental health care for at-risk Veterans.


QPR Gatekeeper Training in Northwestern Pennsylvania

In 2022, the NW PA VSPP began delivering in-person and virtual QPR gatekeeper training at no cost to those living or working in the 15-county region. QPR, which stands for Question, Persuade, and Refer, equips people to recognize the warning signs of a suicide crisis and how to question, persuade, and refer someone for help. QPR is considered an emergency mental health intervention with the intent of identifying and interrupting the crisis and directing that person to proper care.


Components of the NW PA VSPP’s QPR Gatekeeper Training

-        How to Question, Persuade, and Refer someone who may be suicidal

-        The common causes of suicidal behavior and warning signs of suicide

-        How to get help for someone in crisis

-        Resiliency and protective factors within the Veterans community


QPR Training Outcomes to Date

While CDC funding for training and outreach continues through August 2025, data collection and evaluation efforts are ongoing. Between March 2022 and July 2023, the NW PA VSPP conducted 58 in-person and virtual gatekeeper sessions, resulting in 1,066 individuals learning about the QPR method. Of these participants, 421 self-identified as professionals trained in physical or behavioral healthcare, and 645 as working outside healthcare.

All QPR training sessions include a knowledge-based pre- and post-test designed to capture each participant’s level of understanding about the risks and signs of suicide, and their confidence level activating the QPR steps. Evaluation data from individuals who participated in training between May 2022 and July 2023 indicates that 75% of participants scored 80% or higher on the training post-test.


Applying Information from the Training

Participants felt more confident and comfortable asking questions about suicidal ideation and having follow-up conversations with their clients. According to them, this confidence and comfort would help them engage and interact. Other respondents mentioned they would apply the information to look for and identify signs of suicidal thoughts and ideation. Respondents mentioned that the training information will help them to step in and handle a situation if it arises.


Changes in Self-Perception of Skills

Participants were asked to rate their perception of their knowledge and abilities concerning suicide awareness and assisting someone contemplating suicide. Figures 1, 2, and 3 show the response rates.

Figure 1 shows the responses for targeted suicide awareness knowledge and abilities. Before training, some participants did not feel confident in their knowledge and skills. After training, no participants indicated low confidence about suicide prevention. Specifically, after training, participants felt highly capable of recognizing warning signs.

This figure shows the response rates for knowledge and abilities concerning suicide awareness. Results show that before training some participants did not feel confident in their knowledge and skills, but after training, no participants indicated low confidence about suicide prevention.

Figure 1. Change in ratings for targeted suicide awareness abilities.

Figure 2 shows participants’ understanding of suicide and suicide prevention. Before training, some participants reported a low understanding. After training, there was a substantial improvement.

This figure shows participants’ understanding of suicide and suicide prevention. Before training, some participants reported a low understanding. After training, there was a substantial improvement.

Figure 2. Change in participant understanding of suicide and suicide prevention.

Figure 3 displays participants’ responses to how likely they are to ask someone about suicide and if it is appropriate to ask. Some disagreement existed prior to, but more importantly, some disagreement continued to persist even after training. This finding presents an area for improvement to understand better the hesitancy of some participants to engage in questioning.

This figure displays participants’ responses to how likely they are to ask someone about suicide and if it is appropriate to ask.  Some disagreement existed prior to training and continued to persist even after training.

Figure 3. Change in rating for asking about suicide and appropriateness.


Looking Ahead

Participating in QPR gatekeeper training can be an effective way to learn more about the causes of suicide and develop suicide prevention skills. For Veterans and those in their community/family network, recognizing potential warning signs of suicide is vital. Developing comfort and confidence using QPR with a friend, family member, client, or community member can help those in crisis access behavioral healthcare and needed services. To learn more about the NW PA VSPP and participate in our training and outreach, visit


1.     Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [Online]. (2023)

2.     Raue PJ, Ghesquiere AR, Bruce ML. Suicide risk in primary care: identification and management in older adults. Curr Psychiatry Rep. 2014 Sep;16(9):466. doi: 10.1007/s11920-014-0466-8. PMID: 25030971; PMCID: PMC4137406.

3.     Department of Veteran’s Affairs: 2021 National Veteran Suicide Prevention Annual Report. 2021. [Accessed: Sep 9, 2021]. Available from URL: 2021 National Veteran Suicide Prevention Annual Report (

4.     Matthieu MM, Cross W, Batres AR, Flora CM, Knox KL. Evaluation of gatekeeper training for suicide prevention in veterans. Arch Suicide Res. 2008;12(2):148-54. doi: 10.1080/13811110701857491. PMID: 18340597.


Dr. Janice Pringle is an epidemiologist by training, with extensive experience in health services research. She is a Professor at the University of Pittsburgh, School of Pharmacy, and the founder and Director of the Program Evaluation and Research Unit (PERU) within the University of Pittsburgh, School of Pharmacy. Her area of expertise is health services research and organizational health, especially as it relates to healthcare innovation implementation. She has conducted numerous health services research studies and program evaluation efforts involving (but not limited to): screening, brief intervention and referral to treatment (SBIRT), innovative addiction treatment approaches, chronic disease intervention and prevention models, medication adherence interventions, and patient access to care improvement efforts. She has also developed a framework for assessing organizational health and guiding systems transformation, which has been used with the Veterans Health Administration, primary care practices, and integrated care practices, among other healthcare sites and entities. Additionally, she is the Co-Chair of the Pennsylvania Department of Drug and Alcohol Program’s Clinical Standards Committee. Throughout her career, Dr. Pringle has secured over $150 million in grants from a variety of sources, and she has developed healthcare policy research and briefs that have been used to inform policy development at both the state and federal level.

Dr. Debra Moore is a quantitative research methodologist by training, with extensive experience in measurement and program evaluation. She is currently the Director of Program Evaluation and Quality Improvement with the Program Evaluation and Research Unit (PERU) at the University of Pittsburgh. In this position she leads a team of evaluators that develop, monitor, and implement the evaluation efforts for all projects across PERU’s portfolios. Prior to joining PERU, Dr. Moore spearheaded a five-year multimillion-dollar redesign of the statewide Federal accountability assessment for students with the most significant cognitive disabilities. During that time, she moved the assessment to a digital platform, designed and implemented validity studies to ensure the technical adequacy of the redesigned assessments, and completed a successful Federal peer review. Additionally, she worked as a quantitative methodologist and psychometrician developing instruments to measure ‘at scale’ the instructional practices of teachers and refining researcher-created instruments that predict future interest in STEM careers and engagement in science activities and exhibits. She also used various data-mining techniques to determine patterns in a large federal educational data set for proposed pathways to STEM careers. For the NIH-funded Clinical and Translational Science Institute at the University of Pittsburgh, Dr. Moore developed new outcomes-based curricular frameworks for the degree-granting and certificate programs and assessed the implementation of those frameworks. Additionally, she served as measurement specialist, program evaluator, and statistical and psychometric consultant for more than a dozen NSF, IES, and other grant-funded projects evaluating projects, programs, and educational interventions and taught courses in statistics, research methodology, and assessment.


Contact Information
University of Pittsburgh, School of Pharmacy
Program Evaluation and Research Unit (PERU)
5607 Baum Blvd, Pittsburgh, PA 15206