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IIR 04-211 – HSR&D Study

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IIR 04-211
Suicide Among Veterans: Using the VA Depression Registry to Inform Care
Marcia T. Valenstein MD AB
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: July 2005 - June 2008

BACKGROUND/RATIONALE:
Reducing suicide is a national and a VA priority. VA patients in depression treatment are at high risk for suicide. To develop effective suicide prevention programs, VA policymakers and clinicians need basic information about absolute suicide rates among these patients and information about suicide risk factors within the depression treatment population.

OBJECTIVE(S):
Our primary objectives were to determine overall suicide rates among the VA depression treatment population and patient characteristics associated with higher suicide rates. Additional goals included determining suicide rates among important subgroups of depressed patients and suicide rates during potentially high-risk treatment periods. An exploratory goal was to assess the level of monitoring provided to depressed patients during high-risk periods and to examine whether higher levels of monitoring were associated with reduced suicide risks.

METHODS:
We conducted a retrospective cohort study using data from a comprehensive sample of VA patients receiving depression treatment. We described suicide rates, patient risk factors for suicide, levels of clinical monitoring during high-risk treatment
periods and relationships between patient risk factors, monitoring, and suicide risks. Our primary outcome was suicide as documented in National Death Index data. We calculated unadjusted suicide rates and median time to suicide since the date of the initial depression diagnosis, by age group, gender, race/ethnicity, and specific psychiatric and substance abuse comorbidities. We used Cox’s proportional hazards regression models to assess the relationships between suicide and the exposures of interest, adjusting for other covariates. In exploratory analyses, we used propensity scoring and instrumental variable techniques to examine the relationship between levels of clinical monitoring and suicide, while accounting for likely treatment selection.

FINDINGS/RESULTS:
The overall suicide rate for VA patients in depression treatment (excluding individuals with unknown race) was 88/100,000 person-years during the observation period; cohort patients were followed for an average of 2.5 years during the study period.
Suicide rates per 100,000 person-years were higher for men (90) than for women (29) and for whites (95) than for African Americans (27). Veterans of Hispanic origin had lower suicide rates (46) than those not of Hispanic origin (87). Patient aged 18-44 years had a suicide rate of 95 suicides per 100,000 person-years, compared with 78 for patients aged 45-64 and 90 for patients aged 65 and older. Concurrent PTSD and service connection were associated with lower suicide rates. In the first 60 weeks following antidepressant starts, dose changes, and psychiatric hospitalizations, the suicide rate was 114/100,000 person-years. Suicide rates were 568/100,000 p-y in the first 12 weeks following psychiatric hospitalizations and 210/100,000 p-y following new antidepressant starts. Suicide rates remained above the base rate for 48 weeks following inpatient discharge and 12 weeks following antidepressant treatment events. Adults aged 61-80 years were at highest risk in these 12-week periods. (Further results addressing other specific aims and results from additional project related studies are reported in the text and the attached articles/manuscripts.)

IMPACT:
This project was the largest and most comprehensive examination of suicide among patients receiving VA treatment for depression. Suicide rates were documented for the entire VA depression treatment population and for important subgroups of these patients. We also documented suicide rates during high-risk treatment periods and the monitoring offered to patients during these high-risk periods, overall and by age, ethnicity, and psychiatric status. Finally, we examined the relationship between monitoring and suicide. Supplemental methodological and content relevant studies were completed. We believe study results will inform the field about these critical issues and will have practical implications for VA clinicians treating depressed patients and for VA administrators organizing preventive services for these patients.

PUBLICATIONS:

Journal Articles

  1. Smith EG, Kim HM, Ganoczy D, Stano C, Pfeiffer PN, Valenstein M. Suicide risk assessment received prior to suicide death by Veterans Health Administration patients with a history of depression. The Journal of clinical psychiatry. 2013 Mar 1; 74(3):226-32.
  2. Valenstein M, Kim HM, Ganoczy D, Eisenberg D, Pfeiffer PN, Downing K, Hoggatt K, Ilgen M, Austin KL, Zivin K, Blow FC, McCarthy JF. Antidepressant agents and suicide death among US Department of Veterans Affairs patients in depression treatment. Journal of Clinical Psychopharmacology. 2012 Jun 1; 32(3):346-53.
  3. Kim HM, Smith EG, Stano CM, Ganoczy D, Zivin K, Walters H, Valenstein M. Validation of key behaviourally based mental health diagnoses in administrative data: suicide attempt, alcohol abuse, illicit drug abuse and tobacco use. BMC health services research. 2012 Jan 23; 12(1):18.
  4. Pfeiffer PN, Szymanski BR, Valenstein M, McCarthy JF, Zivin K. Trends in antidepressant prescribing for new episodes of depression and implications for health system quality measures. Medical care. 2012 Jan 1; 50(1):86-90.
  5. Li Z, Pfeiffer PN, Hoggatt KJ, Zivin K, Downing K, Ganoczy D, Valenstein M. Emergent anxiety after antidepressant initiation: a retrospective cohort study of Veterans Affairs Health System patients with depression. Clinical therapeutics. 2011 Dec 1; 33(12):1985-1992.e1.
  6. Seyfried LS, Kales HC, Ignacio RV, Conwell Y, Valenstein M. Predictors of suicide in patients with dementia. Alzheimer's & dementia : the journal of the Alzheimer's Association. 2011 Nov 1; 7(6):567-73.
  7. Pfeiffer PN, Ganoczy D, Zivin K, Valenstein M. Benzodiazepines and adequacy of initial antidepressant treatment for depression. Journal of Clinical Psychopharmacology. 2011 Jun 1; 31(3):360-4.
  8. Luchins DJ, McCarthy JF, Mach JJ, Jordan N. Quantifying the contribution of VA service-connected disability pensions to the "check effect". Psychiatric services (Washington, D.C.). 2011 May 1; 62(5):551-3.
  9. Smith EG, Craig TJ, Ganoczy D, Walters HM, Valenstein M. Treatment of Veterans with depression who died by suicide: timing and quality of care at last Veterans Health Administration visit. The Journal of clinical psychiatry. 2011 May 1; 72(5):622-9.
  10. Kim HM, Eisenberg D, Ganoczy D, Hoggatt K, Austin KL, Downing K, McCarthy JF, Ilgen M, Valenstein M. Examining the relationship between clinical monitoring and suicide risk among patients with depression: matched case-control study and instrumental variable approaches. Health services research. 2010 Oct 1; 45(5 Pt 1):1205-26.
  11. Kim HM, Zivin K, Ganoczy D, Pfeiffer P, Hoggatt K, McCarthy JF, Downing K, Valenstein M. Predictors of alternative antidepressant agent initiation among U. S. veterans diagnosed with depression. Pharmacoepidemiology and drug safety. 2010 Oct 1; 19(10):1049-56.
  12. Valenstein M, Eisenberg D, McCarthy JF, Austin KL, Ganoczy D, Kim HM, Zivin K, Piette JD, Olfson M, Blow FC. Service implications of providing intensive monitoring during high-risk periods for suicide among VA patients with depression. Psychiatric services (Washington, D.C.). 2009 Apr 1; 60(4):439-44.
  13. Pfeiffer PN, Ganoczy D, Ilgen M, Zivin K, Valenstein M. Comorbid anxiety as a suicide risk factor among depressed veterans. Depression and anxiety. 2009 Jan 1; 26(8):752-7.
  14. Valenstein M, Kim HM, Ganoczy D, McCarthy JF, Zivin K, Austin KL, Hoggatt K, Eisenberg D, Piette JD, Blow FC, Olfson M. Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts. Journal of affective disorders. 2009 Jan 1; 112(1-3):50-8.
Conference Presentations

  1. McCarthy JF, Valenstein MT, Ilgen MA, Ignacio RV, Blow FC. Suicide among Patients in the Veterans Affairs Health System: Rural-Urban Differences in Rates, Risks and Methods. Paper presented at: University of Michigan Albert J. Silverman Annual Research Conference; 2011 Jun 15; Ann Arbor, MI.
  2. McCarthy JF, Valenstein MT, Ilgen MA, Ignacio RV, Blow FC. Suicide among Patients in the Veterans Affairs Health System: Rural-Urban Differences in Rates, Risks and Methods. Paper presented at: American Association of Suicidology Annual Conference; 2011 Apr 11; Portland, OR.
  3. Pfeiffer PN, Ganoczy D, Ilgen MA, Zivin KZ, Valenstein MT. Comorbid anxiety as a suicide risk factor among depressed veterans. Presented at: Albert J. Silverman Research Annual Conference; 2009 Jun 17; Ann Arbor, MI.
  4. McCarthy JF, Post EP, Austin K, Kim H, Yano E, Zivin KZ, Hoggatt K, Kilbourne AM, Blow FC, Valenstein MT. Adoption of Primary Care-Mental Health Integrated Care Models, FY99-04 Associations with Suicide Risk among Patients with Depression. Paper presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
  5. Valenstein MV. Suicide Among Veterans with Depression. Paper presented at: VA VISN 12 Mental Health Practice Conference; 2007 Sep 26; Rolling Meadows, IL.
  6. Valenstein MV, Kim HM, McCarthy JF, Bambauer KZ, Hoggatt KH, Ganoczy DG, Austin KL, Eisenberg D, Blow FC. Periods of high suicide risk among VA patients in depression treatment. Paper presented at: National Institute of Mental Health Mental Health Services Research Annual Conference; 2007 Jul 24; Washington, DC.
  7. Bambauer KZ, Kim HM, McCarthy JF, Austin KL, Hoggatt KJ, Walters HM, Valenstein MV. Suicide mortality among individuals receiving treatment for depression in the VA Health system: associations with patient and treatment setting characteristics. Paper presented at: VA Transforming Mental Health Care Conference; 2007 Jul 17; Alexandria, VA.
  8. McCarthy JF, Valenstein MV, Visnic SV, Dixon LD, Blow FC, Slade EP. Distance Limits Initiation of Mental Health Intensive Case Management Services Among High-Risk Patients with Serious Mental Illness. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 4; Orlando, FL.
  9. McCarthy JF, Valenstein MV, Dixon LD, Blow FC, Slade EP. Distance Limits Initiation of Mental Health Intensive Case Management Services Among High-Risk Patients with Serious Mental Illness. Paper presented at: VA HSR&D National Meeting; 2007 Feb 21; Arlington, VA.
  10. Valenstein M. Data and Examining Issues of Depression Treatments and Suicide. Paper presented at: National Institute of Mental Health Annual Workshop; 2006 Nov 9; Bethesda, MD.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: none
Keywords: Depression, PTSD
MeSH Terms: none

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