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IIR 10-331 – HSR&D Study

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IIR 10-331
Veteran Interactions with VA Primary Care Prior to Suicide
Steven K. Dobscha MD
VA Portland Health Care System, Portland, OR
Portland, OR
Funding Period: September 2011 - August 2014

BACKGROUND/RATIONALE:
As many as 6,500 Veterans take their own lives each year. Many patients visit healthcare clinicians prior to suicide, and primary care clinicians may be in a unique position to intervene. Unfortunately, little is known about the characteristics of patients who make contact with primary care clinicians prior to suicide, as well as the content of these interactions.

OBJECTIVE(S):
1) Describe characteristics of, and healthcare received by, suicide decedents in VA primary care in the year prior to death compared to a matched sample of Veterans who did not die by suicide; 2) Evaluate content of last interactions of Veteran suicide decedents with VA primary care clinicians; and 3) Describe characteristics of, and care received by, the subgroup of Operation Iraqi Freedom (OEF/OIF) Veteran suicide decedents.

METHODS:
This is a retrospective descriptive and case-control study. We obtained state vital data in collaboration with VA Mental Health Services-Suicide Prevention and the Veterans Integrated Service Network (VISN)-2 Center of Excellence for Suicide Prevention for 11 States. We linked these data to VA's Corporate Data Warehouse (CDW) to identify Veterans who died by suicide in 2009 and who received VA healthcare in the 12 months prior to death. The OEF/OIF Roster was used to identify OEF/OIF status and provide military history for the subgroup of OEF/OIF Veterans. We conducted medical record review using VA's Compensation and Pension Records Interchange. Medical record review variables included whether clinicians screened or assessed for mental disorders and suicidal ideation, follow-up for suicidal ideation, predisposing and protective factors for suicide, reasons for last contacts, and presence of emotional distress at last contacts. In analyses, we summarized patient characteristics, primary care team assessments, and clinical actions taken, and compared these variables to those associated with a 1:2 control sample of age, sex, and primary care provider-matched Veterans who did not die by suicide. Multi-level conditional logistic regression models were used to adjust for clustering within states to determine multivariate correlates of suicide.

FINDINGS/RESULTS:
Aim 1: We identified 297 Veterans who had at least one VA primary care visit during the year prior to death; we matched these cases to 594 controls. Average subject age was 63 years; 97% were male. Among cases who received care within 6 months of death, rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors documented in the 6 months prior to death were all significantly greater in cases compared to controls. In the final multivariable model describing men in the sample, non-white race (OR=0.51; 95% CI=0.27-0.98) and VA service-connected disability (OR=0.54; 95% CI=0.36-0.80) were associated with decreased odds of suicide, while anxiety disorder other than PTSD (OR=3.52; 95% CI=1.79-6.92), functional decline (OR=2.52; 95% CI=1.55-4.10), depression (OR=1.82; 95% CI=1.07-3.10), and endorsement of suicidal ideation (OR=2.27; 95% CI=1.07-4.83) were associated with greater odds of suicide. We then examined the primary care received by cases and controls during the 12 months prior to death. Among Veterans with positive depression screens or mental health conditions identified in primary care (n=118 matched pairs), cases and controls did not differ in receipt of further exploration for alcohol use disorder (76% vs, 79%, p=.68) or suicidal ideation (46% vs. 49%, p=.69), receipt of any specialty mental health treatment (72% vs. 63%, p=.13), average numbers of mental health specialty visits (12.8 vs. 10.2, p=.51) or receipt of antidepressant prescriptions (64% vs. 59%, p=.35).

Aim 2: We next examined last interactions with VA healthcare of the cases who received any VA healthcare during the six months prior to death. Ninety-one (31%) of these Veterans presented with acute care needs at their last interactions, 45 (15%) presented with heightened affective states, and 15 (5%) presented with two or more psychosocial stressors. Only 20 of 53 (38%) Veterans who were asked about suicidal ideation endorsed it. In multivariate analyses, only changes in functional status were associated (AOR=2.58, p=.04) with dying within one week of last interactions (versus dying later). Primary care was involved in last clinical interactions for 136 (46%) of these Veterans. Rates of acute care needs, heightened affective states were similar when comparing this group to the overall sample.

Aim 3: Because there were only 11 OEF/OIF Veterans in the main 2009 sample, we expanded the years examined and added a qualitative content analysis of medical records to learn as much about this group as possible. Thirty-one OEF/OIF Veterans died by suicide in 2008-2009 and received VA care during the six months prior to death. Most were male (87%), white, non-Hispanic (84%), with almost half unmarried/single at time of death (45%). Mean age was 35. Most died by firearms (74%), while 23% died of suffocation, 10% of poisoning, and the remaining by other or unknown means. A majority of these Veterans (80%) had specialty mental health visits during the 6 months prior to death. Approximately half (54%) had depression diagnoses, 41% had PTSD diagnoses, and 7% had substance use disorder diagnoses. Sixty-one percent received an antidepressant in the 6 months prior to death. Initial results from the qualitative content analysis show that this group displayed multiple, frequent, and severe psychosocial stressors prior to suicide that likely interacted with frequently present, active mental health conditions. Most patients received appropriate types and intensity of care, though the use of benzodiazepines prior to death was common and in some cases likely contraindicated.

IMPACT:
We found that mental health conditions and psychosocial stressors are very common among Veterans treated in VA primary care who die by suicide. A majority of Veterans asked about suicidal ideation during their last interactions prior to suicide deny it. We found no meaningful differences in the VA primary care received when comparing cases to controls, though note that our additional and ongoing content analysis review of medical records for the OEF/OIF and women subgroups may reveal more information. Our findings suggest that assessment for anxiety disorders, functional decline, and acute psychosocial stressors in primary care settings may be especially important for determining suicide risk in these populations; continued development of identification strategies and specific treatment approaches for these conditions in primary care is warranted.

PUBLICATIONS:

Journal Articles

  1. Denneson LM, Williams HB, Jacobson LE, Nguyen D, Dobscha SK. Psychosocial and healthcare experiences of OEF/OIF veterans prior to suicide: qualitative analysis of VA medical records. Military Behavioral Health. 2016 Jun 10; 5(1):1-11.
  2. Denneson LM, Kovas AE, Britton PC, Kaplan MS, McFarland BH, Dobscha SK. Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide. Suicide & Life-Threatening Behavior. 2016 Jun 1; 46(3):363-74.
  3. Denneson LM, Cromer RD, Jacobson LE, Teo AR, Dobscha SK. Female Veterans Who Died by Suicide: Qualitative Analysis of Medical Records. Military Behavioral Health. 2016 Feb 17; 4(3):276-284.
  4. Denneson LM, Williams HB, Kaplan MS, McFarland BH, Dobscha SK. Treatment of veterans with mental health symptoms in VA primary care prior to suicide. General hospital psychiatry. 2016 Jan 1; 38:65-70.
  5. Teo AR, Choi H, Andrea SB, Valenstein M, Newsom JT, Dobscha SK, Zivin K. Does Mode of Contact with Different Types of Social Relationships Predict Depression in Older Adults? Evidence from a Nationally Representative Survey. Journal of the American Geriatrics Society. 2015 Oct 1; 63(10):2014-22.
  6. 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.
  7. Dobscha SK, Denneson LM, Kovas AE, Teo A, Forsberg CW, Kaplan MS, Bossarte R, McFarland BH. Correlates of suicide among veterans treated in primary care: case-control study of a nationally representative sample. Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:853-60.
HSR&D or QUERI Articles

  1. Dobscha SK. The Role of Primary Care in Addressing Suicide Risk. Forum. 2012 May 1; 5(1): 6.
Center Products

  1. Denneson LM, Cromer RD, Jacobson LE, Teo AR, Dobscha SK. Qualitative Content Analysis of VA Healthcare Records of Veteran Women who Died by Suicide. Patient-Safety Center of Inquiry for Suicide Prevention Learning Community Conference Call. 2015 Jul 16.
  2. Bahraini N, Bossarte R, Brenner LA, Dobscha SK, Oslin D, Wendleton L. Identifying Veterans at Risk For Suicidal Behavior. White Paper Report for VA Central Office Patient Services Leadership. 2014 Jan 15.
VA Cyberseminars

  1. Teo AR, Denneson LM. Suicide Risk Assessment and Prevention: A Systematic Review Focusing on Veterans. Veterans Health Administration Northwest Mental Illness Research Education and Clinical Center (MIRECC) Webinar [Cyberseminar]. Veterans Health Administration Northwest Mental Illness Research Education and Clinical Center (MIRECC). 2016 Jun 1.
  2. Dobscha SK, Denneson LM. Interactions with VHA care prior to suicide: Implications for VHA providers. [Cyberseminar]. 2015 Mar 9.
Conference Presentations

  1. Dobscha SK, Cromer RD, Denneson LM, Nguyen D, Teo AR. Medical problems in women veterans who die by suicide: Content analysis of electronic medical records. Paper presented at: Academy of Psychosomatic Medicine Annual Meeting; 2015 Nov 13; New Orleans, LA.
  2. Denneson LM, Cromer RD, Jacobson LE, Teo A, Dobscha SK. Qualitative Content Analysis of VA Healthcare Records of Veteran Women who Died by Suicide. Paper presented at: VA Patient Safety Center of Inquiry for Suicide Prevention Monthly Meeting; 2015 Jul 16; Little Rock, AR.
  3. Denneson LM, Cromer RD, Jacobson LE, Teo A, Dobscha SK. Qualitative Content Analysis of VA Healthcare Records of Veteran Women who Died by Suicide. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  4. Cromer RD, Denneson LM, Jacobson LE, Dobscha SK. Between the Lines: Reading & Conducting Research with Mental Health Notes. Paper presented at: Anthropology and Mental Health Interest Group Annual Conference; 2014 Dec 2; Washington, DC.
  5. Dobscha SK, Denneson LM, Kovas AE, Teo AR, Forsberg CW, Kaplan MS, Bossarte R, McFarland B. Correlates of Suicide among Veterans Treated in VA Primary Care. Paper presented at: Academy of Psychosomatic Medicine Annual Meeting; 2014 Nov 14; Fort Lauderdale, FL.
  6. 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.
  7. Dobscha SK, Ganzini LK, Rosenstein D, Worley L. Assessment and Management of Suicide Risk in Nonpsychiatric Settings. Paper presented at: Academy of Psychosomatic Medicine Annual Meeting; 2013 Nov 14; Tucson, AZ.
  8. Dobscha SK. Focused Review of Suicide for the Consult Liaison Psychiatrist. Presented at: Academy of Psychosomatic Medicine Annual Meeting; 2013 Nov 13; Tucson, AZ.


DRA: Mental, Cognitive and Behavioral Disorders
DRE: Prognosis, Prevention
Keywords: Clinical Diagnosis and Screening, Reintegration Post-Deployment, Suicide
MeSH Terms: none