Suicidal ideation, behavior, and mortality in male and female US veterans with severe mental illness

Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT) for US Veterans With Serious Mental Illness: Community Engagement Approach

BACKGROUND

Peer specialists are hired, trained, and accredited to share their lived experience of psychiatric illness to support other similar individuals through the recovery process. There are limited data on the role of peer specialists in suicide prevention, including their role in intervention development.

OBJECTIVE

To better understand peer specialists within the Veterans Health Administration (VHA), we followed partnership community engagement and a formative research approach to intervention development to (1) identify barriers, facilitators, and perceptions of VHA peer specialists delivering a suicide prevention service and (2) develop and refine an intervention curriculum based on an evidence-informed preliminary intervention framework for veterans with serious mental illness (SMI).

METHODS

Following the community engagement approach, VHA local and national peer support and mental health leaders, veterans with SMI, and veteran peer specialists met to develop a preliminary intervention framework. Next, VHA peer specialist advisors (n=5) and scientific advisors (n=6) participated in respective advisory boards and met every 2-4 months for more than 18 months via videoconferencing to address study objectives. The process used was a reflexive thematic analysis after each advisory board meeting.

RESULTS

The themes discussed included (1) the desire for suicide prevention training for peer specialists, (2) determining the role of VHA peer specialists in suicide prevention, (3) integration of recovery themes in suicide prevention, and (4) difficulties using safety plans during a crisis. There were no discrepancies in thematic content between advisory boards. Advisor input led to the development of Suicide Prevention by Peers Offering Recovery Tactics (SUPPORT). SUPPORT includes training in general suicide prevention and a peer specialist-delivered intervention for veterans with SMI at an increased suicide risk. This training aims to increase the competence and confidence of peer specialists in suicide prevention and the intervention supports veterans with SMI at an increased suicide risk through their recovery process.

CONCLUSIONS

This paper intends to document the procedures taken in suicide prevention intervention development, specifically those led by peer specialists, and to be a source for future research developing and evaluating similar interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05537376; https://classic.clinicaltrials.gov/ct2/show/NCT05537376.

Sexual and Gender Minority Status and Suicide Mortality: An Explainable Artificial Intelligence Analysis

Objectives: Suicide risk is elevated in lesbian, gay, bisexual, and transgender (LGBT) individuals. Limited data on LGBT status in healthcare systems hinder our understanding of this risk. This study used natural language processing to extract LGBT status and a deep neural network (DNN) to examine suicidal death risk factors among US Veterans. Methods: Data on 8.8 million veterans with visits between 2010 and 2017 was used. A case-control study was performed, and suicide death risk was analyzed by a DNN. Feature impacts and interactions on the outcome were evaluated. Results: The crude suicide mortality rate was higher in LGBT patients. However, after adjusting for over 200 risk and protective factors, known LGBT status was associated with reduced risk compared to LGBT-Unknown status. Among LGBT patients, black, female, married, and older Veterans have a higher risk, while Veterans of various religions have a lower risk. Conclusion: Our results suggest that disclosed LGBT status is not directly associated with an increase suicide death risk, however, other factors (e.g., depression and anxiety caused by stigma) are associated with suicide death risks.

Correlates of suicidal behaviors and genetic risk among United States veterans with schizophrenia or bipolar I disorder

Persons diagnosed with schizophrenia (SCZ) or bipolar I disorder (BPI) are at high risk for self-injurious behavior, suicidal ideation, and suicidal behaviors (SB). Characterizing associations between diagnosed health problems, prior pharmacological treatments, and polygenic scores (PGS) has potential to inform risk stratification. We examined self-reported SB and ideation using the Columbia Suicide Severity Rating Scale (C-SSRS) among 3,942 SCZ and 5,414 BPI patients receiving care within the Veterans Health Administration (VHA). These cross-sectional data were integrated with electronic health records (EHRs), and compared across lifetime diagnoses, treatment histories, follow-up screenings, and mortality data. PGS were constructed using available genomic data for related traits. Genome-wide association studies were performed to identify and prioritize specific loci. Only 20% of the veterans who reported SB had a corroborating ICD-9/10 EHR code. Among those without prior SB, more than 20% reported new-onset SB at follow-up. SB were associated with a range of additional clinical diagnoses, and with treatment with specific classes of psychotropic medications (e.g., antidepressants, antipsychotics, etc.). PGS for externalizing behaviors, smoking initiation, suicide attempt, and major depressive disorder were associated with SB. The GWAS for SB yielded no significant loci. Among individuals with a diagnosed mental illness, self-reported SB were strongly associated with clinical variables across several EHR domains. Analyses point to sequelae of substance-related and psychiatric comorbidities as strong correlates of prior and subsequent SB. Nonetheless, past SB was frequently not documented in health records, underscoring the value of regular screening with direct, in-person assessments, especially among high-risk individuals.

Suicide Probability Among Patients With Schizophrenia and Bipolar Disorder

PURPOSE

To evaluate the possibility of suicide and related factors among individuals with schizophrenia and bipolar disorder (BD).

METHOD

Data were collected for 270 individuals registered in a community mental health center using the Suicide Probability Scale (SPS). Subsequently, t test and multiple linear regression analyses were conducted on independent samples.

RESULTS

There was no statistically significant difference found between mean SPS scores of participants with schizophrenia and BD. However, hostility subscale mean scores of participants with schizophrenia were higher than those of participants with BD, and the difference was statistically significant. Sex, family history of mental illness, need for help with medication, suicidal ideation in the past 10 days, and number of suicide attempts were important predictors of suicide probability.

CONCLUSION

Individuals with schizophrenia and BD and in remission should be evaluated periodically for the possibility of suicide. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

Suicide Rates and Risks Across U.S. Industries: A 29-Year Population-Based Survey

OBJECTIVE

Suicide rates in the working-age U.S. population have increased by over 40% in the last two decades. Although suicide may be linked with characteristics of workplaces and their industries, few studies have reported industry-level suicide rates. No study has reported suicide rates by industry using nationally representative data. This study estimates suicide risks across industries in the U.S. working population.

METHODS

Industry-level estimates of suicide risks require substantial data; we combined 29 years of U.S. suicide data using the National Health Interview Survey (NHIS)-Mortality Linked data from 1986 through 2014, with mortality follow-up through 2015. We conducted survey-weighted Poisson regression analyses to estimate suicide mortality rates and rate ratios across all populations and stratified by gender. All analyses were adjusted first for age, and then for age, employment status, marital status, race/ethnicity, and rurality/urbanicity (demographic-adjusted). Rate ratios compared results for workers in each industry to those for all industries, accounting for the NHIS survey design.

RESULTS

A total of 1,943 suicide deaths were recorded. Age-adjusted suicide rates per 100,000 were highest in the furniture, lumber, and wood industry group (29.3), the fabricated metal industry (26.3), and mining (25.8). Demographic-adjusted rates were higher among men than women in most industries. Demographic-adjusted rate ratios were significantly elevated in the furniture, lumber, and wood industries (Rate Ratio, RR = 1.60, 95% confidence interval, CI = 1.18-2.18); chemicals and allied products (RR = 1.49, 95%CI = 1.04-2.13); and construction (RR = 1.21, 95% CI = 1.03-1.41).

CONCLUSION

Several industries had significantly high suicide rates. Suicide prevention efforts may be particularly useful for workers in those industries.

Correlates of suicidal behaviors and genetic risk among United States veterans with schizophrenia or bipolar I disorder

Objective

Persons diagnosed with schizophrenia (SCZ) or bipolar I disorder (BPI) are at high risk for self-injurious behavior, suicidal ideation, and suicidal behaviors (SB). Characterizing associations between diagnosed mental and physical health problems, prior pharmacological treatments, and aggregate genetic factors has potential to inform risk stratification and mitigation strategies.

Methods

In this study of 3,942 SCZ and 5,414 BPI patients receiving VA care, self-reported SB and ideation were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS). These cross-sectional data were integrated with electronic health records (EHR), and compared by lifetime diagnoses, treatment histories, follow-up screenings, and mortality data. Polygenic scores (PGS) for traits related to psychiatric disorders, substance use, and cognition were constructed using available genomic data, and exploratory genome-wide association studies were performed to identify and prioritize specific loci.

Results

Only 20% of veterans who self-reported SB had a corroborating ICD-9/10 code in their EHR; and among those who denied prior behaviors, more than 20% reported new-onset SB at follow-up. SB were associated with a range of psychiatric and non-psychiatric diagnoses, and with treatment with specific classes of psychotropic medications (e.g., antidepressants, antipsychotics, etc.). PGS for externalizing behaviors, smoking, suicide attempt, and major depressive disorder were also associated with attempt and ideation.

Conclusions

Among individuals with a diagnosed mental illness, a GWAS for SB did not yield any significant loci. Self-reported SB were strongly associated with clinical variables across several EHR domains. Overall, clinical and polygenic analyses point to sequelae of substance-use related behaviors and other psychiatric comorbidities as strong correlates of prior and subsequent SB. Nonetheless, past SB was frequently not documented in clinical settings, underscoring the value of regular screening based on direct, in-person assessments, especially among high-risk individuals.

Mental Health Conditions- and Substance Use-Associated Emergency Department Visits during the COVID-19 Pandemic in Nevada, USA

Background-Mental health conditions and substance use are linked. During the COVID-19 pandemic, mental health conditions and substance use increased, while emergency department (ED) visits decreased in the U.S. There is limited information regarding how the pandemic has affected ED visits for patients with mental health conditions and substance use. Objectives-This study examined the changes in ED visits associated with more common and serious mental health conditions (suicidal ideation, suicide attempts, and schizophrenia) and more commonly used substances (opioids, cannabis, alcohol, and cigarettes) in Nevada during the COVID-19 pandemic in 2020 and 2021 compared with the pre-pandemic period. Methods-The Nevada State ED database from 2018 to 2021 was used (n = 4,185,416 ED visits). The 10th Revision of the International Classification of Diseases identified suicidal ideation, suicide attempts, schizophrenia, and the use of opioids, cannabis, alcohol, and cigarette smoking. Seven multivariable logistic regression models were developed for each of the conditions after adjusting for age, gender, race/ethnicity, and payer source. The reference year was set as 2018. Results-During both of the pandemic years (2020 and 2021), particularly in 2020, the odds of ED visits associated with suicidal ideation, suicide attempts, schizophrenia, cigarette smoking, and alcohol use were all significantly higher than those in 2018. Conclusions-Our findings indicate the impact of the pandemic on mental health- and substance use-associated ED visits and provide empirical evidence for policymakers to direct and develop decisive public health initiatives aimed at addressing mental health and substance use-associated health service utilization, especially during the early stages of large-scale public health emergencies, such as the COVID-19 pandemic.

Crisis service utilization following completion of a suicide safety plan for Veterans with and without affective and nonaffective psychosis

OBJECTIVE

Psychosis is associated with increased suicide risk. Safety planning is a suicide prevention practice that is associated with decreased suicidal behavior and psychiatric hospitalizations. A common feature of safety planning is listing of crisis line numbers. The primary purpose of this study was to compare Veterans with and without psychosis who completed a safety plan in terms of their next year crisis service use, including Veterans Crisis Line (VCL) calls, and suicidal behavior.

METHODS

Data were drawn from the VA San Diego's electronic medical record system for (N = 1602) safety plans from 2018 to 2021. Clinical records of crisis services and suicide attempt/death were recorded for one year after the safety plan.

RESULTS

Following completion of a safety plan, Veterans with psychosis were more likely to have a next year psychiatric hospitalization (OR = 4.1), emergency department visit (OR = 2.3), and psychiatric emergency clinic visit (OR = 2.2) than those without psychosis. In contrast, there were no group differences in likelihood of calling the VCL.

CONCLUSIONS

Veterans with psychosis who recently completed a safety plan do not show elevated rates of VCL use that are commensurate with increases in crisis service use. Interventions for this high-risk group may focus on understanding the motivation and ability to call the VCL as ways to enhance safety planning.

Ecological momentary assessment of interpersonal theory of suicide constructs in people experiencing psychotic symptoms

BACKGROUND

People with psychotic disorders are at an increased risk of suicide, but there is little understanding of suicidal ideation (SI) in this population. The Interpersonal Psychological Theory of Suicide posits that perceived burdensomeness (PB) and thwarted belonginess (TB) contribute to SI. To our knowledge there are no studies using ecological momentary assessment (EMA) to assess these interpersonal risk factors in a sample of individuals with psychotic disorders. This study investigated the validity and variability of PB and TB, and whether SI, EMA-measured psychotic symptoms, mood, and social context relate to PB and TB.

METHOD

Ninety-six participants with a psychotic disorder, including mood disorders with psychosis completed in-lab assessments of current SI, and then EMA surveys on a smartphone 3×/day for 10 days, answering questions about burdensomeness, belongingness, symptoms (i.e., hearing voices, experiencing suspiciousness), mood (i.e., happy, sad), and social context.

RESULTS

Burdensomeness varied within-participants less than belongingness (t (95) = -3.74, p=< .001). Participants with SI had higher mean burdensomeness ratings (t (94) = -2.70, p < .01) and lower mean belongingness ratings (t (94) = 3.68, p < .001) than did participants without SI. Being with others, greater psychotic experiences, less happiness, and greater sadness related to greater burdensomeness. SI status, being alone, greater psychotic experiences, less happiness, and greater sadness related to less belongingness.

CONCLUSIONS

This study examined the real-time influences of SI and psychotic symptoms on burdensomeness and belongingness. Hearing voices, suspiciousness, mood, and SI are related to interpersonal suicide-related risk factors. In this sample, social context had a differential effect on burdensomeness and belongingness.

Effect of EAP Psychological Intervention on Improving the Mental Health of Medical Workers Under the Novel Coronavirus Epidemic in China

Background: Due to the novel coronavirus epidemic, medical workers are under immense psychological pressure. As such, the East Campus of Shanghai Sixth People's Hospital actively adopted the Symptoms Checklist 90 (SCL-90) to evaluate the mental health of hospital staff before and after the psychological intervention from the Employee Assistance Program (EAP). Methods: Medical workers from the East Campus of Shanghai Sixth People's Hospital were recruited for this study. Psychological evaluations were conducted using the SCL-90, with a score of >160 regarded as a positive result, or in other words, an indication of abnormal psychological symptoms. The EAP adopted different forms of psychological interventions for healthcare professionals, and participation in these measures was entirely voluntary. Medical workers completed the SCL-90 again after participating in the psychological intervention, and we analyzed the changes between their two assessments. Results: Of the 1,198 total medical staff present at the hospital, 844 participated in the initial survey, while only 652 completed the survey a second time (i.e., post-psychological intervention). Multivariate logistic regression analysis found that the psychological status of hospital staff was correlated with gender, education background, and fertility status (P < 0.05). The results showed that, compared with women, men's mental health status was better, with an OR value of 0.598 (0.372-0.962). Groups with high school, junior high school, and below education levels were at higher risk of psychological problems, with OR values of 23.655 (2.815-198.784) and 9.09 (2.601-31.801), respectively. Administrative occupations and having two or more children were protective factors for mental health, and the OR values were 0.400 (0.175-0.912) and 0.327 (0.152-0.703), respectively. Following the psychological intervention, we found that the mental health of hospital workers improved, as indicated by their second SCL-90 evaluations, although the proportion of medical staff willing to participate in the second evaluation was lower than the initial assessment. There were differences in the SCL-90 scores among different occupations, and there were also differences in the scores of employees of different occupations who had participated in the two evaluations. The employees of different positions who participated in the two evaluations were matched and analyzed and found that the depression and anxiety of the doctor group were significantly reduced. In the nursing group, the total score, somatization, interpersonal sensitivity, depression, and anxiety were significantly reduced. In the medical technician group, depression, anxiety, and paranoia were reduced considerably. Among office staff, no significant differences were found. Among workers, the total score, depression, and anxiety were significantly reduced. Conclusion: Hospitals have the potential to alleviate and reduce the psychological pressure placed on medical staff members through the EAP, which can actively adopt intervention and guidance measures. The findings of this study have important implications, as reducing abnormal psychological symptoms of healthcare professionals can be helpful in the fight against the coronavirus epidemic.

Cooperative Studies Program (CSP) #572: A Study of Serious Mental Illness in Veterans as a Pathway to personalized medicine in Schizophrenia and Bipolar Illness

BACKGROUND

Personalization of psychiatric treatment includes treatment of symptoms, cognition and functional deficits, suicide, and medical co-morbidities. VA Collaborative Study 572 examined a large sample of male and female veterans with schizophrenia (n=3,942) and with bipolar disorder (n=5,414) with phenotyping and genomic analyses. We present the results to date and future directions.

METHODS

All veterans received a structured diagnostic interview and assessments of suicidal ideation and behavior, PTSD, and health. Veterans with schizophrenia were assessed for negative symptoms and lifetime depression. All were assessed with a cognitive and functional capacity assessment. Data for genome wide association studies were collected. Controls came from the VA Million Veteran Program.

RESULTS

Suicidal ideation or behavior was present in 66%. Cognitive and functional deficits were consistent with previous studies. 40% of the veterans with schizophrenia had a lifetime major depressive episode and PTSD was present in over 30%. Polygenic risk score (PRS) analyses indicated that cognitive and functional deficits overlapped with PRS for cognition, education, and intelligence in the general population and PRS for suicidal ideation and behavior correlated with previous PRS for depression and suicidal ideation and behavior, as did the PRS for PTSD.

DISCUSSION

Results to date provide directions for personalization of treatment in SMI, veterans with SMI, and veterans in general. The results of the genomic analyses suggest that cognitive deficits in SMI may be associated with general population features. Upcoming genomic analyses will reexamine the issues above, as well as genomic factors associated with smoking, substance abuse, negative symptoms, and treatment response.

Evidence for avolition in bipolar disorder? A 30-day ecological momentary assessment comparison of daily activities in bipolar disorder and schizophrenia

OBJECTIVES

Disability is common in bipolar disorder (BD) and predicted by persistent sadness. We used ecological momentary assessment (EMA) to examine daily activities in people with BD and schizophrenia. We classified activities as productive, unproductive, or passive recreation, relating them to momentary sadness, location, and social context.

METHODS

71 people with BD and 102 people with schizophrenia were sampled 3 times/day for 30 days with an EMA survey. Each survey asked where they were, with whom, what they were doing, and if they were sad.

RESULTS

People with BD were home more than 50% of the time. There were no differences in prevalence of activity types across diagnoses. People with BD were less likely to report only one activity since the prior survey, but the most surveys still reported only one. For both groups, sadness and being home and alone since the last survey was associated with less productive activity and more passive recreation.

CONCLUSIONS

Participants with BD and schizophrenia manifested high levels of unproductive and passive activities, predicted by momentary sadness. These activity patterns are consistent with descriptions of avolition and they minimally differentiated people with BD and schizophrenia. Previous reports of negative symptoms in BD may have been identifying these behaviors.