Preventing Suicide among Veterans

September 2016

September 5-11 is National Suicide Prevention Week. Suicide is a national public health concern. In 2013, suicide was the 10^th leading cause of death for all ages – and the 2nd leading cause of death for persons ages 15 to 34 – with rates equal to 113 suicides each day or one every 13 minutes in the United States.^1,2 In 2014, an average of 20 Veterans died from suicide each day, with 6 of 20 Veterans having been users of VA healthcare. Between 2001 and 2014, Veteran suicides increased at a rate higher than adult civilians: the civilian rate increased by 23%, while suicide among Veterans increased by 32%. In 2014, approximately 65% of all Veterans who died from suicide were aged 50 years or older. Moreover, the increasing rate of suicide among women Veterans prompted Congress to pass the Female Veterans Suicide Act, which President Obama signed into law on June 30, 2016.³

While VA works to reach Veterans who need mental healthcare (more than 1.6 million Veterans received specialized mental healthcare in FY2015)⁴ , HSR&D continues to support research on suicide, including risk factors, screening, and prevention. In addition, HSR&D's Center for Mental Healthcare and Outcomes Research (CeMHOR) focuses on improving access and engagement in mental and specialty mental healthcare for Veterans, and the primary goal of HSR&D's Evidence-Based Therapies for PTSD CREATE (Collaborative Research to Enhance and Advance Transformation and Excellence) is to improve Veterans' access to and engagement in evidence-based treatments for PTSD – a risk factor for suicidal ideation.⁵

HSR&D Research on Suicide

Following are descriptions and findings from several specific research projects conducted by HSR&D investigators on suicidal ideation and suicide among Veterans.

Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities Compared to Veterans Seeking VA Treatment Only

Among current and former military personnel, research has focused mainly on suicide mortality, with relatively fewer studies about suicidal ideation and attempt – and fewer still examining the problem of suicidal risk among female Veterans. To answer this need, VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention's (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey, which was administered across 10 states (n=10,406 Veterans; 93% male). VHM survey items included lifetime diagnoses of mental illnesses, service in a combat zone, sources of mental healthcare, and past 12-month suicidal ideation and attempt. Investigators also evaluated the association of different locations of mental health treatment (i.e., VA facility only, non-VA facility only, both VA and non-VA facilities) with suicidal ideation in the past 12 months. Investigators conducted additional analyses using the subgroup of individuals who reported seeking mental health care (n=760).Findings show:

• Among Veterans who received mental health treatment in the past 12 months, Veterans who received services from both VA and non-VA facilities had over four times the odds of reporting suicidal ideation than Veterans who received services only from the VA; however this association was significant only for male Veterans.
• This study showed differential use of VA mental health services by gender in that a higher percentage of female Veterans reported getting mental health treatment in the past 12 months from only non-VA facilities than did male Veterans (10% vs.3%).
• Women were more likely than men to report a lifetime diagnosis of depression, anxiety, or PTSD (24% vs. 15% respectively). Men and women also differed significantly in where they received mental health treatment; e.g., while 3% of men reported receiving mental health treatment from a non-VA facility, 10% of women reported receiving mental health treatment from a non-VA facility.
• In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.

Implications: Research and evaluation of VA's mental health treatment for Veterans experiencing suicidal risk should strive to examine results by gender. Female Veterans are a relatively small proportion of the VA population, so aggregate analyses of all Veterans may mask unique findings among women.

Blosnich J, Brenner L, and Bossarte R. Population mental health among U.S. military Veterans: Results of the Veterans health module of the Behavioral Risk Factor Surveillance System, 2011-2012. Annals of Epidemiology. August 2016;26(8):592-596.

Sexual Trauma during Military Service Increases Risk of Subsequent Suicide among Veterans

While mental health conditions (i.e., depression, PTSD, schizophrenia, and substance use disorder) are reliably associated with suicide risk, the risks posed by deployment to Iraq or Afghanistan are less clear. Moreover, little is known about other military experiences that may increase risk for suicide, such as military sexual trauma (MST). This was the first large-scale, population-based study to document sexual trauma as a risk for suicide mortality. Using VA data, investigators identified more than 6 million male Veterans and 363,680 female Veterans who received VA outpatient services between FY2007 and FY2011, and who were screened for MST. The primary outcome was death by suicide. Adjusted models that included age, medical morbidity, rural residence, and mental health diagnoses were calculated. Findings show:

• Women and men who reported MST had an increased risk of suicide. MST remained an independent risk factor even after adjusting for other known risk factors for suicide among Veterans, including mental health conditions, medical morbidity, and demographic characteristics.
• Among Veterans who reported MST, those who died by suicide were significantly more likely to be treated for mental health conditions determined by their provider to be related to MST experiences: men 50% vs. 36%, and women 67% vs. 48%.
• Of the Veterans in this study, 9,017 completed suicide during the follow-up period. The increased risk associated with MST appears to account for a substantial number of suicides annually, including between 10% and 20% of all suicides among women Veterans under VA care.

Implications: This is the first study to document that sexual trauma during military service increases subsequent risk of suicide. Findings have informed VA approaches to MST services and suicide prevention.

Kimerling R, Makin-Byrd K, Louzon S, Ignacio R, McCarthy J. Military sexual trauma and suicide mortality. American Journal of Preventive Medicine. June 2016;50(6):684-691.

Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans

Although prior studies identified specific types of chronic pain as markers of increased suicide risk, none have examined pain treatment as a potential additional indicator for risk among those with pain. This retrospective study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Using VA data, investigators identified 123,946 Veterans with chronic non-cancer pain who received opioids in FY2004-2005. [Veterans being treated with palliative or hospice care were excluded.] Investigators used data from the National Death Index to examine risk of suicide death by any method, including intentional overdose death, from 2004 to 2009. This study focused on maximum prescribed morphine-equivalent daily opioid dose and opioid fill type as the primary predictors. Other variables included: pain and other physical conditions (i.e., headache, neuropathy, chronic pain, acute pain, COPD, cardiovascular disease, sleep apnea), in addition to psychiatric conditions (i.e., depression, PTSD, substance use disorders). Patient demographics also were examined. Findings show:

• Increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled.
  • Compared to those receiving <20 milligrams/day (mg/d), hazard ratios were 1.48 for 20 to <50 mg/d, 1.69 for 50 to <100 mg/d, and 2.15 for 100+ mg/d.
  • Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors.
• Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%; n=1,669), with overdose accounting for 20% (n=532) of all suicides.

Implications: Risk of suicide mortality was greater among Veterans receiving higher doses of opioids, thus providers may want to view high opioid dose as a marker of elevated risk for suicide.

Ilgen M, Bohnert A, Ganoczy D, Bair M, McCarthy J, and Blow F. Opioid dose and risk of suicide. Pain. May 2016;157(5):1079-1084.

Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans

Recent DoD reports on medication use among active duty service members deployed in support of conflicts in Iraq and Afghanistan indicate potentially problematic use of central nervous system (CNS)-acting drugs. According to the Army Institute of Public Health, 46% of those who completed suicides, 90% of those who attempted suicide, and 87% of those with suicidal ideation received a CNS-acting prescription in the year preceding the event. Prior studies in VA have tended to focus on individual classes of CNS drugs. This HSR&D study examined the prevalence of CNS polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Investigators identified 303,716 Veterans who had served in Iraq and/or Afghanistan in support of post-9/11 conflicts, and who had received inpatient or outpatient VA healthcare from October 2009 through September 2011. Investigators then assessed the number of unique CNS medications dispensed from VA pharmacies during FY2011. Demographic and clinical characteristics, such as comorbid conditions associated with CNS polypharmacy (e.g., pain, PTSD, TBI, depression, anxiety, substance use disorder) also were examined. Findings show:

• Of the 303,716 Veterans in this study, 25,546 (8%) had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors.
• Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy.

Implications: Data suggest that CNS polypharmacy may be used as a "trigger tool" to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.

Collett G, Song K, Jaramillo C, Potter J, Finley E, and Pugh MJ. Prevalence of central nervous system polypharmacy and associations with overdose and suicide-related behaviors in Iraq and Afghanistan war Veterans in VA care 2010-2011. Drugs: Real World Outcomes. March 2016; 3(1):45-52.

Individual- and VA Facility-Level Factors Associated with Higher Risk of Suicide-Related Events among Veterans Receiving Opioid Therapy for Chronic Pain Management

This retrospective study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and VA facility-level delivery of recommended care, and individual-level suicide-related events. Using VA administrative data, investigators identified all VA patients who were prescribed any short-acting opioids on a chronic basis (CSA) – or any long-acting (LA) opioids from VA providers during FY2010. During this period, 393,657 Veterans received CSA opioids and 93,805 received LA opioids (N=487 and 462; 81% CSA opioids, 19% LA opioids) across 139 VA facilities. Possible patient risk factors also were examined, including physical and mental health conditions. Findings show:

• Within 180 days following an opioid prescription, 6,482 patients (1.6% of study population) on CSA opioids and 1,982 patients on LA opioids (2.1% of population) experienced suicide-related events.

• At the individual level, Veterans who received opioid therapy for chronic pain management and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events.
• Receiving opioid therapy (CSA or LA opioids) at VA facilities that had higher rates of drug screening was associated with decreased patient-level risk of suicide-related events. Receiving long-acting opioid therapy at facilities that provided more follow-up after new prescriptions was also associated with decreased patient-level risk of suicide-related events whereas receiving long-acting opioid therapy at facilities having higher sedative co-prescription rates was associated with increased patient-level risk of suicide-related events.
• Analyses conducted for VA patients with substance use disorder (SUD), suggest that among those patients prescribed CSA opioids, higher rates of regular drug screening and higher rates of SUD specialty treatment or SUD-specific pharmacotherapies provision at the facility-level were associated with decreased patient-level risk of suicide-related events. Among patients with SUD prescribed LA opioids, higher rates of patients participating in rehabilitation medicine at the facility-level was associated with decreased patient-level risk of suicide-related events.

Implications: Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorder in specialty substance use treatment and rehabilitation medicine may help prevent suicide-related events.

Im J, Shachter R, Oliva E, Henderson P, Paik M, and Trafton J for the PROGRES Team. Association of Care Practices with Suicide Attempts in US Veterans Prescribed Opioid Medications for Chronic Pain Management. Journal of General Internal Medicine. July 2015;30(7):979-991.

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References

1. Suicide. Facts at a Glance. National Center for Injury Prevention and Control. Division of Violence Prevention. Centers for Disease Control and Prevention.

2. Suicide in America: 2015. National Institute of Mental Health.

3. New VA Study Finds 20 Veterans Die by Suicide Each Day. Military.com. July 7, 2016.

4. VA Mental Health Care. Fact Sheet. VA Office of Public Affairs, Media Relations. April 2016.

5. Hudenko W, Homaifar B, and Wortzel H. The Relationship between PTSD and Suicide. VA's National Center for PTSD.

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