- Post 9/11 Veterans Less Likely to Delay Mental Health Treatment
This study compared delay of treatment for PTSD, major depressive disorder (MDD), and/or alcohol-use disorder (AUD) among post-9/11 Veterans relative to pre-9/11 Veterans and civilians. Findings showed that post-9/11 Veterans were less likely than both pre-9/11 Veterans and civilians to delay mental health treatment for PTSD and depression. Median time to PTSD treatment was 2.5 years for post-9/11 Veterans compared to 16 years and 15 years, for pre-9/11 Veterans and civilians, respectively. Median time to depression treatment was 1 year for post-9/11 Veterans compared to 7 years and 5 years, for pre-9/11 Veterans and civilians, respectively. No differences in treatment delay were observed between post-9/11 Veterans and pre-9/11 Veterans or civilians for alcohol-use disorder. Increased engagement in PTSD and depression treatment for post- vs. pre-9/11 Veterans could be attributable to a host of recent historic, cultural, and policy changes, including: DoD’s universal post-deployment mental health screening; educational public health initiatives; enhanced eligibility for VA benefits for post-9/11 Veterans; VA’s suicide prevention hotline; VA mobile health resources (e.g., PTSD Coach); and VA’s integration of mental health services into primary care settings.
Date: March 7, 2019
- Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness
Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future suicide-related distress and/or attempts among a high-risk Veteran population.
Date: February 8, 2019
- Links Between Opioid Use and Suicide
This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Unique Link between Homelessness and Suicide
Evidence suggests suicide rates are much higher among those who are homeless or have been homeless. This study sought to replicate these previous findings with a larger, national population cohort. After controlling for common risk factors, results suggest a unique link between homelessness and suicide. Veterans with a history of homelessness were 8.8 times more likely to have attempted suicide than Veterans with no history of homelessness (25% vs. 3%). In the total study cohort (Veterans and non-Veterans), lifetime homelessness was significantly and independently associated with lifetime suicide attempts. The association between homelessness and suicide was stronger among Veterans than non-Veterans.
Date: January 2, 2019
- Medical Records Flag for Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified suicide prevention as a top priority and established policies to include high-risk suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and suicide-attempt diagnoses. Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
- Evaluating Care Coordination Program for Pregnant Veterans
The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
Date: May 23, 2018
- Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea, suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
Date: December 28, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or suicide.
Date: July 18, 2017
- Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
- Systematic Review of Suicide Risk Assessment and Prevention
This systematic review evaluated studies assessing the accuracy of methods to identify individuals at increased risk for suicide, and the effectiveness and adverse effects of healthcare interventions relevant to Veteran and military populations in reducing suicide and suicide attempts. Findings showed that suicide rates were reduced in 6 of 8 observational studies of various types of multiple-component population-level interventions, including two studies in Veteran and military populations. Only 2 of 10 trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care, however, most trials were inadequately designed to detect differences. No studies described the adverse effects of risk assessment methods or interventions for suicide prevention. Risk assessment methods are sensitive predictors of subsequent suicide and suicide attempts in studies, but the frequency of false positives limits their clinical utility. Future research should continue to refine these methods and examine their clinical applications.
Date: June 15, 2017
- Factors Associated with Suicide within One Week of Discharge from VA Psychiatric Facilities
To better understand system and organizational factors associated with post-discharge suicide, this study reviewed root-cause analysis (RCA) reports of death by suicide within seven days of discharge from all VA inpatient mental health units between FY2002 and FY2015. Findings showed that risk for suicide in the week following hospital discharge may be highest during the first few days after discharge. There were 141 reports of suicide within seven days of discharge: 40% occurred during the first day of discharge; 67% within 72 hours of discharge, and nearly 80% within four days of discharge. Further, 43% of suicides followed an unplanned discharge. Root causes for suicide fell into three major categories: 1) challenges for clinicians and patients following the established process of care, 2) awareness and communication of suicide risk, and 3) flaws in the established process of care. No association was found between length of hospital stay and days to suicide. Authors suggest that current VA policies mandating mental health follow-up within 7 days of discharge may be insufficient and that other methods of intervention to better reach this vulnerable patient population may need to be considered (e.g., tele-monitoring). The authors also suggest that inpatient teams be aware of the potentially heightened risk for suicide in patients whose discharge is unplanned.
Date: June 1, 2017
- Meta-Analysis of Interventions to Prevent Suicide
This study conducted a meta-analysis of randomized controlled trials (RCTs) that compared the efficacy of various interventions versus control to prevent death by suicide among adults. Of the studies included in this review, 29 RCTs reported on complex psychosocial interventions, with 3 reporting on the WHO Brief Intervention and Contact (BIC) intervention, which includes an educational session on suicide prevention followed by regular contact with a trained provider (phone or in-person) for up to 18 months. The WHO BIC intervention was associated with significantly lower odds of death by suicide. No other suicide prevention intervention showed a statistically significant effect in reducing death by suicide.
Date: June 1, 2017
- “Virtual Hope Box” Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to Suicide
Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. They then assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of suicide and self-harm. Findings showed that VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures. The most frequently cited reasons for using VHB by Veterans were for distress, when emotions were overwhelming, when they felt like hurting themselves, and for relaxation, distraction, and/or inspiration. Data suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills. Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare.
Date: November 15, 2016
- Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
Date: June 24, 2016
- Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
Date: June 15, 2016
- Central Nervous System Polypharmacy May Increase Risk of Overdose and Suicide-Related Behavior among OEF/OIF Veterans
This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
Date: March 1, 2016
- Increased Dose of Prescription Opioids Raises Risk of Suicide among Veterans with Chronic Non-Cancer Pain
This study examined the association between prescribed opioid dose and suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of suicides involved firearms (64%), with overdose accounting for 20% of all suicides.
Date: January 5, 2016
- Sexual Trauma during Military Service Increases Risk of Subsequent Suicide among Veterans
This was the first large-scale, population-based study of sexual trauma and suicide mortality that examined risks associated with military sexual trauma (MST) among both male and female Veterans receiving VA care. Findings showed that women and men who reported MST had an increased risk of suicide, and MST remained an independent risk factor even after adjusting for other known risk factors for suicide among Veterans, including mental health conditions, medical morbidity, and demographic characteristics. Among Veterans who reported MST, those who died by suicide were significantly more likely to be treated for mental health conditions determined by their provider to be related to MST experiences: men 50% vs. 36%, and women 67% vs. 48%. Overall, 2% of the Veterans in this study reported MST when screened (1% of men, and 21% of women), with 97% reporting no MST, and 0.3% declining to complete the screen.
Date: December 14, 2015
- Individual and Facility-Level Factors Associated with Higher Risk of Suicide Attempt among Veterans Receiving Opioid Therapy
This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent suicide-related events.
Date: July 1, 2015
- Rates of Suicide Higher among Transgender Veterans
This study sought to document all-cause and suicide mortality among VA healthcare users with an ICD-9-CM diagnosis consistent with transgender status. Findings showed that the crude suicide rate among Veterans with transgender-related diagnoses across the 10-year study period was approximately 82/100,000 person-years, which approximated the crude suicide death rates for Veterans with serious mental illness (e.g., depression, schizophrenia). However, this rate was higher than in both the general VA and U.S. populations. Comparisons of age at time of death suggest Veterans with transgender-related diagnoses may be dying by suicide at younger ages than Veterans without such diagnoses. The average age of transgender Veterans at the time of death by suicide was 49 years compared with studies that show the average age of death among non-transgender Veterans who die from suicide was between 55 and 60 years.
Diseases of the circulatory system and neoplasms were the first and second leading causes of death among transgender Veterans, however, the other ranked causes of death differed somewhat from patterns among the general U.S. population for the same time period. For example, certain infectious and parasitic diseases were the 6th leading cause of death among transgender Veterans, whereas they ranked 9th among the general U.S. population. Authors suggest future research is needed to examine how transgender Veterans seek or receive mental health services and that programs aimed at suicide prevention may benefit from clinical education and training about transgender populations.
Date: December 1, 2014
- Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care
This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis. Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. The odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with suicide, nor was a pain diagnosis or general medical comorbidity. Also, non-white race and a VA service-connected disability rating were associated with decreased odds of suicide. The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.
Date: December 1, 2014
- JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
- Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation. Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with all three categories of SRB. Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within VA. Risk for SRB was highest in the 18-25 year old age group.
Date: July 17, 2014
- “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide
Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
Date: May 15, 2014
- Risk of Suicide-Related Behavior among Older Veterans Receiving Antiepileptic Drugs
This study examined the temporal relationship between new antiepileptic drug (AED) monotherapy exposure and suicide-related behavior (SRB) in older Veterans. Findings showed that Veterans receiving their first AED during the study period were more likely to have suicide-related behavior during the 30 days prior to AED exposure than at any other time period in the year before and after exposure, even after controlling for psychiatric comorbidity. There were 106 SRB events among 92 Veterans in the year after exposure, with approximately 22% (n=16) of those Veterans also having an SRB event before their first AED exposure. Moreover, the rate of SRB after starting on an AED was gradually reduced over time. Results suggest that the peak in suicide-related behavior is prior to AED exposure. However, as the risk for recurrent SRB was 22% in individuals with SRB prior to exposure to AED therapy, these Veterans should be followed closely to prevent recurrent SRB.
Date: November 26, 2013
- Non-Cancer Pain Associated with Suicide
This study evaluated associations between non-cancer, pain-related clinical diagnoses (arthritis, back pain, migraine, tension headache or headache symptom, psychogenic pain, neuropathy, fibromyalgia) and suicide. Findings showed that, after controlling for demographics, most clincial diagnoses of non-cancer pain conditions were associated with risk of suicide in this large national cohort of Veterans. After further controlling for co-occuring psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain, migraine, and psychogenic pain. In Veterans with a pain condition who died by suicide, the two most common methods of suicide were firearms (68%) and poisoning (17%). There was no relationship between the number of pain conditions and suicide risk. The authors suggest that there is a need for increased awareness of suicide risk among Veterans with back pain, migraine, and psychogenic pain, which may not be fully explained by comorbid psychiatric diagnoses.
Date: July 1, 2013
- Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare
This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for suicide attempts and completion among Veterans.
Date: July 1, 2013
- Association between Several Common Antiepileptic Drugs and Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed suicide-related behavior than Veterans with no AED exposure. Findings indicated that suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
- Risk of Suicide and Mental Disorder Comorbidity among Male Veterans Using VA Healthcare
This study examined mental disorder comorbidity and suicide in a large national cohort of Veterans who use VA healthcare, particularly the association between differing two-way combinations of mental disorders and suicide risk. Findings showed that among Veterans who died by suicide between FY00 and FY06 (0.25% of the study cohort), 47% had been diagnosed with a mental disorder(s) including 19% with one mental disorder and 27% with two or more. Each mental disorder was associated with increased risk for suicide. However, nearly all two-way combinations of mental disorders showed a smaller increase in risk for suicide than would be expected by considering the risk associated with each disorder separately, which is interpreted to indicate sub-additive risk. Depression was the most common diagnosis among Veterans who died by suicide (31%), followed by substance use disorder (21%), anxiety disorder (15%), PTSD (12%), schizophrenia (9%), and bipolar disorder (9%).
Date: October 22, 2012
- Pre-Military Trauma Associated with Post-Recruit Training Suicide Attempts among Marines
This study examined pre- and post-Marine recruit training risk factors for suicide attempts among current and former Marines in the 10 years following training. Findings showed that stressful and traumatic life events (e.g., childhood physical, sexual and emotional abuse, sexual harassment during recruit training) and suicide attempts made before recruit training had strong associations with suicide attempts after recruit training. Those who experienced at least one life stressor prior to joining the Marines had 4 times the odds of suicide attempt compared to those who did not report any life stressors prior to joining. Half of the Marines in this study who died by suicide (per death certificate) in the 10 years following recruit training (n=3) reported at least one significant life stressor prior to joining the Marines. Marines who experienced military sexual harassment during recruit training had 3 times the odds of suicide attempt in the 10 years following training compared with those who did not report this experience. Marines with PTSD symptoms consistent with a diagnosis had about double the odds of suicide attempts compared with those without PTSD symptoms.
Date: October 20, 2012
- Prescription Drug and Alcohol Misuse Associated with Higher Suicide Deaths among Veterans with Depression
This study sought to assess the association between factors noted in the electronic medical record and suicide mortality for a cohort of Veterans who had received treatment for depression. Findings showed that suicidal behaviors and substance-related variables were the strongest independent predictors of suicide. Compared with Veterans without a suicide attempt or ideation, those with a suicide attempt in the prior year were 7 times more likely to die of suicide, and Veterans with suicidal ideation without an attempt were 3 times more likely to die of suicide. Veterans with prescription drug misuse and those with alcohol abuse were 7 times and 3 times, respectively, more likely to die of suicide than those without. Based on these findings, the authors suggest that prescription drug and alcohol misuse assessments should be prioritized in suicide assessments among Veterans diagnosed with a depressive disorder. Veterans for whom providers considered a hospitalization for psychological issues had 3 times higher risk of suicide death than those for whom hospitalization was not considered.
Date: October 1, 2012
- Promoting Gun Safety and Delayed Gun Access to High-Risk Patients is Acceptable to Veterans and Providers
This study explored VA stakeholders’ perceptions about gun safety and interventions to delay gun access among Veterans with a mental health diagnosis during high-risk periods. Findings showed that several measures to promote gun safety and to delay access to guns for high-risk patient groups are acceptable to VA patients and providers, if judiciously applied. For example, most patients and clinicians in this study indicated that routine screening for gun access was acceptable, particularly for patients receiving mental healthcare. Clinicians and patients reported having very little discussion regarding gun ownership during the course of routine treatment. Both groups indicated that gun access was typically discussed only during suicide or homicide risk assessments, and then only if the patient expressed suicidal/homicidal ideation that involved guns. However, nearly all patients felt that clinicians should routinely speak to their patients about guns. One of the most widely suggested and accepted interventions – across all stakeholders – was further education on suicide, including risks related to guns, for VA patients, family members, and clinicians.
Date: September 5, 2012
- QI Intervention for VA Programs Serving Homeless Veterans
Through the Getting To Outcomes (GTO) intervention, staff members at three homeless programs were able to make noticeable improvements in their programming. Although none of the improvements incorporated the wholesale adoption of a specific evidence-based program, most improvements involved programs becoming more evidence-based; e.g., using evidence-based guidelines to manage high-risk patients (i.e., Veterans at risk of suicide) and supporting additional substance abuse treatment for Veterans who had relapsed, while keeping them in their current VA housing. Many staff members experienced some challenges adding GTO activities to their already busy workload, and some felt the process could be more transparent and inclusive. Staff members stated that high levels of communication, commitment to the program, and technical assistance were critical to the success of the intervention.
Date: August 1, 2012
- Warning Signs Associated with Suicide among Veterans Receiving VA Healthcare
Of the 381 Veterans in this study who used VA healthcare in their last year of life, 67 (18%) died by suicide within one week of contact. Among these Veterans, documented suicidal ideation was the strongest predictor of suicide. Psychotic symptoms noted during the last VA healthcare visit also were associated with suicide. Of the 381 Veterans who used VA healthcare in their last year of life, 174 (46%) died within one month of contact. Among these Veterans, the warning signs noted above (suicidal ideation and psychotic symptoms) were also risk factors that predicted suicide within a month of contact. Authors note that assessment of suicidal ideation is critical to identifying Veterans at immediate risk, but that both suicidal ideation and psychotic symptoms may also suggest ongoing risk.
Date: July 13, 2012
- Review Supports One-to-One Peer Mentorship among Veterans
Across a broad range of populations, peer mentors appeared to be acceptable, credible sources of information. This may be particularly true among current and former members of the Armed Forces, who are accustomed to a culture of mutual support. The literature suggests that peers are capable of conducting assessment and triage, coaching and teaching, and providing direct social support. A White Paper identified three areas where peer mentorship (PM) might play a unique role for military/Veteran populations: coping with combat and operational stress, suicide prevention, and recovery-related issues downstream from combat/injury. In addition, the review suggests PM might play a role in reducing stigma, improving treatment adherence, increasing knowledge of treatment resources, and augmenting or teaching self-management skills.
Date: July 1, 2012
- Killing Experiences Independently Associated with Suicidal Ideation among Vietnam Veterans
Vietnam Veterans in this study with war-related killing experiences were twice as likely to report suicidal ideation as those who did not kill, even after accounting for PTSD, depression, substance use disorder diagnoses, and combat exposure. This is the first study demonstrating that killing experiences are independently associated with suicidal ideation, after taking mental health diagnoses into account. In regression analyses that included demographic variables, PTSD, depression, substance use disorders, combat experiences, and killing experiences, PTSD was the only variable significantly associated with suicide attempts. Nearly 14% of Veterans in this study met diagnostic criteria for current PTSD.
Date: April 13, 2012
- AJPH Features Articles on Veterans and Suicide
This special supplement of AJPH focuses on Veterans and mental health, and includes four articles on suicide among Veterans.
Date: January 1, 2012
- Less than One-Quarter of Veterans who Complete Suicide Access VA Healthcare in Year Prior to Death
This study sought to determine the number of Veterans who completed suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete suicide may access VA healthcare at similar rates as Veterans who do not commit suicide. Of those Veterans who completed suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete suicide. Of those who completed suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran suicide.
Date: April 4, 2011
- Rates of Accidental Poisoning among VA Patients Higher than General Population
This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of suicide.
Date: April 1, 2011
- Suicide Risk Factors for OIF Veterans
This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
Date: January 22, 2011
- Veterans who Commit Suicide May Not Show Apparent Emotional Distress During Last Healthcare Contact
This retrospective study examined VA healthcare contacts (by phone or in person) by Veterans in the year prior to their deaths by suicide. The majority of Veterans in this study were seen for routine VA medical care in the year prior to committing suicide, and did not show apparent signs of emotional distress at their last healthcare visit. In the year prior to death, nearly 50% of the Veterans had one or more mental health contacts, and 63% had one or more primary care contacts. Just over half of the Veterans received care in the 30 days prior to death, with 20% receiving mental health care and 15% receiving primary care. Forty percent of these Veterans were assessed for suicidal ideation during the year prior to death, and 16% were assessed during their last contact. Nearly three-quarters of those who were specifically asked about thoughts of suicide in the year prior to death denied having such thoughts. The median number of days between final VA healthcare contact and date of death was 42. Of the 26 Veterans whose final contacts were with mental health, 87% were assessed for depression, substance use disorder, or PTSD, and 54% were assessed for suicidal ideation. Of the 22 Veterans whose final contacts were with primary care, 55% were assessed for depression, substance use disorder, or PTSD, and 9% were assessed for suicidal ideation.
Date: December 1, 2010
- Link between Psychiatric Diagnosis and Higher Risk of Suicide among Veterans
As part of VA’s ongoing evaluation of suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for suicide among women, increasing their risk of suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by suicide. A diagnosis of bipolar disorder increased the risk of suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall, suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
Date: November 1, 2010
- Most VA Patients with Substance Use Disorders Who Die from Suicide Use Violent Means
Most VA patients with substance use disorders (SUDs) who died from suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent suicide. Alcohol use was associated with a lower likelihood of non-violent suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent suicide, the strength of the association between the disorder and type of suicide was greater for non-violent than violent suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
Date: July 1, 2010
- Checklist Successfully Identifies VA Environmental Hazards for Inpatient Suicide
This is the first study to examine the implementation and effectiveness of the Mental Health Environment of Care Checklist to improve patient safety. Findings show that between 2007 and 2008, 7,642 environmental suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms.
Date: February 1, 2010
- Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
Date: February 1, 2010
- Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with suicide-related behaviors (42.2% with dementia vs. 25.8% without).
Date: January 11, 2010
- Substance Abuse is Strongest Predictor of Suicide among Veterans with Depression
This study was an analysis designed to derive an empirically-based set of interactions related to rates of suicide in a national sample of VA patients diagnosed with depression. Findings show that among Veterans with depression those at highest risk for suicide have the combined risk factors of a substance use disorder (SUD), non-African American race, and a psychiatric inpatient stay in the past 12 months. Substance use disorder was also identified as the strongest single risk factor for suicide. Among Veterans without a substance use disorder, gender was the strongest predictor of suicide risk – rates were significantly higher for men than for women. Ethnicity also was related to suicide risk in this group. African American Veterans without an SUD were less likely to die by suicide compared to non-African American Veterans. The authors suggest that providers treating patients with these characteristics should be aware of these risks and consider target strategies to screen for current suicidal ideation.
Date: November 1, 2009
- Suicide Risk Significantly Higher for VHA Patients Compared to the General Population
Suicide rates among the Veterans enrolled in the VA healthcare system during FY00 and FY01 were found to be significantly higher than those in the general population. However, the differentials between suicide rates for VA patients and the general population were less than what might be expected given previous comparisons. Overall, for men and women combined, suicide risks among Veterans were 66% higher than those observed in the general population. Among male Veterans, suicide rates were highest for those aged 30-49 years and lowest among Veterans aged 18-29 and 60-69. Among women Veterans, suicide rates were highest among those aged 50-59 years. It is important to emphasize that this study compares a general population to users of a health care system where the prevalence of all conditions would be expected to be higher. Also, the study population precedes current conflicts in Iraq and Afghanistan.
Date: April 15, 2009
- Study Suggests Additional Interventions for Veterans with SUD and History of Abuse
Men with a history of physical or sexual abuse had more severe drug problems at intake, but by six months there were no group differences in drug use. However, veterans with a history of sexual abuse had more severe psychiatric problems at all time points and were more likely to report significant suicidality at intake and 6 month follow-up. This suggests that additional interventions may be warranted for veterans with SUD and a history of sexual abuse. Also, routine screening for suicidality in SUD treatment programs may be warranted given the prevalence of lifetime sexual abuse among SUD patients and the relationship between sexual abuse and attempted suicide.
Date: December 1, 2008
- Improving the Environment of Care to Reduce Inpatient Suicide and Suicide Attempts in VA Facilities
Authors provide 5 recommendations for reducing environmental hazards for suicide on inpatient psychiatric units.
Date: August 1, 2008