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DHI 08-096 – HSR&D Study

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DHI 08-096
Outcomes and Correlates of Suicidal Ideation in OEF/OIF Veterans
Steven K. Dobscha MD
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: October 2008 - April 2012

BACKGROUND/RATIONALE:
In 2007, the Department of Veterans Affairs (VA) introduced a national performance measure requiring suicidal ideation (SI) assessment for all Veterans with positive depression screens. To date, there is little empirical evidence supporting the use of population-based SI assessment for improving outcomes. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans frequently have risk factors for suicide. It is important to know if the VA's structured SI assessment process facilitates delivery of timely and appropriate mental health care.

OBJECTIVE(S):
The main objective of this study was to identify process outcomes among OEF/OIF Veterans with depression who received brief structured assessments for SI in VA facilities. Specifically, our goals were to 1) Identify process outcomes following positive SI assessments, comparing post-assessment care of Veterans with positive assessments to Veterans with negative assessments, 2) Identify key correlates of positive SI assessments, and 3) Evaluate clinician adherence to recommendations for suicide risk assessment following positive SI assessments, 4) Explore Veterans' experiences of SI assessments and their perceptions of clinicians' responses to assessment results. Additional aims included identifying the prevalence of positive assessments among OEF/OIF Veterans who screen positive for depression; comparing accuracy of depression, SI, PTSD, alcohol, and pain screening data in local and regional VA databases; and describing rates and correlates of SI assessments within one day of positive depression screens.

METHODS:
This was a mixed-methods, case-control study.
QUANTITATIVE: We collected data from administrative databases of three VA facilities for all Veterans screened with the Patient Health Questionnaire-2 (PHQ-2) over 18 months (April 1, 2008-September 30, 2009), and determined the prevalence of positive SI assessments (in most cases, endorsement of PHQ-9 9th item or VHA Pocket Card SI assessment) among Veterans meeting criteria for major depression (PHQ-2 3). Because screen-related data storage processes varied across the sites, for VAMC 1 we used a regional data warehouse and for VAMCs 2 and 3, developed computerized text search algorithms to identify depression screens. Using these data sources, we identified our study sample: 1662 Veterans who had positive depression screens in primary care or mental health settings. We compared Veterans with SI to Veterans with no SI on demographics, depression severity, medical morbidity, International Classification of Diseases (ICD-9) psychiatric diagnoses documented prior to or at the time of SI assessment. Multivariate regression was used to identify correlates of receiving assessments and of positive SI assessments. Then, for the 12 months after SI assessment, we identified approaches used to address positive SI assessments and measured healthcare visits, psychiatric diagnoses, and treatment with antidepressants.
QUALITATIVE: We conducted individual interviews with a purposive sample of 34 OEF/OIF Veterans with SI from three study sites to learn about their perceptions of brief SI assessments and the healthcare system's response to screening. A grounded theory approach was used to analyze qualitative data.

FINDINGS/RESULTS:
QUANTITATIVE: Eighty-one percent of Veterans in our sample received brief structured assessments for SI within 30 days of positive depression screens, and 32% had positive SI assessments. Ninety-four percent were assessed within one day of positive depression screens. In a model adjusted for intra-site correlations, assessment was less likely during months 8-12 and 13-18 of the study period and more likely to occur among Veterans receiving depression or post-traumatic stress disorder (PTSD) diagnoses on the day of SI assessment. The likelihood of positive SI assessments was greater at VAMC 1 and 3 as compared to VAMC 2, and as PHQ-2 scores increased. Positive assessments were more likely for divorced/widowed, but lower for Reserve/Guard and white/non-Hispanic Veterans. Among the subgroup of 694 Veterans with prior-year VA utilization, depressive disorder and bipolar/schizophrenia diagnoses increased the likelihood of positive SI assessments. During the year after SI assessment, Veterans with assessments had fewer primary care visits, but more mental health and emergency department visits; more often received major depression, PTSD, substance use disorder diagnoses; and more often received an antidepressant prescription compared to Veterans who did not have SI assessments or who had negative SI assessments. Within the group of 230 primary care patients who had positive SI assessments, 214 (93%) had providers who documented specific acknowledgement of the positive assessments. For a majority (>65%), clinicians documented exploration for risk factors including hopelessness, past suicide attempts, psychiatric (including substance use) disorders, and pain, as well as relationship and occupational problems. A medication initiation or change was noted for 58% of patients, and mental health follow-up was arranged for 93%. Clinicians documented inquiries about firearms for only 23% of the patients, and recommendations to restrict access to firearms for 6%.
QUALITATIVE: Veterans generally accepted the rationale for brief structured SI assessments and appreciated that the language used was understandable and straightforward, though this was sometimes juxtaposed by frustration with over-simplification of their experiences through "yes/no" questions. A small number had alarming misinterpretations of the rationale for the assessment process. Veterans who trusted their providers were more willing to disclose suicidal thoughts. Many Veterans admitted to being unsure of, or fearful of, what might follow disclosure of suicidal thoughts; they were unaware of what the mental health care process might look like should they become involved. However, the reality of how providers responded was generally felt to be appropriate for the circumstances.

IMPACT:
This study identified important correlates of SI among OEF/OIF Veterans with symptoms of depression, described process and utilization outcomes of screening for SI, and improved understanding of the brief structured assessment process for SI from the perspectives of Veterans. The findings will inform future VA policy regarding SI screening and assist clinicians in caring for Veterans who may have suicidal ideation.

PUBLICATIONS:

Journal Articles

  1. Denneson LM, Teo AR, Ganzini L, Helmer DA, Bair MJ, Dobscha SK. Military Veterans' Experiences with Suicidal Ideation: Implications for Intervention and Prevention. Suicide & Life-Threatening Behavior. 2015 Aug 1; 45(4):399-414.
  2. Denneson LM, Corson K, Helmer DA, Bair MJ, Dobscha SK. Mental health utilization of new-to-care Iraq and Afghanistan Veterans following suicidal ideation assessment. Psychiatry Research. 2014 Jul 30; 217(3):147-53.
  3. Dobscha SK, Denneson LM, Kovas AE, Corson K, Helmer DA, Bair MJ. Primary care clinician responses to positive suicidal ideation risk assessments in veterans of Iraq and Afghanistan. General hospital psychiatry. 2014 May 1; 36(3):310-7.
  4. Ganzini L, Denneson LM, Press N, Bair MJ, Helmer DA, Poat J, Dobscha SK. Trust is the basis for effective suicide risk screening and assessment in veterans. Journal of general internal medicine. 2013 Sep 1; 28(9):1215-21.
  5. Corson K, Denneson LM, Bair MJ, Helmer DA, Goulet JL, Dobscha SK. Prevalence and correlates of suicidal ideation among Operation Enduring Freedom and Operation Iraqi Freedom veterans. Journal of affective disorders. 2013 Jul 1; 149(1-3):291-8.
  6. Dobscha SK, Corson K, Helmer DA, Bair MJ, Denneson LM, Brandt C, Beane A, Ganzini L. Brief assessment for suicidal ideation in OEF/OIF veterans with positive depression screens. General hospital psychiatry. 2013 May 1; 35(3):272-8.
  7. Basham C, Denneson LM, Millet L, Shen X, Duckart J, Dobscha SK. Characteristics and VA health care utilization of U.S. Veterans who completed suicide in Oregon between 2000 and 2005. Suicide & Life-Threatening Behavior. 2011 Jun 1; 41(3):287-96.
  8. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011 Apr 6; 305(13):1315-21.
  9. Denneson LM, Basham C, Dickinson KC, Crutchfield MC, Millet L, Shen X, Dobscha SK. Suicide risk assessment and content of VA health care contacts before suicide completion by veterans in Oregon. Psychiatric services (Washington, D.C.). 2010 Dec 1; 61(12):1192-7.
  10. Waitzfelder B, Gerzoff RB, Karter AJ, Crystal S, Bair MJ, Ettner SL, Brown AF, Subramanian U, Lu SE, Marrero D, Herman WH, Selby JV, Dudley RA. Correlates of depression among people with diabetes: The Translating Research Into Action for Diabetes (TRIAD) study. Primary Care Diabetes. 2010 Dec 1; 4(4):215-22.
  11. Helmer DA, Chandler HK, Quigley KS, Blatt M, Teichman R, Lange G. Chronic widespread pain, mental health, and physical role function in OEF/OIF veterans. Pain medicine (Malden, Mass.). 2009 Oct 1; 10(7):1174-82.
Conference Presentations

  1. Denneson LM, Teo AR, Ganzini LK, Helmer DA, Bair MJ, Dobscha SK. OEF/OIF Veterans’ Experiences with Suicidal Ideation: Implications for Intervention. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  2. Dobscha SK. Benefits and Limitations of Suicide Risk Assessment Processes in VA. Paper presented at: VA / Department of Defense Suicide Prevention Annual Conference; 2015 Jan 27; Dallas, TX.
  3. Denneson LM, Teo AR, Ganzini LK, Helmer DA, Bair MJ, Dobscha SK. Military Veterans' Voices on Contemplating Suicide and Implications for Effective Intervention. Presented at: American Association of Suicidology Annual Conference; 2014 Apr 11; Los Angeles, CA.
  4. Dobscha SK. Trust is the Basis for Effective Assessment for Suicidal Ideation in Veterans. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2013 Nov 6; Boston, MA.
  5. Denneson LM, Corson K, Helmer D, Bair M, Dobscha SK. VA Mental Health Care Utilization among OEF/OIF Veterans after Suicidal Ideation Assessment. Paper presented at: American Association of Suicidology Annual Conference; 2013 Apr 27; Austin, TX.
  6. Dobscha SK, Corson K, Denneson LM, Kovas A, Bair M, Helmer D. Clinician Documentation of Discussions with OEF/OIF Veterans Following Positive Brief Assessments for Suicidal Ideation. Poster session presented at: Academy of Psychosomatic Medicine Annual Meeting; 2012 Nov 15; Atlanta, GA.
  7. Dobscha SK. Brief Assessments for Suicidal Ideation in VA Ambulatory Settings. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 19; National Harbor, MD.
  8. Ganzini LK, Press NA, Helmer D, Bair M, Poat J, Dobscha SK. Trust is the basis for effective screening for suicidal ideation. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
  9. Corson K, Denneson LM, Helmer DA, Duckart JP, Bair MJ, Dobscha SK. Rates and Correlates of Positive Suicidal Ideation Screens among OEF/OIF Veterans with Positive Depression Screens. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD.
  10. Corson K, Dobscha SK. Suicidal Ideation among OEF/OIF Veterans with Positive Depression Screens: Prevalence and Correlates. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 17; National Harbor, MD.
  11. Corson K, Helmer DA, Bair MJ, Denneson LA, Dobscha SK. Suicidal ideation screens among OEF/OIF Veterans with positive depression screens. Poster session presented at: American Association of Suicidology Annual Conference; 2012 Apr 18; Baltimore, MD.
  12. Dobscha SK, Corson K, Helmer D, Bair M, Denneson LM, Ganzini LK. Screening for Suicidal Ideation in VA Ambulatory Settings. Paper presented at: Academy of Psychosomatic Medicine Annual Meeting; 2011 Nov 19; Phoenix, AZ.
  13. Dobscha SK. Addressing the Crisis of Suicide in Our Counties. Paper presented at: National Association of Counties Annual Conference; 2011 Jul 18; Portland, OR.
  14. Helmer DA, McComb A, Corson K, Bair M, Yu H, St. Julien U, Dobscha S. Detecting suicidal thoughts in Veterans of Iraq and Afghanistan: The importance asking directly. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Jun 13; Seattle, WA.
  15. Denneson LM, Basham CM, Dickinson KC, Crutchfield M, Millet L, Shen X, Dobscha SK. Utilization, Chronic and Acute Suicide Risk Assessment, and Risk Presentation in VA Care by Veterans who Completed Suicide in Oregon 2000-2005. Paper presented at: VA / Department of Defense Suicide Prevention Annual Conference; 2011 Mar 16; Boston, MA.
  16. Dobscha SK. Pain, Depression and Suicide. Paper presented at: VA National Pain Management Conference; 2011 Mar 2; Jacksonville, FL.
  17. McComb A, Helmer DA, Corson K, Bair M, Ganzini L, Dobscha S. Positive depression screening in OEF-OIF Veterans is associated with mental healthcare engagement within 30 days. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2010 Nov 9; Denver, CO.
  18. Denneson L, Basham CM, Dickinson K, Crutchfield M, Millet L, Shen X, Dobscha SK. Suicide Risk Assessment and Content of Last VA Healthcare Visits in the Year Prior to Suicide Completion in Oregon. Poster session presented at: VA Implementing a Public Health Model for Meeting the Mental Health Needs of Veterans Annual Mental Health Conference; 2010 Jul 28; Baltimore, MD.
  19. Dobscha SK. Pain and Suicide. Presented at: VA Suicide Prevention Coordinator Conference; 2010 Jul 26; Baltimore, MD.
  20. El-Serag R, Helmer DA, McComb A, Dobscha SK. Women Veterans Are Less Likely to Receive Mental Health Care Following a Positive Depression Screen. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 15; Arlington, VA.
  21. Helmer DA, McComb A, Corson K, Bair M, Ganzini LK, Dobscha SK. Positive Depression Screening in OEF/OIF Veterans is Associated with Mental Healthcare Engagement within 30 Days. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA.
  22. Denneson L, Basham CM, Dickinson K, Crutchfield M, Millet L, Shen X, Dobscha SK. Suicide Risk Assessment and Content of Last VA Healthcare Visits in the Year Prior to Suicide Completion in Oregon. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR.
  23. Helmer DA, Seal K, Hunt S, Chardos J, Burgo L, Felker B. Integration of general medicine and mental health services for recent combat Veterans. Presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN.
  24. Gutierrez PM, Bahraini N, Basham CM, Hedfegaard HB, Denneson L, Dobscha SK. Lessons Learned About Veteran Suicide from the Colorado and Oregon Violent Death Reporting Systems. Paper presented at: American Association of Suicidology Annual Conference; 2010 Apr 22; Orlando, FL.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders
DRE: Etiology, Prevention
Keywords: Deployment Related, Depression, Screening, Suicide
MeSH Terms: none