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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 Portfolio Assignment: Mental and Behavioral Health |
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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. External Links for this ProjectNIH ReporterGrant Number: I01HX000590-01Link: https://reporter.nih.gov/project-details/8088819 Dimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Mental, Cognitive and Behavioral Disorders
DRE: Prognosis, Prevention Keywords: none MeSH Terms: none |
