Characteristics and Injury Mechanisms of Veteran Primary Care Suicide Decedents with and without Diagnosed Mental Illness

Prospective comparison of risk factors for firearm suicide and non-firearm suicide in a large population-based cohort of current and former US service members: findings from the Millennium Cohort Study

Background

Suicide is a leading cause of death among service members and veterans. Among suicide methods, firearms are the most lethal and commonly used method among military populations. Limited research has compared risk factors for the various suicide methods. This study evaluated and compared risk factors for firearm versus non-firearm suicides using data from the Millennium Cohort Study, a large longitudinal military cohort.

Methods

Using a competing risk approach, we identified factors associated with each suicide method. Risk factors included demographics, mental health diagnoses, mental health symptoms, military-specific characteristics, health behaviors, and psychosocial factors. Cause of death was assessed from July 1, 2001, through December 31, 2018.

Findings

Among 201,565 eligible participants with a mean [SD] age of 29.0 [58.1] years, there were 139,789 (69.3%) male, 61,776 (30.7%) female, 15,927 (7.9%) Hispanic, 24,667 (12.3%) non-Hispanic Black, 14,138 (7.0%) Asian, Pacific Islander, American Indian or Multiracial, and 146,736 (72.8%) non-Hispanic White participants. During the study period, 330 died by firearm suicide and 168 died by non-firearm suicide. Overall, effect estimates for risk factors were similar across both methods of suicide. After adjustment, men (HR: 3.69, 95% CI: 2.59, 5.24) and those who screened positive for depression (HR: 1.97, 95% CI: 1.36, 2.87) had an elevated risk for firearm suicide. In contrast, those who self-reported a history of bipolar diagnosis (HR: 3.40, 95% CI: 1.76, 6.55) had significantly increased risk for non-firearm suicide.

Interpretation

Findings suggest that prevention and intervention strategies overall may not need to be differentiated by specific demographic, military, or health factors. Targeted interventions that consider sex and mental health screens might have relative utility in preventing firearm related suicide risk compared with non-firearm suicide.

Funding

Military Operational Medicine Research Program, Defense Health Program, and Department of Veterans Affairs.

A Critical Review of Text Mining Applications for Suicide Research

Purpose of Review

Applying text mining to suicide research holds a great deal of promise. In this manuscript, literature from 2019 to 2021 is critically reviewed for text mining projects that use electronic health records, social media data, and death records.

Recent Findings

Text mining has helped identify risk factors for suicide in general and specific populations (e.g., older adults), has been combined with structured variables in EHRs to predict suicide risk, and has been used to track trends in social media suicidal discourse following population level events (e.g., COVID-19, celebrity suicides).

Summary

Future research should utilize text mining along with data linkage methods to capture more complete information on risk factors and outcomes across data sources (e.g., combining death records and EHRs), evaluate effectiveness of NLP-based intervention programs that use suicide risk prediction, establish standards for reporting accuracy of text mining programs to enable comparison across studies, and incorporate implementation science to understand feasibility, acceptability, and technical considerations.

Therapeutic Risk Management and Firearm-related Lethal Means Safety

Safety planning to reduce suicide or other-directed violence risk involves efforts toward "making the environment safe," including working collaboratively with at-risk patients to encourage voluntary changes in their firearm storage decisions [ie, lethal means safety (LMS) counseling]. This column provides a conceptual framework and real-world evidence to support the delivery of LMS counseling to at-risk patients, as well as guidance on asking about firearm access and making individualized safety recommendations. It also reviews important elements related to documenting LMS discussions and legal considerations related to these conversations.

Clinical strategies for reducing firearm suicide

Suicide is complex, with psychiatric, cultural, and socioeconomic roots. Though mental illnesses like depression contribute to risk for suicide, access to lethal means such as firearms is considered a key risk factor for suicide, and half of suicides in the USA are by firearm. When a person at risk of suicide has access to firearms, clinicians have a range of options for intervention. Depending on the patient, the situation, and the access to firearms, counseling on storage practices, temporary transfer of firearms, or further intervention may be appropriate. In the USA, ownership of and access to firearms are common and discussing added risk of access to firearms for those at risk of suicide is not universally practiced. Given the burden of suicide (particularly by firearm) in the USA, the prevalence of firearm access, and the lethality of suicide attempts with firearms, we present the existing evidence on the burden of firearm suicide and what clinicians can do to reduce their patients' risk. Specifically, we review firearm ownership in the USA, firearm injury epidemiology, risk factors for firearm-related harm, and available interventions to reduce patients' risk of firearm injury and death.

Association of mental disorders with firearm suicides: A systematic review with meta-analyses of observational studies in the United States

In the United States (US), 61% of all suicide cases may involve firearms, and some evidence suggests that mental disorders may play a role in suicide by firearm. We performed the first systematic review and meta-analyses to investigate: (i) whether mental disorders are associated with suicide by firearm, and (ii) whether the risk of using a firearm compared with alternative means is associated with higher levels of suicide in individuals with a mental disorder METHODS AND FINDINGS: We searched twelve databases from inception to the 24th of May 2020. We retrieved 22 observational studies conducted in the US. Random-effects meta-analyses showed individuals who had a diagnosis of a mental disorder had lower odds (odds ratios (OR)= 0.50, 95% CI: 0.36 to 0.69; I²=100 (95% CI: 87 to 100%), of dying by suicide with a firearm than those who did not have a diagnosis of a mental disorder. Secondary analysis showed that decedents who had a mental health diagnosis resulted in lower odds of dying by suicide by using firearms than using other means LIMITATIONS: Risk of bias revealed a heterogeneous and poor definition of mental disorders as well as lack of control for potential demographic confounding factors. In the meta-analyses, studies were combined in the same analytic sample as 77% of these studies did not specify the type of mental disorder CONCLUSION: While our results seem to suggest that having a mental disorder may not be consistently associated with the odds of dying by suicide using a firearm, the presence of substantial heterogeneity and high risk of bias precludes any firm conclusions.

Association of Potential for Deaths of Despair With Age and Military Service Era

INTRODUCTION

Predictors of deaths of despair, including substance use disorder, psychological distress, and suicidality, are known to be elevated among young adults and recent military veterans. Limited information is available to distinguish age effects from service-era effects. We assessed these effects on indicators of potential for deaths of despair in a large national sample of U.S. adults aged ≥19 years.

MATERIALS AND METHODS

The study was a retrospective, cross-sectional analysis of publicly available data for 2015-2019 from 201,846 respondents to the National Survey on Drug Use and Health (NSDUH), which measures psychological symptoms and substance use behaviors using standardized scales and diagnostic definitions. Indicators of potential for a death of despair included liver cirrhosis, past-year serious suicidal ideation, serious psychological distress per the Kessler-6 scale, and active substance use disorder (e.g., binge drinking on ≥5 occasions in the past month, nonmedical use of prescribed controlled substances, and illicit drug use). Bivariate, age-stratified bivariate, and multivariate logistic regression analyses were performed using statistical software and tests appropriate for the NSDUH complex sampling design. Covariates included demographic characteristics, chronic conditions, and religious service attendance.

RESULTS

Indicators were strongly and consistently age-associated, with ≥1 indicator experienced by 45.5% of respondents aged 19-25 years and 10.7% of those aged ≥65 years (P < .01). After age stratification, service-era effects were modest and occurred only among adults aged ≥35 years. The largest service-associated increase was among adults aged 35-49 years; service beginning or after 1975 was associated (P < .01), with increased prevalence of ≥1 indicator (30.2%-34.2% for veterans and 25.2% for nonveterans) or ≥2 indicators (6.4%-8.2% for veterans and 5.4% for nonveterans). Covariate-adjusted results were similar, with adjusted probabilities of ≥1 indicator declining steadily with increasing age: among those 19-34 years, 39.9% of nonveterans and 42.2% of Persian Gulf/Afghanistan veterans; among those aged ≥65 years, 10.3% of nonveterans, 9.2% of World War II/Korea veterans, and 14.4% of Vietnam veterans.

CONCLUSIONS

After accounting for age, military service-era effects on potential for a death of despair were modest but discernible. Because underlying causes of deaths of despair may vary by service era (e.g., hostility to Vietnam service experienced by older adults versus environmental exposures in the Persian Gulf and Afghanistan), providers treating veterans of different ages should be sensitive to era-related effects. Findings suggest the importance of querying for symptoms of mental distress and actively engaging affected individuals, veteran or nonveteran, in appropriate treatment to prevent deaths of despair.

Assessment of Rates of Suicide Risk Screening and Prevalence of Positive Screening Results Among US Veterans After Implementation of the Veterans Affairs Suicide Risk Identification Strategy

IMPORTANCE

In 2018, the Veterans Health Administration (VHA) implemented the Veterans Affairs (VA) Suicide Risk Identification Strategy to improve the identification and management of suicide risk among veterans receiving VHA care.

OBJECTIVES

To examine the prevalence of positive suicide screening results among veterans in ambulatory care and emergency departments (EDs) or urgent care clinics (UCCs) and to compare acuity of suicide risk among patients screened in these settings.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the VA's Corporate Data Warehouse (CDW) to assess veterans with at least 1 ambulatory care visit (n = 4 101 685) or ED or UCC visit (n = 1 044 056) at 140 VHA medical centers from October 1, 2018, through September 30, 2019.

EXPOSURES

Standardized suicide risk screening and evaluation tools.

MAIN OUTCOMES AND MEASURES

One-year rate of suicide risk screening and evaluation, prevalence of positive primary and secondary suicide risk screening results, and levels of acute and chronic risk based on the VHA's Comprehensive Suicide Risk Evaluation.

RESULTS

A total of 4 101 685 veterans in ambulatory care settings (mean [SD] age, 62.3 [16.4] years; 3 771 379 [91.9%] male; 2 996 974 [73.1%] White) and 1 044 056 veterans in ED or UCC settings (mean [SD] age, 59.2 [16.2] years; 932 319 [89.3%] male; 688 559 [66.0%] White) received the primary suicide screening. The prevalence of positive suicide screening results was 3.5% for primary screening and 0.4% for secondary screening in ambulatory care and 3.6% for primary screening and 2.1% in secondary screening for ED and UCC settings. Compared with veterans screened in ambulatory care, those screened in the ED or UCC were more likely to endorse suicidal ideation with intent (odds ratio [OR], 4.55; 95% CI, 4.37-4.74; P < .001), specific plan (OR, 3.16; 95% CI, 3.04-3.29; P < .001), and recent suicidal behavior (OR, 1.95; 95% CI, 1.87-2.03; P < .001) during secondary screening. Among the patients who received a Comprehensive Suicide Risk Evaluation, those in ED or UCC settings were more likely than those in ambulatory care settings to be at high acute risk (34.1% vs 8.5%; P < .001).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, population-based suicide risk screening and evaluation in VHA ambulatory care and ED or UCC settings may help identify risk among patients who may not be receiving mental health treatment. Higher acuity of risk among veterans in ED or UCC settings compared with those in ambulatory care settings highlights the importance of scaling up implementation of brief evidence-based interventions in the ED or UCC to reduce suicidal behavior.