Suicide mortality among male veterans discharged from Veterans Health Administration acute psychiatric units from 2005 to 2010

Evaluating the Effectiveness of Safety Plans for Mitigating Suicide Risk in Two Samples of Psychiatrically Hospitalized Military Veterans

Although safety plans (SPs), following the Stanley-Brown Safety Planning Intervention protocol, are required for suicidal veterans receiving treatment in the Veterans Health Administration (VHA), prior studies have shown that they are frequently incomplete or are not sufficiently personalized to the unique circumstances of each patient. In two studies, we examined SP completeness, SP quality (i.e., degree to which the SP was clear, actionable, and personalized), and SP fidelity (i.e., sum of completeness and quality). We also examined which SP steps were associated with a reduced likelihood of future psychiatric rehospitalizations (Study 1) and suicide attempts (Study 2) following hospital discharge. Participants were veterans admitted to two VHA acute inpatient psychiatric units for suicide risk (Study 1: N = 78; Study 2: N = 132). SPs were coded by independent raters on completeness, quality, and fidelity; step scores (e.g., Step 1 quality) were summed to create whole-plan scores (e.g., SP quality). In Study 1, 52.5% of participants had an SP and, in Study 2, 93.1% of participants had an SP. In Study 1, whole plan scores were not associated with subsequent psychiatric hospitalization status, but higher Step 2 (internal coping) fidelity scores were associated with decreased likelihood of rehospitalization (AHR = 0.05, 95% CI [0.30, 0.84], p = .008). In Study 2, higher whole-plan quality (AHR = 0.79, 95% CI [0.66, 0.95], p = .012) and fidelity (AHR = 0.84, 95% CI [0.71, 0.99], p = .040) scores were associated with a decreased likelihood of future suicide attempt. Step 1 (warning signs) quality (HR = 0.48, 95% CI [0.30, 0.76], p = .002) and fidelity scores (AHR = 0.57, 95% CI [0.37, 0.90], p = .016) were associated with a decreased likelihood of future suicide attempt. The association of SP characteristics differs by outcome of interest, and fidelity of internal coping strategies may contribute to preventing rehospitalizations, whereas quality and fidelity of warning signs may help prevent future suicide attempts. Overall, results suggest that mandating SPs without training and implementation strategies to ensure quality is not enough.

Psychiatric diagnoses, somatic disorders, and emergency dispatches among individuals who used a national suicide crisis line

Crisis line responders initiate emergency dispatches by activating 911 or other local emergency services when individuals are determined to be at imminent risk for undesired outcomes. This study examined the association of characteristics, psychiatric diagnoses, and somatic symptoms with emergency dispatches in a national sample. Veterans Crisis Line data were used to identify contacts (i.e., calls, texts, chats, emails) that were linked with medical records and had a medical encounter in the year prior to contact. Hierarchical logistic regression clustered by responders was used to identify the association among demographics, psychiatric diagnoses, and somatic disorders, and emergency dispatches. Analyses examined 247,340 contacts from 2017 to 2020, with 27,005 (10.9%) emergency dispatches. Odds of an emergency dispatch increased with each diagnosis (three diagnoses Adjusted Odds Ratio [AOR] (95% CI) = 1.88 [1.81,1.95]). Odds were highest among individuals with substance use disorders (SUD) (alcohol AOR (95% CI) = 1.85 [1.80,1.91]; drugs AOR (95% CI) = 1.63 [1.58, 1.68]), which may be a result of intoxication or overdose during contact, requiring further research. Having more psychiatric and somatic conditions was associated with greater odds of an emergency dispatch, indicating that comorbidity contributed to the need for acute care.

Lessons Learned From Implementing a Caring Contacts Clinical Practice Guideline Recommendation

The U.S. Department of Veterans Affairs (VA) and Department of Defense clinical practice guideline on the treatment of veterans at risk for suicide recommends considering caring contacts interventions after a psychiatric hospitalization for suicidal ideation or suicide attempt. This quality improvement project examined the implementation of the recommendation at a large VA health care system. The project enrolled 29% of hospitalized veterans (N=135 of 462). Enrollment barriers included lack of staff availability and veteran ineligibility due to homelessness or housing instability. Opportunities to improve the reach of the intervention in future quality improvement processes are discussed, especially because acceptability of the intervention was high among veterans.

A Paucity of Data on Veterans 65 and Older and Risk of Suicide: A Systematic Review

Older veterans are vastly underrepresented in studies that shape national suicide prevention strategies. This is of great concern because factors that impact younger veterans may not be as robust in later life. Although younger veterans have higher rate of suicide, the highest counts of death by suicide are in older veterans. However, it remains unclear from the extant literature what factors may influence increased or decreased risk of late-life suicide in veterans. The objective of this systematic review was to identify risk and protective factors related to suicide outcomes (i.e., ideation, attempt, death, or suicide-related behavior [SRB]) among older veterans. Furthermore, it offers data regarding future study directions and hypothesis generation for late-life suicide research and for informing potential intervention and prevention efforts in this area. We searched 4 databases from inception up to May 5, 2022. We screened 2,388 abstracts for inclusion and 508 articles required full text review. The final sample included 19 studies published between 2006 and 2022. We found five domains of factors studied (i.e., neuropsychiatric, social determinants of health, aging stereotypes, residential and supportive housing settings, and multifactorial-neuropsychiatric/mental health and physical health) with more risk factors than protective factors reported. Across the three suicide outcomes only neuropsychiatric factors were consistently identified as risk factors. Neuropsychiatric factors also comprised the largest group of risk factors studied. More innovative targets to consider for intervention and more innovative methods to predict suicide in late-life are needed. There is also continued necessity to design suicide prevention interventions for older veterans given lethality trends.

Encouraging the use of the Veterans Crisis Line among high-risk Veterans: A randomized trial of a Crisis Line Facilitation intervention

The Veterans Crisis Line (VCL) is a core component of VA's suicide prevention strategy. Despite the availability and utility of the VCL, many Veterans do not utilize this resource during times of crisis. A brief, psychoeducational behavioral intervention (termed Crisis Line Facilitation [CLF]) was developed to increase utilization of the VCL and reduce suicidal behaviors in high-risk Veterans. The therapist-led session includes educational information regarding the VCL, as well as a chance to discuss the participant's perceptions of contacting the VCL during periods of crisis. The final component of the session is a practice call placed to the VCL by both the therapist and the participant. The CLF intervention was compared to Enhanced Usual Care (EUC) during a multi-site randomized clinical trial for 307 Veteran participants recently hospitalized for a suicidal crisis who reported no contact with the VCL in the prior 12 months. Initial analyses indicated that participants randomized to the CLF intervention were less likely to report suicidal behaviors, including suicide attempts compared to participants randomized to receive EUC over 12-months of follow-up (χ² = 18.48/p < 0.0001), however this effect was not sustained when analyses were conducted on an individual level. No significant differences were found between conditions on VCL utilization. Initial evidence suggests a brief CLF intervention has an impact on preventing suicidal behaviors in Veterans treated in inpatient mental health programs; however, it may not change use of the VCL. This brief intervention could be easily adapted into clinical settings to be delivered by standard clinical staff.

Spreading a Strategy to Prevent Suicide After Psychiatric Hospitalization: Results of a Quality Improvement Spread Initiative

BACKGROUND

Suicide after psychiatric hospitalization is a major concern. Poor treatment engagement may contribute to risk. The World Health Organization Brief Intervention and Contact (BIC) Program is an evidence-based practice shown to prevent suicide after psychiatric discharge in international trials. There have been no efforts to implement BIC into routine practice in US populations.

METHODS

The authors conducted a 12-month quality improvement (QI) collaborative at six US Department of Veterans Affairs (VA) medical centers serving a large rural population. Sites had low to moderate performance on a VA quality measure of mental health postdischarge care; a measure assessing the proportion of discharged patients who achieve the required number of visits ≤ 30 days. Sites received programmatic support to implement BIC locally. Implementation was assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework.

RESULTS

Overall, teams had high participation in programmatic activities and enrolled 85% of eligible patients that they approached. Among 70 enrolled patients, 81.4% achieved the VA quality measure of mental health postdischarge care, suggesting good treatment engagement. On average, patients rated BIC as excellent. Team members agreed that BIC was easy to use, implementable, possible, and doable. Factors facilitating implementation included standardized operating procedures to standardize processes. Barriers included insufficient staffing and loss to follow-up. Most sites plan to continue to enroll patients and to expand BIC to other areas.

CONCLUSION

A QI collaborative can facilitate implementation of BIC in six VA facilities that provide inpatient psychiatric treatment. BIC may appeal to patients and providers and may improve treatment engagement.

Association between post-traumatic stress disorder severity and death by suicide in US military veterans: retrospective cohort study

BACKGROUND

There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality.

AIMS

This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality.

METHOD

Retrospective study that included all US Department of Veterans Affairs (VA) patients with a PTSD diagnosis and at least one symptom severity assessment using the PTSD Checklist (PCL) between 1 October 1999 and 31 December 2018 (n = 754 197). We performed multivariable proportional hazards regression models using exposure groups defined by level of PTSD symptom severity to estimate suicide mortality rates. For patients with multiple PCL scores, we performed additional models using exposure groups defined by level of change in PTSD symptom severity. We assessed suicide mortality using the VA/Department of Defense Mortality Data Repository.

RESULTS

Any level of PTSD symptoms above the minimum threshold for symptomatic remission (i.e. PCL score >18) was associated with double the suicide mortality rate at 1 month after assessment. This relationship decreased over time but patients with moderate to high symptoms continued to have elevated suicide rates. Worsening PTSD symptoms were associated with a 25% higher long-term suicide mortality rate. Among patients with improved PTSD symptoms, those with symptomatic remission had a substantial and sustained reduction in the suicide rate compared with those without symptomatic remission (HR = 0.56; 95% CI 0.37-0.88).

CONCLUSIONS

Ameliorating PTSD can reduce risk of suicide mortality, but patients must achieve symptomatic remission to attain this benefit.

Suicidal Depression in Ancient Egypt

OBJECTIVE

To evaluate the oldest record of a depressed individual contemplating suicide.

METHOD

A directed review of ancient Egyptology literature of translations and discussion regarding a papyrus that is approximately 4,000 years old.

RESULTS

The content of the document is consistent with a man going through a severe depression and is contemplating suicide. However, this does not appear to be a suicide note, but more of an ancient example of 'journaling' or working through the thoughts of suicide and its possible consequences to the man's eternal life in the afterworld.

CONCLUSIONS

Presentation of depression, the reasons for considering suicide, and the process by which an individual works through those thoughts have not varied significantly over the past 4,000 years.

Veterans Crisis Line Call Outcomes: Distress, Suicidal Ideation, and Suicidal Urgency

INTRODUCTION

This study evaluates the effectiveness of the Veterans Crisis Line on immediate call outcomes (i.e., caller distress, suicidal ideation, and suicidal urgency) for veterans who provide identifying information.

METHODS

Coders rated pre- and post-distress, suicidal ideation, and suicidal urgency for 647 calls from 2019 veteran callers. Intraclass correlation coefficients examined inter-rater reliability. Multilevel generalized linear modeling examined pre-post changes.

RESULTS

Inter-rater reliability was good for distress, excellent for suicidal ideation, and fair for urgency. Callers had 5 times greater odds of a reduction in distress (AOR=5.03, 95% CI=3.98, 6.49), almost 5 times greater odds of a reduction in suicidal ideation (AOR=4.92, 95% CI=3.49, 6.94), and 11 times greater odds of a reduction in suicidal urgency (AOR=11.01, 95% CI=2.72, 44.50) at the end of calls than at the beginning.

CONCLUSIONS

Veterans Crisis Line callers who provide identifying information experience reductions in distress and suicidal ideation during the call. Research is needed to examine the reduction in suicidal urgency because of fair reliability, generalizability of results to other callers, post-call treatment contact and engagement, and risk for suicide attempts and death.

Suicide among Veterans receiving Veterans Health Administration Home Based Primary Care and following discharge from Community Living Centers

INTRODUCTION

Veterans who receive Veterans Health Administration (VHA) Home Based Primary Care (HBPC) services and those discharged from VHA Community Living Centers (CLC) may be at increased risk of suicide. No studies to date have assessed suicide risks among HBPC patients. This study examined suicide risks among recipients of VHA HBPC services and following discharge from VHA CLCs, as compared to other Veteran VHA users.

METHODS

We identified three cohorts of 2013 Veteran VHA patients: 47,842 HBPC users, 17,725 with live discharges from CLCs, and 5,554,635 other VHA users. Using proportional hazards regression, we assessed risk of suicide through 2016.

RESULTS

Overall, HBPC recipients did not differ from the other cohorts in suicide risk. Although in unadjusted analyses CLC discharged patients had greater suicide risk than the general VHA patient cohort (hazard ratio (HR) = 1.73, 95% confidence interval = 1.25-2.41), this became nonsignificant when controlling for diagnoses.

CONCLUSIONS

Overall findings did not identify differential suicide risk among VHA HBPC recipients in 2013, when compared to other Veteran VHA patient cohorts. Veterans discharged from VHA CLCs have increased mental health morbidity, which was associated with increased suicide risk.

Stress Disorders and the Risk of Nonfatal Suicide Attempts in the Danish Population

Accurate documentation of the associations between stress disorders and suicide attempts provides important information about a high-risk population and target group for preventative interventions. In this case-cohort study, cases were all individuals born or residing in Denmark who made a nonfatal suicide attempt during 1995-2015 (n = 22,974). The comparison subcohort included a 5% random sample of the Danish population on January 1, 1995 (n = 265,183). Stress disorder diagnoses and suicide attempts were identified using ICD-10 codes from national medical registries. The presence of any stress disorder substantially increased the rate of suicide attempts versus the comparison subcohort, rate per 100,000 person-years (PYs) = 604 vs. 13. We observed associations between each type of stress disorder and suicide attempts, hazard ratios (HRs) = 10.1-37.6, even after adjustment for potential confounders, adjusted HRs = 1.8-8.3, with the strongest associations for adjustment disorder relative to other diagnoses. After adjusting for demographic and health variables, the rate of suicide attempts among individuals with any stress disorder diagnosis was nearly 13 times the suicide attempt rate in the comparison cohort. A bias analysis demonstrated that associations remained robust despite potential differential misclassification of suicide attempts. Study strengths included the use of individual-level data linked across administrative and medical registries in the setting of universal health care and the use of longitudinal analyses capturing data over 20 years. The study demonstrated associations between the full range of stress disorders and suicide attempts, extending research specific to posttraumatic stress disorder.

Suicide and Seizures: A National Cohort Study in Veterans

Objective

The increased rate of suicide associated with epilepsy has been described, but no studies have reported the rates of suicide and suicide-related behavior (SRB) associated with psychogenic nonepileptic seizures (PNESs).

Methods

This retrospective cohort study analyzed data from October 2002 to October 2017 within Veterans Health Administration services. Of 801,734 veterans, 0.09% had PNES, 1.37% had epilepsy, and 98.5% had no documented seizures. Veterans coded for completed suicide, suicide attempts, and suicidal ideation were identified from electronic health records. The primary measure was the suicide-specific standardized mortality ratio (SMR) based on the number of suicide deaths and CDC national suicide mortality database. A Poisson regression was used to calculate the relative risk (RR) of suicide across groups.

Results

A total of 1,870 veterans (mean age [SD] 33.76 [7.81] years) completed suicide. Veterans with PNES (RR = 1.75, 95% confidence interval [CI] 0.84-4.24) and veterans with epilepsy (RR = 2.19, 95% CI 2.10-2.28) had a higher risk of suicide compared with the general veteran population. Veterans with PNES or epilepsy had a higher risk of suicide and SRB if they had comorbid alcohol abuse, illicit drug abuse, major depression, posttraumatic stress disorder, and use of psychotropic medications. Conversely, those who were married or attained higher education were at a decreased risk. The SMR for completed suicide for PNES, epilepsy, and the comparison group was 2.65 (95% CI 1.95-5.52), 2.04 (95% CI 1.60-2.55), and 0.70 (95% CI 0.67-0.74), respectively.

Conclusions

Veterans with seizures (both psychogenic and epileptic) are at a greater risk of death by suicide and SRB than the comparison group. These findings suggest that although the pathophysiology of PNES and epilepsy is different, the negative impact of seizures is evident in the psychosocial outcomes in both groups.

A comorbid mental disorder paradox: Using causal diagrams to understand associations between posttraumatic stress disorder and suicide

OBJECTIVE

Although some studies document that posttraumatic stress disorder (PTSD) increases suicide risk, other studies have produced the paradoxical finding that PTSD decreases suicide risk. We sought to understand methodologic biases that may explain these paradoxical findings through the use of directed acyclic graphs (DAGs).

METHOD

DAGs are causal diagrams that visually encode a researcher's assumptions about data generating mechanisms and assumed causal relations among variables. DAGs can connect theories to data and guide statistical choices made in study design and analysis. In this article, we describe DAGs and explain how they can be used to identify biases that may arise from inappropriate analytic decisions and data limitations.

RESULTS

We define a particular form of bias, collider bias, that is a likely explanation for why studies have found a supposedly protective association of PTSD with suicide. This protective association is interpreted by some researchers as evidence that PTSD reduces the risk of suicide. Collider bias may occur through inappropriate adjustment for a psychiatric comorbidity, such as adjustment for variables that are affected by PTSD and share common causes with suicide.

CONCLUSIONS

We recommend that researchers collect longitudinal measurements of psychiatric comorbidities, which would help establish the temporal ordering of variables and avoid the biases discussed in this article. Furthermore, researchers could use DAGs to explore how results may be impacted by design and analytic decisions prior to execution. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Temporal sequences of suicidal and nonsuicidal self-injurious thoughts and behaviors among inpatient and community-residing military veterans

BACKGROUND

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) are major health concerns among military veterans yet little is known about the temporal relations among these outcomes. This study examined the temporal relations between suicidal and nonsuicidal SITBs among higher-risk veterans. Specifically, we identified when SITBs emerged and evaluated the role of nonsuicidal self-injury (NSSI) in the medical lethality of suicide attempts (SA), relative risk, and survival time of suicidal SITBs (i.e., suicide ideation [SI], suicide plan, SA).

METHOD

Cross-sectional data were collected from two samples examining suicide risk among veterans receiving inpatient psychiatric care (n = 157) and community-residing veterans with current depression and/or past month SI (n = 200). Participants completed an interview to assess SITBs.

RESULTS

SITBs emerged between ages 14-28 years with behaviors emerging, on average, earlier among inpatient veterans. The time lag between SITBs was not significantly different between groups. Inpatient veterans had a significantly shorter time lag from SI to SA. NSSI history predicted an increase in relative risk for all suicidal SITBs and shorter survival time. There was no association between NSSI history and medical lethality of the most serious SA for both groups.

LIMITATIONS

Limitations included use of cross-sectional, retrospective self-report with age-of-onset endorsed in years and not all SITBs were assessed (e.g., passive SI).

CONCLUSIONS

Veterans with a NSSI history are at high risk for suicidal SITBs and have a shorter survival time. Results showed thoughts (i.e., NSSI thoughts, SI) emerged before behavior (i.e., NSSI, SA) and NSSI emerged before SA.

Shorter and longer-term risk for non-fatal suicide attempts among male U.S. military veterans after discharge from psychiatric hospitalization

Although there are key differences in shorter-term (days 1-90) and longer-term (days 91-365) risk factors for suicide after discharge from inpatient psychiatry, there are no comparable data on non-fatal suicide attempts. Risk factors for non-fatal attempts in the first 90 days after discharge were compared with those over the remainder of the year to identify temporal changes in risk. Records were extracted from 208,554 male veterans discharged from Veterans Health Administration acute psychiatric inpatient units from 2008 through 2013. Proportional hazard regression models identified correlates of non-fatal attempts for 1-90 days and 91-365 days; adjusted piecewise proportional hazards regression compared risk between these time frames. 5010 (2.4%) veterans made a non-fatal attempt, 1261 (0.60%) on days 1-90 and 3749 (1.78%) on days 91-365. Risk across both time frames was highest among younger veterans ages 18-59, and those hospitalized with a suicide attempt or suicidal ideation. It was lowest among those with a dementia diagnosis. Risk estimates were generally stable over time but increased among those with substance use disorders and decreased among those with sleep disturbance and discharged against medical advice. Estimates of some risk factors for non-fatal attempts change over time in the year after discharge and differ from those that change for suicide. Different preventive approaches may be needed to reduce shorter and longer-term risk for non-fatal attempts and suicide in the year after discharge.

Developing and testing Crisis Line Facilitation (CLF) to encourage help-seeking in adults receiving inpatient treatment for a suicidal crisis

Military Veterans are at overall greater risk of suicide than non-Veterans and have experienced increases in rates of suicide that are on par with or exceed those of the general population. The Department of Veterans Affairs has undertaken several initiatives to reduce suicide among Veterans, including the development and expansion of the Veterans Crisis Line (VCL). The VCL has the potential to reduce suicidal behaviors, but it is likely underutilized by high-risk Veterans. This paper describes the development of Crisis Line Facilitation (CLF) a brief intervention, designed to increase use of the VCL in this high-risk population. In a single session, CLF presents psychoeducational information about the VCL, discusses the participant's perceived barriers and facilitators to future use of the VCL, and culminates in the Veteran calling the VCL with the therapist to provide firsthand experiences that may counter negative impressions of the line. The intervention development process, intervention and control condition, and self-reported change indices are presented. Preliminary results (N = 301) suggest Veterans receiving CLF may experience a significant increase in comfort with, and confidence in, using the VCL during future crises compared to those in the control condition.

Suicide risk in people with post-traumatic stress disorder: A cohort study of 3.1 million people in Sweden

BACKGROUND

It is unclear whether post-traumatic stress disorder [PTSD] is associated with suicide risk in the general population, whether this differs by sex, or what the population impact of PTSD is for suicide.

METHODS

We constructed a nationwide cohort of all people living in Sweden, born 1973-1997, followed from their 14th birthday (or immigration, if later) until suicide, other death, emigration or 31 December 2016. We used Cox proportional hazards regression to estimate hazard ratios [HR], and calculated the population impact of PTSD on suicide. We included sensitivity analyses to explore effects of outcome and exposure definitions, and to account for potential competing risks.

RESULTS

Of 3,177,706 participants, 22,361 (0•7%) were diagnosed with PTSD, and 6,319 (0•2%) died by suicide over 49•2 million person-years. Compared with women and men without PTSD, suicide rates were 6•74 (95%CI: 5•61-8•09) and 3•96 (95%CI: 3•12-5•03) times higher in those with PTSD, respectively, after sociodemographic adjustment. Suicide rates remained elevated in women (HR: 2•61; 95%CI: 2•16-3•14) and men (HR: 1•67; 95%CI: 1•31-2•12) after adjustment for previous psychiatric conditions; attenuation was driven by previous non-fatal suicide attempts. Findings were insensitive to definitions or competing risks. If causal, 1•6% (95%CI: 1•2-2•1) of general population suicides could be attributed to PTSD, and up to 53.7% (95%CI: 46.1-60.2) in people with PTSD.

LIMITATIONS

Residual confounding remains possible due to depressive and anxiety disorders diagnosed in primary care but unrecorded in these registers.

CONCLUSIONS

Clinical guidelines for the management of people with PTSD should recognise increased suicide risks.

The Living Ladder: Introduction and Validity Over 6-Month Follow-Up of a One-Item Measure of Readiness to Continue Living in Suicidal Patients

OBJECTIVE

The ability to predict suicide outcomes is limited by the lack of consideration of protective factors. This study examined the validity of the Living Ladder, a measure of readiness to continue living among individuals thinking of suicide.

METHODS

The Living Ladder consists of one item that assesses an individual's readiness to continue living when thinking about suicide. Participants (N = 130) completed the Living Ladder in-person at baseline and by-phone at 1-, 3-, and 6-month follow-up. The prospective association of the Living Ladder with suicidal ideation and risk for a suicide attempt was examined using models adjusting for baseline ideation and suicide attempts, respectively.

RESULTS

Each rung on the Living Ladder was associated with 18% lower likelihood of suicidal ideation, OR (95% CI) = 0.82 (0.68, 0.96), and less severe suicidal ideation among those with ideation. Scores >2, indicating contemplation of living, were associated with 64% lower risk for a suicide attempt, HR (95% CI) = 0.36 (0.13, 0.98). Findings for suicidal ideation were replicated when administered by-phone.

CONCLUSIONS

The Living Ladder is a one-item measure that is prospectively associated with suicidal ideation and suicide attempts. Findings support the relevance of motivation to live to suicide outcomes.

Association Between Positive Results on the Primary Care-Posttraumatic Stress Disorder Screen and Suicide Mortality Among US Veterans

IMPORTANCE

Suicide rates are higher among veterans compared with nonveterans, and the prevalence of posttraumatic stress disorder (PTSD) is higher among veterans compared with the general adult population in the US. To date, no study has examined the association between PTSD screening results and suicide mortality among veterans.

OBJECTIVE

To examine whether veterans receiving care in the US Veterans Health Administration (VHA) health system who had positive results on the Primary Care-Posttraumatic Stress Disorder Screen (PC-PTSD) had a greater risk of suicide mortality compared with those who had negative results and to assess whether such risk decreased over time.

DESIGN, SETTING, AND PARTICIPANTS

Multivariable proportional hazards regression models were used to evaluate suicide mortality risk through December 31, 2016, among a cohort of veterans who received the PC-PTSD in the VHA health system. The VHA administers the PC-PTSD to patients nationwide, and screening results are routinely documented in the VHA Corporate Data Warehouse. The PC-PTSD includes 4 questions regarding PTSD symptoms, to which patients respond with either a positive (yes) or negative (no) answer. All patients who completed the PC-PTSD in 2014 and who did not have a diagnosis of PTSD in the year before screening were included in the analysis. A score of 3 or 4 on the PC-PTSD indicated a positive result, and a score of 0, 1, or 2 indicated a negative result. Data collection and analyses were performed from November 13, 2018, to June 18, 2019.

EXPOSURES

Primary Care-Posttraumatic Stress Disorder Screen (PC-PTSD).

MAIN OUTCOMES AND MEASURES

Suicide mortality risk, as assessed through data obtained from the US Veterans Affairs/Department of Defense Mortality Data Repository.

RESULTS

A total of 1 693 449 PC-PTSDs were completed by 1 552 581 individual veteran patients in 2014. Most of the patients were White (73.9%), married (52.2%), male (91.1%), 55 years or older (62.5%), and had completed only 1 PC-PTSD (92.1%). In multivariable analyses, positive PC-PTSD results (ie, total scores of 3 or 4) were associated with a 58% increase in the risk of suicide mortality at 1 day after screening (hazard ratio [HR], 1.58; 95% CI, 1.19-2.10) and a 26% increase in the risk of suicide mortality at 1 year after screening (HR, 1.26; 95% CI, 1.07-1.48). A positive response on item 4 ("felt numb or detached from others, activities, or your surroundings") of the PC-PTSD was associated with a 70% increase in suicide mortality risk at 1 day after screening (HR, 1.70; 95% CI, 1.27-2.28).

CONCLUSIONS AND RELEVANCE

Positive PC-PTSD results, and specifically reports of feeling numb or detached, were associated with increases in the risk of suicide mortality. These associations decreased over time. The findings of this study can inform interpretation of PC-PTSD responses and suggest the importance of recent improvements made to the VHA suicide risk assessment.

A call to action to address rural mental health disparities

Rural residents in the USA experience significant disparities in mental health outcomes even though the prevalence of mental illness in rural and metropolitan areas is similar. This is a persistent problem that requires innovative approaches to resolve. Adopting and appropriately modifying the National Institute on Minority Health and Health Disparities research framework are the potential approaches to understanding how these disparities might be addressed through research. Using this research framework can facilitate interrogation of multiple levels of influence, encompassing complex domains of influence and consideration of the entire life course trajectory, which is consistent with several National Institute of Mental Health priorities.

Motivational Interviewing to Address Suicidal Ideation: A Randomized Controlled Trial in Veterans

OBJECTIVE

Although the months following discharge from psychiatric hospitalization are a period of acute risk for veterans, there is a dearth of empirically supported treatments tailored to veterans in acute psychiatric hospitalization.

METHOD

We conducted a randomized controlled trial to test the efficacy of Motivational Interviewing to Address Suicidal Ideation (MI-SI) that explored and resolved ambivalence, and a revised MI-SI (MI-SI-R) that resolved ambivalence, on suicidal ideation (SI) in hospitalized veterans who scored > 2 on the Scale for Suicidal Ideation. Participants were randomized to receive MI-SI plus treatment as usual (TAU), MI-SI-R+TAU, or TAU alone. MI-SI+TAU and MI-SI-R+TAU included two in-hospital therapy sessions and one telephone booster session. Participants completed follow-up assessments over 6 months.

RESULTS

Participants in all groups experienced reductions in the presence and severity of SI, but there were no significant differences among the groups. For the presence of SI, results were in the hypothesized direction for both MI-SI+TAU conditions.

CONCLUSIONS

Results are nondefinitive, but the effect size of both versions of MI-SI+TAU on the presence of SI was consistent with prior MI findings. Exploratory analyses suggest MI-SI-R may be preferable to MI-SI. More intensive MI-SI-R with a greater number of follow-ups may increase its effectiveness.

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

A Pilot Study of an Intervention to Prevent Suicide After Psychiatric Hospitalization

A prior meta-analysis found that the World Health Organization Brief Intervention and Contact Program (WHO BIC) significantly reduces suicide risk. WHO BIC has not been studied in high-income countries. We piloted an adapted version of WHO BIC on an inpatient mental health unit in the United States. We assessed the feasibility and acceptability. We also evaluated changes in suicidal ideation, hopelessness, and connectedness using a repeated measures analysis of variance. Of 13 eligible patients, 9 patients enrolled. Patients experienced significant improvements in suicidal ideation, hopelessness, and connectedness at 1 and 3 months (Beck Scale for Suicidal Ideation, F(2,16) = 14.96, p < 0.01; Beck Hopelessness Scale, F(2,16) = 5.88, p < 0.05; perceived burdensomeness subscale, F(2,16) = 10.97, p < 0.013; and thwarted belongingness subscale, F(2,16) = 4.77, p < 0.03). Patients were highly satisfied. An adapted version of WHO BIC may be feasible to implement in a high-resource setting, but trials need to confirm efficacy.

Ten-Year Trend and Correlates of Reported Posttraumatic Stress Disorder among Young Male Veteran Suicide Decedents-Results from the National Violent Death Reporting System, 16 U.S. States, 2005-2014

OBJECTIVE

This study examined trends and correlates of reported post-traumatic stress disorder (PTSD) among young male Veteran suicide decedents, using data from the National Violent Death Reporting System from 2005-2014 on 1,362 male U.S. Veteran suicide decedents aged 18-34 years.

METHODS

Prevalence of reported PTSD (i.e., diagnosis/symptoms) was determined by mental health diagnostic fields and narratives and examined by year. Demographic, incident, and precipitating circumstance characteristics correlated with reported PTSD were identified.

RESULTS

One-hundred ninety-eight (15%) decedents had PTSD evidence. A 30-fold increase in reported PTSD prevalence occurred among decedents aged 25-34 years; however, no increase was observed among younger decedents. Reported PTSD was associated with past deployments (odds ratio (OR): 14.5, 95% confidence interval (95% CI): 9.0-23.4); depression (OR: 1.8, 95% CI: 1.2-2.6); and divorce (OR: 1.7, 95% CI: 1.0-2.7). Recent crisis (OR: 0.6, 95% CI: 0.3-0.9) was inversely associated with reported PTSD.

CONCLUSIONS

Reported PTSD prevalence substantially increased among Veteran suicide decedents aged 25-34 years suggesting it is beginning to play a larger role in suicide for this group. Few correlated suicide risk factors were found, suggesting that if symptoms of PTSD are present, heightened vigilance by providers for suicide risk might be warranted, irrespective of evidence of other risk factors.

Re-Thinking Ethics and Politics in Suicide Prevention: Bringing Narrative Ideas into Dialogue with Critical Suicide Studies

The purpose of this paper is to explore the conviviality between practices of narrative therapy and the emerging field of critical suicide studies. Bringing together ideas from narrative therapy and critical suicide studies allows us to analyze current suicide prevention practices from a new vantage point and offers us the chance to consider how narrative therapy might be applied in new and different contexts, thus extending narrative therapy’s potential and possibilities. We expose some of the thin, singular, biomedical descriptions of the problem of suicide that are currently in circulation and attend to the potential effects on distressed persons, communities, and therapists/practitioners who are all operating under the influence of these dominant understandings. We identify some cracks in the dominant storyline to enable alternative descriptions and subjugated knowledges to emerge in order to bring our suicide prevention practices more into alignment with a de-colonizing, social justice orientation.

Reduction of Postdischarge Suicidal Behavior Among Adolescents Through a Telephone-Based Intervention

OBJECTIVE

Brief telephone follow-up for a patient with suicidal tendencies after he or she has been discharged from an emergency room or hospital has been shown to decrease subsequent suicide attempts. However, despite the high rate of suicidal behavior in adolescents, this intervention has not been examined in this population. As part of a quality improvement intervention, postdischarge telephone contacts were used to attempt to reduce suicidal behavior and inpatient rehospitalizations among adolescents.

METHODS

Adolescents who were hospitalized for suicidal ideation or attempt (N=142) were randomly assigned to one of two telephone interventions delivered over a 90-day period: either a single call intervention (SCI) or a multiple calls intervention (MCI). The intervention consisted of assessment of suicidality, review of safety plan, and discussion of medication and weapon safety, with up to six telephone contacts in the MCI and up to one contact in the SCI. Primary outcome measures included suicidal behavior and inpatient rehospitalizations; secondary outcome measures included adolescents' confidence in their safety plan.

RESULTS

Adolescents receiving the MCI had a significantly lower rate of suicidal behavior (6%) compared with adolescents receiving SCI (17%; odds ratio [OR]=0.28, p=0.037); results persisted while the analysis controlled for relevant covariates (OR=0.25, p=0.032). Similarly, adolescents receiving the MCI reported significantly greater confidence in their safety plan at 90 days (95%vs. 74%; p=0.001), which, in turn, was associated with a lower rate of suicidal behavior (OR=0.95, p=0.019).

CONCLUSIONS

A telephone-based intervention for providing recurrent follow-up soon after discharge is feasible in the adolescent population and may be effective in reducing postdischarge suicidal behavior.

Critical Periods for Increased Mortality After Discharge From Inpatient Mental Health Units: Opportunities for Prevention

OBJECTIVE

Studies of patients in the U.S. Department of Veterans Affairs (VA) health system and elsewhere have documented elevated mortality from suicide during a critical period within 30 to 90 days after discharge from inpatient mental health units. To support program planning, VA evaluated whether the elevated mortality during this critical period was specific to suicide or whether there were similar increases in other causes of death.

METHODS

Indicators of age, gender, inpatient diagnoses, and suicide attempts and ideation from VA records were combined with indicators of vital status and cause of death from the National Death Index. Analyses compared all-cause and cause-specific mortality in the first 30 and 90 days postdischarge with mortality in days 91 to 365 after discharge for the 106,430 VA patients discharged from inpatient mental health units in 2013-2014.

RESULTS

Elevated mortality during the first 30 and first 90 days after discharge was not specific to suicide. Higher rates of all-cause mortality were noted, including elevated mortality due to external causes other than suicide among young and middle-aged patients (ages 18-64) during the first 30 days and among older patients (≥65) during the first 90 days. An increase in natural-cause mortality among older patients was attributable to greater mortality among those with dementia diagnoses.

CONCLUSIONS

Elevated rates of nonsuicide external-cause mortality in the critical period within 30 to 90 days after discharge from inpatient mental health care suggest important opportunities for prevention. Greater mortality among patients with dementia or related neurodegenerative diseases raises questions regarding current strategies for managing behavioral symptoms and transitions to end-of-life care.

Posttraumatic Stress Disorder and Death From Suicide

PURPOSE OF REVIEW

This review summarizes the increasing public health concern about PTSD and suicide, and the population-based studies that have examined this association. Further, we discuss methodological issues that provide important context for the examination of this association.

RECENT FINDINGS

The majority of epidemiologic studies have shown that PTSD is associated with an increased risk of suicide; however, a notable minority of studies have documented a decreased risk of suicide among persons with PTSD. Methodological (e.g., sample size and misclassification) and etiologic issues (e.g., complicated psychiatric comorbidity) may explain the conflicting evidence. PTSD may be associated with an increased risk of suicide, but further research is needed. Increasing the use of appropriate methods (e.g., marginal structural models that can evaluate both confounding and effect modification, machine learning methods, quantification of systematic error) will strengthen the evidence base and advance our understanding.

Is Suicidal Behavior in Mood Disorders Altered by Comorbid PTSD?

BACKGROUND

Suicide is a leading cause of death among US veterans. Associations between depression, posttraumatic stress disorder (PTSD), and suicidal behaviors have been found in this population, yet minimal research has explored how manifestations of self-injurious behavior (SIB) may vary among different diagnostic presentations.

AIMS

This study aimed to identify clinically useful differences in SIB among veterans who experience comorbid mood disorder and PTSD (CMP) compared with those who experience a mood disorder alone (MDA).

METHOD

Participants were 57 US military veterans who reported an incident of intentional SIB. The semistructured Post Self-Injury/Attempted Self-Injury Debriefing Interview was used to examine characteristics of the SIB.

RESULTS

Veterans diagnosed with CMP were more likely than those with MDA to (a) report that the SIB was impulsive and (b) to be under the influence of substances at the time of self-injury.

LIMITATIONS

Generalizability may be limited by small sample size and predominantly European American, male demographics. While highly relevant to routine clinical practice, caution is recommended, as study diagnoses were attained from medical records rather than structured interviews.

CONCLUSION

Safety planning that emphasizes protection against impulsive suicide attempts (e.g., means restriction) may be especially important among veterans with comorbid mood disorder and PTSD.