The rate of suicide among Veterans is high and increasing. While depression is a known risk factor, pain, a common symptom among Veterans in VA care, has recently been shown to be associated with suicide. In VA primary care, depression screening is performed yearly for patients without a current depression diagnosis using the two-item Patient Health Questionnaire (PHQ-2). If the PHQ-2 is 3, further assessment using the nine-item PHQ-9, which includes an item on suicidal ideation, is recommended. If the PHQ-9 is 10 or the suicide item is endorsed, a suicide risk assessment should be performed. Pain screening is conducted independently of depression screening during most VA clinical encounters using the 0 to 10 pain numeric rating scale (NRS). An NRS score 4 indicates moderate to severe pain, and may suggest that further suicide assessment is indicated.
Determine whether pain screening results are associated with depression and suicide risk assessment completion and findings.
We used VA Connecticut Healthcare System administrative data to identify all Veterans who screened positive for depression on the PHQ-2 (n=1,117 of 36,229 screened) in a primary care encounter during calendar year 2009. We selected all female (n=88) and a random sample of male Veterans (n=250), and then conducted a structured review of their electronic medical record (EMR) on the day of the positive screen. A trained reviewer abstracted EMR data to determine if a PHQ-9 was conducted, and whether: depression assessment (e.g. "pt denies depression"); suicide risk assessment (e.g. "thoughts about taking her life"); and, a determination of present suicide risk (e.g. "pt denies suicidal ideation") was documented. We used logistic regression with weighting to account for the sampling to estimate the association between pain and outcomes.
The sample characteristics (n=338) closely matched the total sample (N=1,117): the mean age was 58.2, 92% were male, and 68% were Caucasian. All patients had a pain NRS; 43% reported a score of 4. Twenty-four percent of the sample had a PHQ-9, 81% a depression assessment, 82% a suicide risk assessment, and 8.4% had a suicide risk present. Women Veterans were more likely to report pain (OR=1.72, 95%CI=1.11/2.67) and suicidal ideation (OR=1.83, 95%CI=1.07/3.15). Pain was not associated with the conduct of a PHQ-9 (OR=1.27, 95% CI = 0.96/1.68), nor depression assessment (OR=1.03, 95% CI = 0.78/1.39). Suicide risk assessment was significantly less likely among patients reporting pain (OR=0.67, 95%CI=0.49/0.91). There was no association between pain and the determination of suicide risk (OR=0.85, 95% CI=0.53/1.39).
Veterans reporting moderate to severe pain were equally unlikely to have a PHQ-9 after a positive PHQ-2 screen, and were less likely to be assessed for suicide risk, compared to Veterans reporting mild or no pain. This may be a missed opportunity to identify Veterans at increased suicide risk. These findings have been shared with the facility Section Chief of Internal Medicine in order to help implement changes in depression and suicide screening and assessment practices.
- Goulet JL, Brandt CA, Czlapinski RA, Desai RA, Heapy AA, Kerns RD. The Impact of Pain on Suicide Risk Screening Among Veterans in VA Care. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; Baltimore, MD.