Study Suggests Social Stressors are Strongly Associated with Suicide Ideation and Attempt among Veterans

BACKGROUND:
The National Academy of Medicine recommended collection of social and behavioral determinants of health in 2014, including social stressors (i.e., homelessness, experiencing violence), which are linked to health in strong and complex ways. VA addresses some social stressors by screening all Veterans in VA care for homelessness and military sexual trauma and by offering vocational rehabilitation and supportive housing. However, there is scarce research on how a wider array of social stressors may be collected within VA's electronic health record (EHR), and how they might contribute to outcomes, such as suicidal ideation or suicide attempt. This observational study examined documented social stressors in VA's EHR and how these stressors were associated with suicidal ideation and suicide attempt. Investigators examined EHR data from October 2015 through September 2016 for 293,872 Veterans in VISN 4 with at least one inpatient or outpatient visit, assessing seven types of social stressors: 1) experiences of violence, 2) housing instability, 3) employment or financial problems, 4) legal problems, 5) social or familial problems, 6) lack of access to care or transportation, and 7) non-specific psychological needs. Also, because of the strong relation between mental illness and suicidal ideation and suicide attempt, investigators also accounted for whether Veterans were diagnosed with major depressive disorder, alcohol use disorder, drug use disorder, anxiety disorder, PTSD, schizophrenia, or bipolar disorder.

FINDINGS:

• Social stressors were strongly associated with suicidal ideation and suicide attempt. For example, compared with Veterans who had no social stressors, those with one social stressor had nearly 2.5 times the odds of suicidal ideation, two social stressors had over four times the odds, three social stressors had nearly five times the odds, and four or more social stressors had over eight times the odds – after adjusting for numerous socio-demographic factors and mental illness diagnoses.
• Overall, 16% of Veterans in this study had at least one social stressor in their EHR, and more than 16,000 had two or more.

IMPLICATIONS:

• Social stressors are as relevant as biological factors (e.g., depression) for suicide prevention and treatment. Systematic assessment of a more complete set of these stressors may improve the ability to identify patients at highest risk of suicide.

LIMITATIONS:

• Causality between social stressors and suicide morbidity could not be assessed because of the observational study design.
• Investigators were unable to capture other potential social stressors (e.g., patient income).

AUTHOR/FUNDING INFORMATION:
This study was funded by a pilot research award from VISN 4 and partly supported by HSR&D (IIR 13-334). Dr. Blosnich was supported by an HSR&D Career Development Award. Drs. Blosnich and Dichter are part of HSR&D’s Center for Health Equity Research & Promotion (CHERP). Dr. Montgomery is with VA’s National Center on Homelessness among Veterans and Birmingham VAMC.

Blosnich J, Montgomery A, Dichter M, et al. Social Determinants and Military Veterans’ Suicide Ideation and Attempt: A Cross-Sectional Analysis of Electronic Health Record Data. Journal of General Internal Medicine. November 19, 2019; Epub ahead of print.