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Suicide Prevention

Recent reports indicate that suicide rates are higher among U.S. Veterans when compared with non-Veterans. Veterans who completed the U.S. National Health Interview Survey (NHIS) between 1985 and 1996 had higher suicide rates than non-Veterans. Data from the National Violent Death Reporting System in 16 states also indicate higher than expected rates of suicide among Veterans living in the community.1 Suicide rates have been increasing among active duty Army soldiers and now surpass age and gender-adjusted suicide rates in the general population.

Of direct interest to VHA investigators focused on health system safety, the VHA has assessed suicide mortality among its entire patient population--the only large health care organization to do so. In 2001, suicide rates among VHA health care users were 66 percent higher than the age and gender adjusted general U.S. population. The crude suicide rate among male and female VHA users was 43.1/100,000 and 10.4/100,000 person-years, respectively; whereas, the crude suicide rate among males and females in the general population was 23.2/100,000 and 5.2/100,000 person-years, respectively.2 The capability of determining and following suicide rates in its patient population gives the VHA unparalleled opportunities for assessing the efficacy of suicide prevention programs.

Because of its high-risk population and the priority placed on suicide prevention, the VHA has worked to improve access to evidence-based mental health services, and to develop and implement comprehensive suicide prevention programs. A Veteran-specific telephone hotline option has been implemented in cooperation with the National Suicide Prevention Lifeline. Veterans who call the Lifeline number can press "1" to be routed to trained VHA mental health employees who have access to patients' medical records and who work with VHA suicide prevention coordinators to ensure systematic follow-up of Veteran callers.

VHA has placed suicide prevention coordinators at all VHA facilities to provide ongoing suicide training for staff; identify, track, and monitor high-risk patients; coordinate suicide prevention activities with community agencies; develop local prevention strategies; and participate in patient safety and environmental analysis (e.g., assess the safety of inpatient units). VHA will soon initiate additional initiatives to reduce suicide.

A literature synthesis on suicide prevention was commissioned from the HSR&D Evidence-based Synthesis Program (ESP).3 This synthesis updated the Mann, et al. review of articles published between 1966 through June 2005 to May 2008 and focused on Veteran and military relevant articles. The synthesis identified seven multifaceted studies of military personnel and three studies of U.S. Veterans. The review also identified twenty controlled trials of interventions for individuals who were post-suicide attempt and a large number of observational studies of restricting access to lethal means. The synthesis determined that the quality of the evidence supporting most suicide prevention strategies is low (i.e., further research likely to have an impact on the estimate of effect) or very low (i.e., any estimate of effect is uncertain).

The review concluded that multi-component interventions in military personnel probably reduce suicide risks, although questions remain regarding the relative importance of different components and the impact of these interventions in non-military populations. The synthesis also determined that there are insufficient studies of suicide prevention programs in Veterans to draw conclusions. Research on psychosocial interventions following a suicide attempt had produced a moderate level of evidence that indicated that these interventions were only minimally effective. The synthesis found insufficient data to reach any conclusions about the effectiveness of Community-based Suicide Prevention Centers and determined that there are no studies that assessed the specific effectiveness of hotlines, new outreach, counseling, or treatment coordination programs. Restriction of access to lethal means was thought to have an effect on cause-specific suicides although the quality of evidence was low.

Given the limited evidence for the effectiveness of most suicide prevention efforts, further research in this area is imperative. The VHA has large patient numbers, a strong mandate to reduce suicide rates among its patients, and coordinated roll outs of suicide prevention programs--making it one of the few health systems in which rigorous research on suicide prevention is possible. VHA researchers are thus poised to lead the way in the area of suicide prevention to the benefit of both Veterans and the general population.

  1. Testimony by The Honorable James B. Peake M.D. House Committee on Veterans' Affairs. May 6, 2008.
  2. McCarthy JF, Valenstein M, et al. Suicide Mortality Among Patients Receiving Care in the VHA Health System. American Journal of Epidemiology. 2009; 169: 1033-8.
  3. Greater Los Angeles Veterans Affairs Healthcare System and Southern California/RAND Evidencebased Practice Center (2009). "Strategies for Suicide Prevention in Veterans."

Reducing Suicides in Veterans
by Steven Bagley, M.D., M.S., VA Greater Los Angeles Health Care System

Suicide prediction and reduction are pressing issues for VA. Many Veterans have significant risk factors, such as mood disorders, substance use disorders, pain, disabling chronic medical illness, traumatic brain injury, posttraumatic stress disorder (PTSD), and skill in using firearms. Clinical prediction is a challenge because it requires forecasting a single infrequent act of behavior. The low base rate of suicide in the population means that widespread use of screening tests generates many false positives. Therefore, most clinical attention has been devoted to organizing the interventions by risk strata, typically by providing low-intensity interventions, such as suicide awareness programs, to populations, and higher-intensity interventions, such as case management or post-discharge tracking, to those in high-risk groups or with known risk factors such as prior suicide attempts.

VA has already implemented several suicide reduction programs, and much of this has been coordinated through the Center of Excellence in Canandaigua, New York, and the Mental Illness Research, Education, and Clinical Center in Denver, Colorado. As Valenstein mentions in her research highlight, Suicide Prevention Coordinators (SPCs) are now located at each VA facility. Computerized clinical reminders screen patients for depression, PTSD, and alcohol abuse. A suicide risk "flag" aims to close gaps in treatment, expedite access and follow up, and alert non-medical health providers to keep an eye open for signs of depression or decompensation.

Risk stratification requires knowing details about prior attempts. Policy planning and program evaluation requires accurate aggregate statistics on attempts and completions. It is well recognized that ambiguity exists in the informal vocabulary used (such as "ideation" and "attempt"), and considerable work remains to be done to define terms that can be easily used across different disciplines with accuracy and ease. Further work will also be needed to ensure that comprehensive surveillance of suicide attempts and completions in Veterans is routinely conducted and reported. There are numerous research questions about multifaceted suicide reduction programs, even if they are robustly successful, the question remains as to which facets are causally related to reductions in suicides, and whether there are facilitative or synergistic effects among the program components.


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