Suicide mortality among patients receiving care in the veterans health administration health system

Reconnecting to Internal Sensations and Experiences (RISE): An online, multi-session intervention improves interoceptive sensibility for military personnel

OBJECTIVE

This preregistered randomized controlled trial tested the effects of a four-session, online interoceptive awareness intervention relative to an active comparator, matched for time and attention on interoception and suicidal ideation.

METHOD

Participants (N = 195; 69% male; mean age = 37) were active duty service members (62%) and veterans (38%) who completed measures of interoceptive sensibility, interoceptive accuracy, and suicidal ideation at baseline. They were randomized to either the interoceptive awareness intervention, Reconnecting to Internal Sensations and Experiences (RISE), or the comparator, Healthy Habits. Participants completed the assessment battery again at posttest as well as a 1 and 3-month follow-up.

RESULTS

RISE was rated as acceptable and demonstrated excellent feasibility per completion rates (85% completed all four modules). RISE improved the majority of interoceptive sensibility domains assessed (noticing body sensations, not worrying about sensations of pain or discomfort, emotional awareness, self-regulation, body listening, and body trust), and most of these gains remained at 1 and 3-month follow-ups. There were no differences between conditions on suicidal ideation, perhaps due to the low levels of ideation reported, or interoceptive accuracy.

CONCLUSIONS

RISE is a disseminable, cost-effective, and transdiagnostic intervention that improves interoceptive sensibility up to 3 months.

Cognitive behavioral therapy for suicide prevention among Veterans receiving substance use disorder treatment: Results from a randomized trial

Veterans receiving substance use disorder (SUD) treatment are at a clear elevated risk for engaging in suicidal behaviors. Intervening to reduce suicide risk during an episode of SUD treatment could meaningfully target a key high-risk group of Veterans. Cognitive Behavioral Therapy for Suicide Prevention (CBT-SP) was developed to reduce the frequency and duration of suicidal ideation, as well as decrease suicidal behaviors. The form of CBT-SP in this study progressed from building an understanding of the cognitive model to practicing new skills, and highlighted the links between substance use, craving, self-efficacy and suicidal ideation and attempts. CBT-SP was compared to an attention matched 8-session control condition (termed Supportive Psychoeducational Control [SPC]) during a multi-site randomized controlled trial for 299 Veterans receiving outpatient SUD treatment services within the Veterans Health Administration. The frequency of suicidal ideation remained relatively constant over 24-months of follow-up, however the duration of suicidal ideation decreased, and suicide attempts decreased relative to baseline in both conditions. Forty-two participants (14%) reported at least one suicide attempt during the 2-year follow-up period. No statistically significant differences were found between CBT-SP and SPC on any of these outcomes. Analyses of secondary outcomes indicate that preparatory behaviors for suicide were less common among those in the CBT-SP condition than SPC across the 24-month follow-up (OR, 95%CI = 0.44 (0.25, 0.79); p = 0.02). Veterans in SUD treatment are a high-risk group and delivery of suicide-specific interventions is feasible during SUD care. However, results did not indicate that CBT-SP was superior to SPC on any primary outcomes, underscoring the importance of identifying and testing alternative approaches that support suicide reduction in this group.

Evaluation of the Risk Identification for Suicide and Enhanced Care Model in a Native American Community

Importance

There are many prognostic models of suicide risk, but few have been prospectively evaluated, and none has been developed specifically for Native American populations.

Objective

To prospectively validate a statistical risk model implemented in a community setting and evaluate whether use of this model was associated with improved reach of evidence-based care and reduced subsequent suicide-related behavior among high-risk individuals.

Design, Setting, and Participants

This prognostic study, done in partnership with the White Mountain Apache Tribe, used data collected by the Apache Celebrating Life program for adults aged 25 years or older identified as at risk for suicide and/or self-harm from January 1, 2017, through August 31, 2022. Data were divided into 2 cohorts: (1) individuals and suicide-related events from the period prior to suicide risk alerts being active (February 29, 2020) and (2) individuals and events from the time after alerts were activated.

Main Outcomes and Measures

Aim 1 focused on a prospective validation of the risk model in cohort 1. Aim 2 compared the odds of repeated suicide-related events and the reach of brief contact interventions among high-risk cases between cohort 2 and cohort 1.

Results

Across both cohorts, a total of 400 individuals identified as at risk for suicide and/or self-harm (mean [SD] age, 36.5 [10.3] years; 210 females [52.5%]) had 781 suicide-related events. Cohort 1 included 256 individuals with index events prior to active notifications. Most index events (134 [52.5%]) were for binge substance use, followed by 101 (39.6%) for suicidal ideation, 28 (11.0%) for a suicide attempt, and 10 (3.9%) for self-injury. Among these individuals, 102 (39.5%) had subsequent suicidal behaviors. In cohort 1, the majority (220 [86.3%]) were classified as low risk, and 35 individuals (13.3%) were classified as high risk for suicidal attempt or death in the 12 months after their index event. Cohort 2 included 144 individuals with index events after notifications were activated. For aim 1, those classified as high risk had a greater odds of subsequent suicide-related events compared with those classified as low risk (odds ratio [OR], 3.47; 95% CI, 1.53-7.86; P = .003; area under the receiver operating characteristic curve, 0.65). For aim 2, which included 57 individuals classified as high risk across both cohorts, during the time when alerts were inactive, high-risk individuals were more likely to have subsequent suicidal behaviors compared with when alerts were active (OR, 9.14; 95% CI, 1.85-45.29; P = .007). Before the active alerts, only 1 of 35 (2.9%) individuals classified as high risk received a wellness check; after the alerts were activated, 11 of 22 (50.0%) individuals classified as high risk received 1 or more wellness checks.

Conclusions and Relevance

This study showed that a statistical model and associated care system developed in partnership with the White Mountain Apache Tribe enhanced identification of individuals at high risk for suicide and was associated with a reduced risk for subsequent suicidal behaviors and increased reach of care.

Disrupted interoception in Military Service Members and Veterans with a history of suicidality

INTRODUCTION

This project tested whether Service Members (SM) and Veterans with current suicidal ideation or a history of suicide attempt had greater interoceptive dysfunction than SM and Veterans with past or no suicidal ideation.

METHOD

Participants (N = 195; 69% male) were SM (62%) and Veterans (38%) who completed measures of suicidal thoughts and behaviors and subjective and objective interoceptive dysfunction. Participants were split into the following suicide groups: no suicidality, lifetime ideation, current ideation, and past attempt. Planned orthogonal contrasts tested for differences.

RESULTS

The combined suicidality group (lifetime ideation, current ideation, or past attempt) had worse body trust relative to the no suicidality group, and the current ideation group had worse body trust relative to those with lifetime ideation. Those with a history of suicide attempt had worse body appreciation than the combined group of ideators, and those with current ideation had worse body appreciation relative to those with lifetime ideation. The groups did not differ on objective interoception.

CONCLUSION

Interoception is disrupted among individuals with suicidality histories within a predominantly male-identified military sample. Individuals with current suicidal ideation had both worse body trust and appreciation relative to those with past ideation. Suicide risk assessments may benefit from including questions related to body trust.

Feasibility of recruitment and retention in a remote trial of gatekeeper training for close supports of military veterans: Mixed methods study

Background

VA S.A.V.E. (Signs; Ask; Validate; Encourage/Expedite) is a gatekeeper training, designed to teach individuals how to identify and assist military veterans at risk for suicide. The aim of this pilot was to determine feasibility, barriers, and facilitators of recruitment and retention in a remote trial of VA S.A.V.E.

Methods

We recruited close supports (family and friends) of veterans through Facebook sponsored ads, automatically randomized them to VA S.A.V.E. or an unrelated video training, and followed them for six months. A subgroup completed interviews, and we used a mixed methods framework to integrate quantitative and qualitative findings.

Results

Of 214 participants, 61% were spouses or partners of veterans and 48% knew at least one veteran who had died by suicide. Of the three a priori feasibility benchmarks, two were achieved (enrollment, on average, of twenty participants per week and less than 50% loss to follow-up at the 6-month study endpoint) and one was not (enrollment of at least 50% of eligible individuals). There were three barriers (generic ads, ad text referring to "research," and Facebook as an ad platform) and five facilitators (audience segmentation focused on veterans' family members and friends, an urgent call to action to help a veteran, prior exposure to suicide, emphasizing the benefit of receiving training, and using a university as the campaign messenger) to study participation.

Conclusion

A fully remote trial of VA S.A.V.E. gatekeeper training was feasible in a population of close supports of veterans. Several strategies may further enhance study participation.

U.S. Military veterans and the opioid overdose crisis: a review of risk factors and prevention efforts

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for veterans.

Cognitive effort avoidance in veterans with suicide attempt histories

Suicide attempts (SA) are increasing in the United States, especially in veterans. Discovering individual cognitive features of the subset of suicide ideators who attempt suicide is critical. Cognitive theories attribute SA to facile schema-based negative interpretations of environmental events. Over-general autobiographical memory and facile solutions in problem solving tasks in SA survivors suggest that aversion to expending cognitive effort may be a neurobehavioral marker of SA risk. In veterans receiving care for mood disorder, we compared cognitive effort discounting and evidence-gathering in a beads task between veterans with (SAHx+; n = 26) versus without (SAHx-; n = 22) a history of SA. Groups did not differ in depressed mood or in a proxy metric of premorbid intelligence. Compared to SAHx- participants, SAHx+ participants self-reported significantly more severe cognitive problems in most domains, and also eschewed choice to earn higher monetary reward if earning it required a slightly increased working memory (WM) demand relative to an easy WM task. There was no group difference, however, in extent of evidence-gathering before declaring a conclusion in a beads task. These preliminary data suggest that aversion to expenditure of cognitive effort, potentially as a component of cognitive difficulties, may be a marker for SA risk.

Clinical and economic burden of major depressive disorder with acute suicidal ideation or behavior in a US Veterans Health Affairs database

OBJECTIVE

Although a high incidence of major depressive disorder (MDD) and an increased risk of suicide are observed among the veteran population, there are yet limited real-world data characterizing patients with MDD with acute suicidal ideation/behavior (MDSI) in the Veterans Health Administration (VHA) system. We assessed the clinical and economic burden, including comorbidities, treatment patterns, health care resource utilization, and health care costs, among veterans and their family members with MDSI within the VHA system.

METHODS

This retrospective, longitudinal analysis of VHA datasets (10/1/2015-3/31/2018) evaluated the clinical and economic burden associated with MDSI and compared this population with matched MDD alone (i.e. MDD diagnosis without acute suicidal ideation/behavior) and non-MDD (i.e. neither MDD nor acute suicidal ideation/behavior) cohorts.

RESULTS

Among 11,203 patients with MDSI, the proportions of patients who filled a prescription for ≥1 antidepressant during the 12-month pre- and 6-month post-periods were significantly higher compared with patients with MDD alone (53.7% vs 28.8%, p < .05; and 72.3% vs 44.1%, p < .05; respectively). During the 12-month pre-period, the MDSI cohort had the highest proportion of patients with ≥1 mental health-related inpatient visit compared with the MDD alone and non-MDD cohorts (13.2% vs 2.3% vs 1.4%, respectively; p < .05), and the highest mental health-related costs per patient ($8853 vs $1913 vs $1079, respectively). For the 6-month post-period, the MDSI cohort had the highest proportion of patients with ≥1 mental health-related inpatient visit compared with the MDD alone and non-MDD cohorts (60.4% vs 7.9% vs 0.8%, respectively; p < .05), and had the highest mental health-related costs per patient ($20,334 vs $4803 vs $545, respectively).

CONCLUSIONS

Findings demonstrate significant clinical and economic burden for those in the VHA system diagnosed with MDSI and highlight unmet needs and opportunities for improving the care of this vulnerable group.

Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans

OBJECTIVE

Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.

METHODS

A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

RESULTS

Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).

CONCLUSIONS

As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.

Patient characteristics and treatment utilization in fatal stimulant-involved overdoses in the United States Veterans Health Administration

BACKGROUND AND AIMS

This study aimed to (1) describe trends in stimulant-alone and stimulant and other substance use overdose deaths from 2012 to 2018 and (2) measure patient and service use characteristics across stimulant-related overdose death profiles.

DESIGN

Retrospective cohort study of patients who died from stimulant-involved overdose between annual years 2012 and 2018.

SETTING

United States Veterans Health Administration (VHA). A total of 3631 patients died from stimulant-involved overdose, as identified through the National Death Index.

MEASUREMENTS

Stimulant-involved overdose deaths were categorized by stimulant type (cocaine or methamphetamine/other) and other substance co-involvement. Cause of death data were linked to patient characteristics, including demographic and treatment use preceding overdose from VHA administrative data. We examined trends over time and compared treatment use factors between the following mutually exclusive overdose profiles: cocaine alone, methamphetamine alone, cocaine + opioid, methamphetamine + opioid, any stimulant + other substance and cocaine + methamphetamine.

FINDINGS

The rate of overdose death was 3.06 times higher in 2018 than 2012, with increases across all toxicology profiles. Compared with cocaine-involved overdoses, methamphetamine-involved overdoses were less likely in people who were older [adjusted odds ratio (aOR) = 0.22, 95% confidence interval (CI) = 0.06-0.87 aged 65+ versus 18-29] and more likely among those who lived in rural areas (aOR = 2.73, 95% CI = 1.43-5.23). People who died from stimulant + opioid overdoses had lower odds of a stimulant use disorder diagnosis compared with stimulant alone deaths (cocaine: aOR = 0.55, 95% CI = 0.41-0.75, methamphetamine: aOR = 0.44, 95% CI = 0.29-0.68).

CONCLUSIONS

The rate of deaths among US Veterans from stimulant-related overdose was three times higher in 2018 than 2012. Key differences in characteristics of patients across overdose toxicology profiles, such as geographic location and health-care use, point to distinct treatment needs based on stimulant use type.

Suicide death over the first year of lithium versus valproate treatment in cohorts with and without bipolar disorder

This study examined if lithium's association with suicide risk varies by diagnosis. We performed separate 1:1 high-dimensional propensity score (hdPS)-matching in US Veterans with and without bipolar disorder starting lithium or valproate. Among individuals with bipolar disorder, actively receiving lithium (compared to valproate) was not associated with suicide risk. However, in intent-to-treat analyses (following all individuals with bipolar disorder starting lithium or valproate for all 365 days, regardless of whether they stopped the medication), starting lithium was significantly associated with higher one-year risks of suicide (HR = 1.50, 95% CI: 1.05-2.15, p = 0.03). These intent-to-treat risks were attributable entirely to transiently elevated suicide risks observed among individuals no longer receiving lithium (significant at 180 days [HR = 6.10, CI: 1.37-27.3, p = 0.02] but not 365 days [HR = 2.05, CI: 0.88-4.79, p = 0.10]). Among individuals without bipolar disorder, depending on the analysis, actively receiving lithium was associated with nonsignificantly (HR = 0.43, CI: 0.15-1.20, p = 0.11) or significantly (HR = 0.28, CI: 0.08-0.98, p = 0.047) decreased one-year suicide risks. Study limitations included limited power, brief follow-up, and potential residual confounding. Residual confounding is suggested by the observation that more individuals diagnosed with suicidal ideation started lithium than valproate (with this difference being statistically significant for individuals with bipolar disorder, p = 0.0012). If it were possible to correct for this potential confounding, then the suicide-related risks associated with among individuals discontinuing lithium would be expected to be less, and the suicide-related benefits associated with actively receiving lithium (already statistically significant in some analyses among individuals without bipolar disorder) would be expected to increase. Further research is needed.

Alcohol-involved overdose deaths in US veterans

BACKGROUND

Alcohol-involved overdose deaths are increasing and often occur with other substances but have been minimally studied compared to other causes of overdose.

METHODS

We used national Veterans Health Administration (VHA) records linked to National Death Index data from 2012 to 2018 to examine trends in alcohol-related overdose mortality. Patient characteristics and treatment receipt were compared across categories of alcohol overdose deaths (alcohol-only, alcohol+opioids which may include additional substances, and alcohol+other substances without opioids).

RESULTS

From 2012-2018, 2421 Veterans died from an alcohol-involved overdose (alcohol-only: 868, alcohol+opioids: 1269, alcohol+other substances: 284). The alcohol-involved overdose rate increased 57% during this period. Compared to those who died of an alcohol-only overdose, Veterans who died from alcohol+opioids and alcohol+other substances were more likely Black or Hispanic, and to have an opioid use disorder, but less likely to live in rural areas or to be diagnosed with alcohol use disorder (AUD). Only 32.5% of those who died from alcohol-involved overdose received treatment in a substance use disorder clinic in the year preceding death, compared to 65.1% seen in mental health and 85.7% in primary care. Only 9.5% of Veterans who died from alcohol overdose received medication treatment for AUD and 24.8% received psychotherapy for AUD in the year preceding death.

CONCLUSIONS

Alcohol overdose is increasing primarily related to overdoses involving opioids and other substances. Most patients did not receive any effective medication or psychotherapy treatments for AUD, suggesting further need to identify those at risk and to target treatment for this vulnerable group in healthcare settings.

Comparative risk of suicide by specific substance use disorders: A national cohort study

Substance use disorders (SUDs) are important risk factors for suicide, yet little is known about how suicide risks vary by specific SUDs. We examined these risks for the first time in a large general population to facilitate comparisons across SUDs. A national cohort study was conducted of all 6,947,191 adults in Sweden. SUDs (opioid, sedative/hypnotic, hallucinogen, cannabis, amphetamine, cocaine, and alcohol use disorders) were identified using inpatient, outpatient, and crime data, and suicide deaths using nationwide death data with follow-up during 2003-2016. Cox regression was used to compute hazard ratios (HRs) for suicide death while adjusting for sociodemographic factors and psychiatric, SUD, and somatic comorbidities. Co-sibling analyses assessed for confounding by unmeasured shared familial (genetic and/or environmental) factors. In 79.8 million person-years of follow-up, 15,616 (0.2%) suicide deaths were identified. All SUDs were associated with significantly increased risks, with HRs ranging from 12- to 26-fold and 2.5- to 6.4-fold before and after adjusting for covariates, respectively. After adjusting for all covariates, opioid use disorder was the strongest risk factor (HR, 6.39; 95% CI, 5.53-7.38) (P ≤ 0.002 compared with any other SUD), followed by sedative/hypnotic use disorder (4.62; 4.06-5.27) (P ≤ 0.009 compared with any other SUD except opioid or hallucinogen). Most associations persisted after controlling for shared familial factors, consistent with causal effects. In this large national cohort, all SUDs were associated with significantly increased risks of suicide death, especially opioid and sedative/hypnotic use disorders. These findings may improve risk stratification and inform interventions to prevent suicide in the highest-risk subgroups with SUDs.

A high-need, high-impact educational session on firearms and death by suicide

BACKGROUND

The suicide rate among Veterans is 1.5 times greater than that for civilians, partly a result of the high use of firearms as the means for suicide. One effective strategy to reduce Veteran suicide by firearms is to provide counseling on firearm safety as a method of means reduction. However, many clinicians do not discuss firearm safety with Veterans.

AIMS

This study evaluates a one-hour educational seminar for clinicians on lethal means safety.

MATERIALS AND METHODS

One hundred and ninety clinicians from the Veterans Health Administration, including social workers, psychologists, psychiatrists, and nurses, participated in the training. The seminar was streamed during the South Central Mental Health Illness Research, Education and Clinical Center's Community-Based Outpatient Clinic Mental Health Grand Rounds, for which participants were eligible for continuing education units. Data were collected immediately after the training and four months later.

RESULTS

After completing the training, participants believed that it was important to speak with Veterans about firearm safety and felt knowledgeable and empowered to do so. Four months after the seminar, participants had counseled, on average, over half of Veterans treated about lethal means safety.

DISCUSSION

Participants reported the value of normalizing discussions about firearm safety with their Veterans and focusing on the safety aspect while discussing firearms.

CONCLUSIONS

This webinar was effective in providing clinicians the skills to talk with Veterans about firearm safety and continued to impact their practice four months after training. The training is available for free on our website at https://www.mirecc.va.gov/visn16/public-health-approach-to-firearms-and-death-by-suicide.asp.

Evaluation of the Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment Suicide Risk Modeling Clinical Program in the Veterans Health Administration

IMPORTANCE

The Veterans Health Administration (VHA) implemented a national clinical program using a suicide risk prediction algorithm, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), in which clinicians facilitate care enhancements for individuals identified in local top 0.1% suicide risk tiers. Evaluation studies are needed.

OBJECTIVE

To determine associations with treatment engagement, health care utilization, suicide attempts, safety plan documentation, and 6-month mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used triple differences analyses comparing 6-month changes in outcomes after vs before program entry for individuals entering the REACH VET program (March 2017-December 2018) vs a similarly identified top 0.1% suicide risk tier cohort from prior to program initiation (March 2014-December 2015), adjusting for trends across subthreshold cohorts. Subcohort analyses (including individuals from March 2017-June 2018) evaluated difference-in-differences for cause-specific mortality using death certificate data. The subthreshold cohorts included individuals in the top 0.3% to 0.1% suicide risk tier, below the threshold for REACH VET eligibility, from the concurrent REACH VET period and from the pre-REACH VET period. Data were analyzed from December 2019 through September 2021.

EXPOSURES

REACH VET-designated clinicians treatment reevaluation and outreach for care enhancements, including safety planning, increased monitoring, and interventions to enhance coping.

MAIN OUTCOMES AND MEASURES

Process outcomes included VHA scheduled, completed, and missed appointments; mental health visits; and safety plan documentation and documentation within 6 months for individuals without plans within the prior 2 years. Clinical outcomes included mental health admissions, emergency department visits, nonfatal suicide attempts, and all-cause, suicide, and nonsuicide external-cause mortality.

RESULTS

A total of 173 313 individuals (mean [SD] age, 51.0 [14.7] years; 161 264 [93.1%] men and 12 049 [7.0%] women) were included in analyses, including 40 816 individuals eligible for REACH VET care and 36 604 individuals from the pre-REACH VET period in the top 0.1% of suicide risk. The REACH VET intervention was associated with significant increases in completed outpatient appointments (adjusted triple difference [ATD], 0.31; 95% CI, 0.06 to 0.55) and proportion of individuals with new safety plans (ATD, 0.08; 95% CI, 0.06 to 0.10) and reductions in mental health admissions (ATD, -0.08; 95% CI, -0.10 to -0.05), emergency department visits (ADT, -0.03; 95% CI, -0.06 to -0.01), and suicide attempts (ADT, -0.05; 95% CI, -0.06 to -0.03). Subcohort analyses did not identify differences in suicide or all-cause mortality (eg, age-and-sex-adjusted difference-in-difference for suicide mortality, 0.0007; 95% CI, -0.0006 to 0.0019).

CONCLUSIONS AND RELEVANCE

These findings suggest that REACH VET implementation was associated with greater treatment engagement and new safety plan documentation and fewer mental health admissions, emergency department visits, and suicide attempts. Clinical programs using risk modeling may be effective tools to support care enhancements and risk reduction.

Association Between Buprenorphine for Opioid Use Disorder and Mortality Risk

INTRODUCTION

Veterans with opioid use disorder have an increased risk of suicide and overdose compared with the general population. Buprenorphine, a U.S. Food and Drug Administration-approved medication to treat opioid use disorder, has shown benefits, including decreased risk of illicit drug use and overdose. This study assesses the mortality outcomes with buprenorphine pharmacotherapy among Veterans up to 5 years from treatment initiation.

METHODS

This was a retrospective cohort study of Veterans receiving buprenorphine (2008-2017) across any Veterans Health Administration facility. Buprenorphine pharmacotherapy was evaluated as a time-varying covariate. The primary outcome was death up to 5 years from treatment initiation by suicide and overdose combined; secondary outcomes included suicide, overdose, opioid-specific overdose, and all-cause death. Secondary analyses included evaluating the risk of mortality in recent discontinuation and effect modification by select characteristics. All analyses were conducted in 2020.

RESULTS

Veterans who were not receiving buprenorphine were 4.33 (adjusted hazard ratio; 95% CI=3.60, 5.21) times more likely to die by suicide/overdose than those receiving buprenorphine pharmacotherapy on any given day, with similar protective associations with treatment across secondary outcomes. The risk of suicide/overdose was highest 8-14 days from treatment discontinuation (adjusted hazard ratio=6.54, 95% CI=4.32, 9.91) than in currently receiving buprenorphine pharmacotherapy. There was no evidence of effect modification by the selected covariates.

CONCLUSIONS

Mortality risk was greater among Veterans who were not receiving buprenorphine pharmacotherapy than among those who were. Providers should consider whether buprenorphine pharmacotherapy, either intermittent or continuous, may provide health benefits for their patients and prevent mortality.

Factors associated with multiple suicide attempts in a nationally representative study of U.S. military veterans

OBJECTIVE

Veterans with a history of multiple suicide attempts are at increased risk for suicide mortality relative to those with a single attempt. However, little is known about factors that differentiate veterans who attempt suicide once compared to more than once. This study examined factors that distinguish single suicide attempters (SSA) from multiple suicide attempters (MSA) in a nationally representative sample of U.S. military veterans.

METHODS

Data were analyzed from the 2019-2020 National Health and Resilience in Veterans Study, which surveyed a representative sample of 4069 U.S. veterans.

ANALYSES

(a) estimated the lifetime prevalence of SSA and MSA; and (b) examined factors that differentiated veterans with a SSA from MSA.

RESULTS

The lifetime prevalences of SSA and MSA were 1.9% and 2.0%. The strongest correlates of MSA were history of lifetime depression (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.43-8.35), non-suicidal self-injury (OR, 3.28; 95% CI, 1.27-8.45), drug use disorder (OR, 4.0; 95% CI, 1.67-9.54), and marital status (OR, 0.40, 95% CI, 0.18-0.87), which accounted for 15.5%-41.4% of the total explained variance in MSA.

DISCUSSION

Half of military veterans who have attempted suicide in the United States report more than one attempt, suggesting that suicide attempts are not a one-time occurrence for a substantial proportion of veterans. Veterans who attempt suicide more than once show more deliberate self-harm behavior and have greater psychiatric comorbidities relative to single attempters. Implications for future research examining risk factors for suicide attempts among veterans are discussed.

Ascertainment of Patient Suicides by Veterans Affairs Facilities and Associations With Veteran, Clinical, and Suicide Characteristics

Objectives. To evaluate the sensitivity of health care facility documentation of suicide deaths among US veterans with recent Veterans Health Administration (VHA) care and assess variation in identification by veteran, clinical, and suicide death characteristics. Methods. Cross-sectional analyses included 11 148 veterans who died by suicide in 2013 to 2017, per National Death Index death certificate information, with VHA encounters in the year of death or the previous year. Facility suicide ascertainment was assessed per site reports in the VHA Suicide Prevention Applications Network. Bivariate and multivariable analyses assessed ascertainment by decedent demographic, clinical, utilization, and method of suicide characteristics. Results. Site reports identified 3667 suicide decedents (32.9%). Veteran suicide decedents identified by facilities were more likely to be younger and with clinical risk factors and more recent VHA encounters. Suicide deaths involving poisoning were less likely to be identified than deaths involving other methods. Conclusions. VHA facility ascertainment of suicide deaths among recent patients was neither comprehensive nor representative. Findings will inform efforts to enhance facility suicide surveillance and veteran suicide prevention.

Suicide mortality and related behavior following calls to the Veterans Crisis Line by Veterans Health Administration patients

OBJECTIVES

To assess outcomes for Veterans Health Administration (VHA) patients following calls to the Veterans Crisis Line (VCL).

METHODS

158,927 VHA patients had an initial VCL call in 2010-2015 with documented identifiers. Multivariable proportional hazards regressions assessed risks of suicide and suicide-related behavior through 12 months. Covariates included age, sex, region, mental health encounters in the prior year, time of day, weekday/weekend status, call outcome, and responder determination of caller risk.

RESULTS

Annualized suicide rates per 100,000 within 1, 3, 6, and 12 months were 797, 520, 387, and 298, respectively. Average age was 49.9 (SD = 15.2), 86.5% were male, 68.6% received mental health encounters in the prior year, and 5.9% had calls categorized as at high risk. Adjusting for covariates, suicide risk was greater among male callers and those with calls categorized as at high or moderate risk.

CONCLUSIONS

Veterans Crisis Line serves a high-risk population at a critical time. Rates were particularly high within one month and remained substantially elevated through 12 months. Findings have directly informed ongoing efforts to enhance coordination between VCL and VHA to support suicide prevention.

Suicide among veterans with amyotrophic lateral sclerosis

BACKGROUND

The purpose of this study was to estimate the risk of death by suicide for those with amyotrophic lateral sclerosis (ALS) seeking care within the Veterans Health Administration (VHA).

METHODS

This was a retrospective, cohort study. Extended Cox regression models were used to compare the hazard of suicide between the ALS and the unexposed groups.

RESULTS

The hazard of suicide was 3.98 times higher for those with ALS than for those without (95% confidence interval [CI] , 2.64-6.00; P < .0001). After adjusting for covariates, those with ALS remained at increased risk (hazard ratio, 3.48; 95% CI, 2.31-5.24; P < .001).

CONCLUSIONS

Among those seeking care in the VHA, individuals with ALS are at increased risk for dying by suicide. Additional suicide prevention efforts, including strategies for reducing access to lethal means, are warranted.

Influence of contextual factors on death by suicide in rural and urban settings

PURPOSE

To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users).

METHODS

We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans.

FINDINGS

Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.5<OR>2.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users.

CONCLUSIONS

A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

Hospitalization for Heart Failure Among Patients With Diabetes Mellitus and Reduced Kidney Function Treated With Metformin Versus Sulfonylureas: A Retrospective Cohort Study

Background Metformin and sulfonylurea are commonly prescribed oral medications for type 2 diabetes mellitus. The association of metformin and sulfonylureas on heart failure outcomes in patients with reduced estimated glomerular filtration rate remains poorly understood. Methods and Results This retrospective cohort combined data from National Veterans Health Administration, Medicare, Medicaid, and the National Death Index. New users of metformin or sulfonylurea who reached an estimated glomerular filtration rate of 60 mL/min per 1.73 m2 or serum creatinine of 1.5 mg/dL and continued metformin or sulfonylurea were included. The primary outcome was hospitalization for heart failure. Echocardiogram reports were obtained to determine each patient's ejection fraction (EF) (reduced EF <40%; midrange EF 40%-49%; ≥50%). The primary analysis estimated the cause-specific hazard ratios for metformin versus sulfonylurea and estimated the cumulative incidence functions for heart failure hospitalization and competing events. The weighted cohort included 24 685 metformin users and 24 805 sulfonylurea users with reduced kidney function (median age 70 years, estimated glomerular filtration rate 55.8 mL/min per 1.73 m2). The prevalence of underlying heart failure (12.1%) and cardiovascular disease (31.7%) was similar between groups. There were 16.9 (95% CI, 15.8-18.1) versus 20.7 (95% CI, 19.5-22.0) heart failure hospitalizations per 1000 person-years for metformin and sulfonylurea users, respectively, yielding a cause-specific hazard of 0.85 (95% CI, 0.78-0.93). Among heart failure hospitalizations, 44.5% did not have echocardiogram information available; 29.3% were categorized as reduced EF, 8.9% as midrange EF, and 17.2% as preserved EF. Heart failure hospitalization with reduced EF (hazard ratio, 0.79; 95% CI, 0.67-0.93) and unknown EF (hazard ratio, 0.84; 95% CI 0.74-96) were significantly lower in metformin versus sulfonylurea users. Conclusions Among patients with type 2 diabetes mellitus who developed worsening kidney function, persistent metformin compared with sulfonylurea use was associated with reduced heart failure hospitalization.

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.

Implementation of the standardized, evidence-based three-stage suicide risk screening: Experience of a large Veterans Affairs medical center

ABSTRACT

Suicide is a global public health concern and may be preventable with early identification. The suicide rate among US veterans is increasing. In response to the increase, Veterans Health Administration recommended a new standardized three-step, evidence-based suicide risk screening process across all Veterans Health Administration sites. The purpose of this project was to implement the new three-step suicide screening method and evaluate the rate of provider adherence. The implementation occurred in seven clinical sites in the Veterans Affairs Greater Los Angeles Health care System. Following initial implementation, two Plan-Do-Study-Act (PDSA) evaluated provider adherence to the screening processes. Staff members at each site received suicide prevention education. Staff members had the option of using an embedded template in the course of normal patient care workflow. Plan-Do-Study-Act 1 measured the early results. Staff members achieved a performance adherence rate of 18%, indicating that staff were less likely to proactively screen for risk of suicide. In PDSA-2, the mandatory use of screening replaced the optional use. Staff members achieved a 95% adherence rate after 3 months. Changing the workflow within the electronic health record from optional to mandatory utilization brought forth improvements in suicide prevention screening.

Factors Increasing Risk of Suicide after Traumatic Brain Injury: A State-of-the-Science Review of Military and Civilian Studies

Primary Objective: Survey TBI literature to identify evidence of risk for post-injury suicide.Literature Selection: Search terms ((traumatic brain injury OR TBI) AND (suicidality OR suicidal behaviour OR suicidal ideation)) entered in PubMed, OVID Medline, PsychInfo, and Web of Science for papers published in print 01/01/1997 to 06/30/2019.Analysis of Literature: Authors screened abstracts, excluding duplicates and articles not meeting inclusion/exclusion criteria. Full papers were reviewed to make final exclusions. Data were extracted from 40 papers included co- and premorbid disorders, demographics, injury-related and psychological factors.Results: Persons with TBI have a higher risk for suicide than the general population. Reviewed articles reported comorbid depression and/or PTSD as risk factors for post-TBI suicide. Co- or premorbid substance misuse, sex, and sleep disturbance moderate risk. Quality of the literature was limited by sample size, the predominance of male participants, and inconsistency in reporting of findings.Conclusions: Comorbid depression and PTSD are significant post-TBI risk factors for suicide. Several variables combine to moderate or mediate TBI's connection with suicide. Civilian and military clinician cross-talk and consistent reporting of results from reproducible studies of post-TBI suicide risk factors could improve prevention and treatment efforts in veterans and civilians.

Generalizing the Value of Ongoing Assessments of Suicidal Ideation or Behavior for Estimating the Risk of Subsequent Suicide Attempts

In analyses conducted for program planning, the Veterans Health Administration evaluated associations between self-reports of suicidal ideation and behavior using the Columbia Scale obtained on two occasions separated by three months and clinical or administrative records of suicide attempts over the subsequent three months., Combining information from the two assessments improved prediction of suicidal behavior and found that risk was greater when ideation was reported on both assessments, than when it was first reported at follow-up. The absence of reported ideation at the second assessment was not associated with a clinically relevant reduction in risk. These findings confirm recent reports from the Mental Health Research Network (MHRN).

Adapting Caring Contacts for Veterans in a Department of Veterans Affairs Emergency Department: Results From a Type 2 Hybrid Effectiveness-Implementation Pilot Study

Transitions in care, such as discharge from an emergency department (ED), are periods of increased risk for suicide and effective interventions that target these periods are needed. Caring Contacts is an evidence-based suicide prevention intervention that targets transitions, yet it has not been widely implemented. This pilot study adapted Caring Contacts for a Department of Veterans Affairs (VA) ED setting and population, created an implementation toolkit, and piloted implementation and evaluation of effectiveness. To inform adaptation, qualitative interviews were conducted with stakeholders. Data were used by an advisory board comprised of stakeholders, experts, and veterans to make adaptations and develop an implementation planning guide to delineate steps needed to implement. Key decisions about how to adapt Caring Contacts included recipients, author, content, and the schedule for sending. Pilot implementation occurred at one VA ED. Caring Contacts involved sending patients at risk of suicide brief, non-demanding expressions of care. Program evaluation of the pilot used a type 2 hybrid effectiveness-implementation design to both pilot an implementation strategy and evaluate effectiveness of Caring Contacts. Evaluation included qualitative interviews with veteran patients during implementation. VA electronic health records were used to evaluate VA service utilization in the 6-month periods immediately before and after veterans were delivered their first Caring Contact. Hundred and seventy-five veterans were mailed Caring Contacts and the facility continued adoption after the pilot. Participants were positive about the intervention and reported feeling cared about and connected to VA as a result of receiving Caring Contacts. This project developed an implementation planning process that successfully implemented Caring Contacts at one site. This can be used to further implement Caring Contacts at additional VA or community EDs.

Long-Term Outcomes of Service Women Injured on Combat Deployment

Sex- and gender-based health disparities are well established and may be of particular concern for service women. Given that injured service members are at high risk of adverse mental and behavioral health outcomes, it is important to address any such disparities in this group, especially in regard to patient-reported outcomes, as much of the existing research has focused on objective medical records. The current study addressed physical and mental health-related quality of life, mental health symptoms, and health behaviors (i.e., alcohol use, sleep, and physical activity) among a sample of service women injured on deployment. Results indicate that about half of injured service women screened positive for a mental health condition, and also evidenced risky health behaviors including problematic drinking, poor sleep, and physical inactivity. Many of the mental and behavioral health variables demonstrated statistically significant associations with each other, supporting the relationships between psychological health and behaviors. Results provide additional evidence for the importance of access to integrated and effective mental healthcare treatment for injured service women and the need for screening in healthcare settings that address the multiple factors (e.g., mental health symptoms, alcohol use, poor sleep) that may lead to poor outcomes.

Veterans Justice Programs: Assessing Population Risks for Suicide Deaths and Attempts

OBJECTIVES

Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users.

METHODS

Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators.

RESULTS

Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality.

CONCLUSIONS

Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities.

Suicidal Risks in 12 DSM-5 Psychiatric Disorders

OBJECTIVE

As modern studies evaluating suicidal behaviors in large samples of major psychiatric disorder patients are rare, we compared suicidal risks associated with a variety of psychiatric diagnoses.

METHODS

We quantified rates of intake suicidal ideation and lifetime attempts, suicides, and violent acts (attempts + suicides) in 6050 adult patients in a European psychiatric center, diagnosed with 12 prevalent, DSM-5 psychiatric disorders.

RESULTS

Ideation ranged from 53.9% of subjects with bipolar disorder (BD) with mixed features, to 8.70% in anxiety disorders. Subjects making at least one suicide attempt were most prevalent in BD with mixed or psychotic features. Suicide rates ranked: substance abuse > BD with psychotic features > psychotic disorders ≥ BD-I > major depressive disorder (MDD). Suicidal intensity (acts/100 PEY) was highest with BD, psychotic disorders, and MDD; lethality (lower attempt/suicide ratio) was greatest with substance abuse, psychotic disorders, and BD with psychotic features. Rates of suicidal acts in BD vs. MDD were similarly high among ever-hospitalized subjects but much lower in never-hospitalized MDD subjects. Women had higher overall risks of ideation and attempts, but violent acts and suicide were more likely among men, whereas SMR for suicide was greater among women, presumably reflecting very low risks among women in the regional general population.

CONCLUSIONS

Suicidal risks were particularly high in BD with psychotic or mixed features as well as with substance abuse and in severe MDD with hospitalization.

Risk Factors for Suicide in a National Sample of Veterans With Multiple Sclerosis

OBJECTIVES

To examine risk factors in the year before suicide in a national sample of United States veterans with multiple sclerosis (MS), as well as means of suicide and receipt of mental health services prior to death.

DESIGN

Case control study. Individuals in the Veterans Affairs MS National Data Repository were linked to the National Death Index Plus to obtain death records, including specific causes of death. Participants were veterans with MS who died by suicide and randomly selected nonsuicide MS controls (5 per participant) who were alive at the time of the index suicide. Mental health disorders and medical comorbidities were identified in the year before death for suicides and during the identical time period for controls.

SETTING

Veterans Health Administration.

PARTICIPANTS

Veterans (N=426) who received treatment for MS in the United States Veterans Health Administration between 1999 and 2011. There were 71 deaths by suicide and 355 randomly selected controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Suicide.

RESULTS

Results from the adjusted multivariable model suggest that the following factors were associated with an increased risk for suicide: male sex (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.35-9.42), depression (OR, 1.82; 95% CI, 1.03-3.23), and alcohol use disorder (OR, 3.10; 95% CI, 1.38-6.96). Half (50.7%) had a mental health appointment in the year before suicide. The primary means of suicide was by firearm (62.0%).

CONCLUSIONS

Routine assessment of suicide risk in individuals with MS is warranted, particularly for those with recent history of depression or alcohol use disorder.

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

BACKGROUND

We compared male and female American veterans with schizophrenia or bipolar disorder regarding clinical characteristics associated with lifetime suicidal ideation and behavior. Subsequent mortality, including death by suicide, was also assessed.

METHODS

Data from questionnaires and face-to-face evaluations were collected during 2011-2014 from 8,049 male and 1,290 female veterans with schizophrenia or bipolar disorder. In addition to comparing male-female characteristics, Cox regression models-adjusted for demographic information, medical-psychiatric comorbidities, and self-reported suicidal ideation and behavior-were used to examine gender differences in associations of putative risk factors with suicide-specific and all-cause mortality during up to six years of follow-up.

RESULTS

Women overall were younger, more likely to report a history of suicidal behavior, less likely to be substance abusers, and had lower overall mortality during follow-up. Among women only, psychiatric comorbidity was paradoxically associated with lower all-cause mortality (hazard ratio [HR]=0.53, 95% CI, 0.29-0.96, p = 0.037 for 1 disorder vs. none; HR=0.44, 95% CI, 0.25-0.77, p = 0.004 for ≥2 disorders vs. none). Suicide-specific mortality involved relatively few events, but crude rates were an order of magnitude higher than in the U.S. general and overall veteran populations.

LIMITATIONS

Incomplete cause-of-death information and low statistical power for male-female comparisons regarding mortality.

CONCLUSIONS

Female veterans with SMI differed from females in the general population by having a higher risk of suicide attempts. They also had more lifetime suicide attempts than male veterans with same diagnoses. These differences should inform public policy and clinical planning.

Suicide, Alcohol Intoxication, and Age Among Whites and American Indians/Alaskan Natives

BACKGROUND

Among American Indians/Alaskan Natives (AI/ANs), suicides are disproportionately high among those younger than 40 years of age. This paper examines suicide and alcohol intoxication (postmortem BAC ≥ 0.08 g/dl) by age among Whites and AI/ANs to better understand the reasons for the high rate of suicide among AI/ANs for those younger than 40.

METHODS

Data come from the restricted 2003 to 2016 National Violent Death Reporting System (NVDRS), with postmortem information on 79,150 White and AI/AN suicide decedents of both genders who had a BAC test in 32 states of the United States.

RESULTS

Among Whites, 39.3% of decedents legally intoxicated are younger than 40 years of age, while among AI/ANs the proportion is 72.9% (p < 0.001). Multivariable logistic regression with data divided by age shows that in the 18 to 39 age group, AI/ANs are about 2 times more likely than Whites to have a postmortem BAC ≥ 0.08. Veteran status compared to nonveteran, and history of alcohol problems prior to suicide were also associated with BAC ≥ 0.08. Suicide methods other than by firearm and a report of the presence of 2 or more suicide precipitating circumstances were protective against BAC ≥ 0.08. Results for the age group 40 years of age and older mirror those for the younger group with 1 exception: Race/ethnicity was not associated with BAC level.

CONCLUSIONS

The proportion of suicide decedents with a BAC ≥ 0.08 is higher among AI/ANs than Whites, especially among those 18 to 39 years of age. However, acute alcohol intoxication does not fully explain differences in suicide age structure between AI/ANs and Whites.

Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) in a large sample of Veterans receiving mental health services in the Veterans Health Administration

OBJECTIVE

To evaluate the associations of self-reports of suicidal ideation and behavior using the Columbia-Suicide Severity Rating Scale (C-SSRS) in a survey of patients receiving mental health services in the Veterans Health Administration (VHA) with reports of attempts documented in medical records and administrative data.

METHOD

The C-SSRS was administered to 15,373 Veterans in the Veterans Outcome Assessment (VOA) survey. Concurrent validity was evaluated by comparing self-reports from the past 3 months with VHA records. Predictive validity was evaluated by logistic regression models using attempts over the subsequent 3 months as the outcome.

RESULTS

Tests of concurrent validity found strong associations between self-reports and attempts documented in VHA records, but there were substantial numbers of discordant responses. In tests of predictive validity, area under the ROC curve for predicting future attempts was >0.8. There were differences in the distribution of responses and of psychometric properties across VHA mental health programs.

CONCLUSIONS

Findings support the value of screening and the validity of the self-reports based on the C-SSRS, but limitations in concordance with medical records and variability across programs suggest the need for clinical judgment in interpreting responses.

Assessing psychiatric safety in suicidal emergency department patients

We provide a review of the assessment of suicidal emergency department patients and includes a legal and ethical perspective. Screening tools and psychiatric consultation are important adjuncts to the ED evaluation of potentially suicidal patients. Suicide risk should be assessed, and if positive, an appropriate and safe disposition should be arranged. The aim of this article is to review these assessment tools and consider ethical issues, such as patient autonomy, accountability of the emergency physician, and consultant to Emergency Medical Treatment and Labor Act (EMTALA) as well as confidentiality, privacy, and social issues.

Between- and within-person associations between opioid overdose risk and depression, suicidal ideation, pain severity, and pain interference

BACKGROUND

To better understand overdose (OD) risk and develop tailored overdose risk interventions, we surveyed 234 opioid-using veterans residing in New York City, 2014-2017. Our aim was to better understand how predictors of OD may be associated with physical and mental health challenges, including pain severity and interference, depression and suicidal ideation over time.

METHODS

Veterans completed monthly assessments of the Overdose Risk Behavior Scale (ORBS), pain severity and interference, suicidal ideation, and depression for up to two years and were assessed an average of 14 times over 611 days. To estimate between-person and within-person associations between time-varying covariates and opioid risk behavior, mixed-effects regression was used on the 145-person subsample of veterans completing the baseline and at least three follow-up assessments.

RESULTS

The level of each time-varying covariate at the average of study time (between-person effect) was positively related to ORBS for pain severity and interference, suicidal ideation, and depression. Deviations from individuals' personal trajectories (within-person effect) were positively related to ORBS for pain severity and interference, suicidal ideation, and depression.

CONCLUSIONS

US military veterans endure physical and mental health challenges elevating risk for opioid-related overdose. When pain severity, pain interference, suicidal ideation and depression were higher than usual, opioid risk behavior was higher. Conversely, when these health issues were less of a problem than usual, opioid risk behavior was lower. Assessing the physical and mental health of opioid-using veterans over time may support the development and implementation of interventions to reduce behaviors that increase the likelihood of overdose.

Adapting and implementing Caring Contacts in a Department of Veterans Affairs emergency department: a pilot study protocol

Background

Suicide among veterans is a problem nationally, and suicide prevention remains a high priority for the Department of Veterans Affairs (VA). Focusing suicide prevention initiatives in the emergency department setting provides reach to veterans who may not be seen in mental health and targets a critical risk period, transitions in care following discharge. Caring Contacts is a simple and efficacious suicide prevention approach that could be used to target this risk period. The purpose of this study is to (1) adapt Caring Contacts for use in a VA emergency department, (2) conduct a pilot program at a single VA emergency department, and (3) create an implementation toolkit to facilitate spread of Caring Contacts to other VA facilities.

Methods

This project includes planning activities and a pilot at a VA emergency department. Planning activities will include determining available data sources, determining logistics for identifying and sending Caring Contacts, and creating an implementation toolkit. We will conduct qualitative interviews with emergency department staff and other key stakeholders to gather data on what is needed to adapt and implement Caring Contacts in a VA emergency department setting and possible barriers to and facilitators of implementation. An advisory board of key stakeholders in the facility will be created. Qualitative findings from interviews will be presented to the advisory board for discussion, and the board will use these data to inform decision making regarding implementation of the pilot. Once the pilot is underway, the advisory board will convene again to discuss ongoing progress and determine if any changes are needed to the implementation of the Caring Contacts intervention.

Discussion

Findings from the current project will inform future scale-up and spread of this innovation to other VA medical center emergency departments across the network and other networks. The current pilot will adapt Caring Contacts, create an implementation toolkit and implementation guide, evaluate the feasibility of gathering outcome measures, and provide information about what is needed to implement this evidence-based suicide prevention intervention in a VA emergency department.

Association of Treatment With Metformin vs Sulfonylurea With Major Adverse Cardiovascular Events Among Patients With Diabetes and Reduced Kidney Function

IMPORTANCE

Before 2016, safety concerns limited metformin use in patients with kidney disease; however, the effectiveness of metformin on clinical outcomes in patients with reduced kidney function remains unknown.

OBJECTIVE

To compare major adverse cardiovascular events (MACE) among patients with diabetes and reduced kidney function who continued treatment with metformin or a sulfonylurea.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of US veterans receiving care within the national Veterans Health Administration, with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2001 through 2016. There were 174 882 persistent new users of metformin and sulfonylureas who reached a reduced kidney function threshold (estimated glomerular filtration rate <60 mL/min/1.73 m2 or creatinine ≥1.4 mg/dL for women or ≥1.5 mg/dL for men). Patients were followed up from reduced kidney function threshold until MACE, treatment change, loss to follow-up, death, or study end (December 2016).

EXPOSURES

New users of metformin or sulfonylurea monotherapy who continued treatment with their glucose-lowering medication after reaching reduced kidney function.

MAIN OUTCOMES AND MEASURES

MACE included hospitalization for acute myocardial infarction, stroke, transient ischemic attack, or cardiovascular death. The analyses used propensity score weighting to compare the cause-specific hazard of MACE between treatments and estimate cumulative risk accounting for the competing risks of changing therapy or noncardiovascular death.

RESULTS

There were 67 749 metformin and 28 976 sulfonylurea persistent monotherapy users; the weighted cohort included 24 679 metformin and 24 799 sulfonylurea users (median age, 70 years [interquartile range {IQR}, 62.8-77.8]; 48 497 men [98%]; and 40 476 white individuals [82%], with median estimated glomerular filtration rate of 55.8 mL/min/1.73 m2 [IQR, 51.6-58.2] and hemoglobin A1c level of 6.6% [IQR, 6.1%-7.2%] at cohort entry). During follow-up (median, 1.0 year for metformin vs 1.2 years for sulfonylurea), there were 1048 MACE outcomes (23.0 per 1000 person-years) among metformin users and 1394 events (29.2 per 1000 person-years) among sulfonylurea users. The cause-specific adjusted hazard ratio of MACE for metformin was 0.80 (95% CI, 0.75-0.86) compared with sulfonylureas, yielding an adjusted rate difference of 5.8 (95% CI, 4.1-7.3) fewer events per 1000 person-years of metformin use compared with sulfonylurea use.

CONCLUSIONS AND RELEVANCE

Among patients with diabetes and reduced kidney function persisting with monotherapy, treatment with metformin, compared with a sulfonylurea, was associated with a lower risk of MACE.

Contextual Factors Associated With County-Level Suicide Rates in the United States, 1999 to 2016

IMPORTANCE

Understanding geographic and community-level factors associated with suicide can inform targeted suicide prevention efforts.

OBJECTIVES

To estimate suicide rates and trajectories, assess associated county-level contextual factors, and explore variation across the rural-urban continuum.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included all individuals aged 25 to 64 years who died by suicide from January 1, 1999, to December 31, 2016, in the United States. Spatial analysis was used to map excess risk of suicide, and longitudinal random-effects models using negative binomial regression tested associations of contextual variables with suicide rates as well as interactions among county-level contextual variables. Data analyses were conducted between January 2019 and July 2019.

EXPOSURE

County of residence.

MAIN OUTCOMES AND MEASURES

Three-year county suicide rates during an 18-year period stratified by rural-urban location.

RESULTS

Between 1999 and 2016, 453 577 individuals aged 25 to 64 years died by suicide in the United States. Decedents were primarily male (349 082 [77.0%]) with 101 312 (22.3%) aged 25 to 34 years, 120 157 (26.5%) aged 35 to 44 years, 136 377 (30.1%) aged 45 to 54 years, and 95 771 (21.1%) aged 55 to 64 years. Suicide rates were higher and increased more rapidly in rural than in large metropolitan counties. The highest deprivation quartile was associated with higher suicide rates compared with the lowest deprivation quartile, especially in rural areas, although this association declined during the period studied (rural, 1999-2001: incidence rate ratio [IRR], 1.438; 95% CI, 1.319-1.568; P < .001; large metropolitan, 1999-2001: 1.208; 95% CI, 1.149-1.270; P < .001; rural, 2014-2016: IRR, 1.121; 95% CI, 1.032-1.219; P = .01; large metropolitan, 2014-2016: IRR, 0.942; 95% CI, 0.887-1.001; P = .06). The presence of more gun shops was associated with an increase in county-level suicide rates in all county types except the most rural (rural: IRR, 1.001; 95% CI, 0.999-1.004; P = .40; micropolitan: IRR, 1.005; 95% CI, 1.002-1.007; P < .001; small metropolitan: IRR, 1.010; 95% CI, 1.006-1.014; P < .001; large metropolitan: IRR, 1.012; 95% CI, 1.006-1.018; P < .001). High social capital was associated with lower suicide rates than low social capital (IRR, 0.917; 95% CI, 0.891-0.943; P < .001). High social fragmentation, an increasing percentage of the population without health insurance, and an increasing percentage of veterans in a county were associated with higher suicide rates (high social fragmentation: IRR, 1.077; 95% CI, 1.050-1.103; P < .001; percentage of population without health insurance: IRR, 1.005; 95% CI, 1.004-1.006; P < .001; percentage of veterans: IRR, 1.025; 95% CI, 1.021-1.028; P < .001).

CONCLUSIONS AND RELEVANCE

This study found that suicide rates have increased across the nation and most rapidly in rural counties, which may be more sensitive to the impact of social deprivation than more metropolitan counties. Improving social connectedness, civic opportunities, and health insurance coverage as well as limiting access to lethal means have the potential to reduce suicide rates across the rural-urban continuum.

Negative Life Events (NLEs) Contributing to Psychological Distress, Pain, and Disability in a U.S. Military Sample

Introduction

The objective was to explore how negative life events (NLEs, e.g., litigation related to pain and disability, failing most recent physical fitness test, and financial difficulties) are related to pain coping and psychological adjustment to pain in active duty military personnel.

Materials and Methods

Data were gathered as part of the Evaluation of Suicidality, Cognitions, and Pain Experience study, a DoD-funded cross-sectional assessment of chronic pain and emotional coping among a cohort of military members. The investigators examined data from 147 respondents with complete survey and pain assessment data.

Results

The sample was active duty, male (62.6%), in a relationship or married (83.0%), and had children (68.7%). The majority of the sample endorsed zero NLEs (72.0%); 23.8% endorsed one NLE, 4.2% endorsed two NLEs, and no one endorsed all three NLEs. A significantly higher proportion of participants endorsing one or more NLEs reported suicidal ideation compared to those who reported no NLEs (χ2(2) = 8.61, p = 0.014). A higher number of endorsed NLEs coincided with higher symptom severity related to psychosocial distress (depression, thwarted belongingness, perceived burdensomeness, PTSD, and suicide cognitions) and poor pain coping (rumination, helplessness, and less acceptance of chronic pain).

Conclusions

Findings revealed that NLEs may impart a significant burden on military pain sufferers. Greater numbers of endorsed NLEs are associated with increased psychosocial distress and poor pain coping. Future longitudinal studies examining long-term psychosocial distress/poor pain coping as related to NLEs would help to elaborate the long-term consequences of NLEs on pain coping and psychosocial distress.

The Relationship between Suicidal Responses and Traumatic Brain Injury and Severe Insomnia in Active Duty, Veteran, and Civilian Populations

This study examined how a positive traumatic brain injury (TBI) screening and insomnia severity relate to suicidal outcomes across active duty, veteran, and civilian samples. Data were used from 3,993 participants from 19 studies. We conducted a series of analyses by group to identify which significantly differed on the variables of interest. TBI and insomnia each had independent relationships with outcomes over and above the impact of the other factor. Veterans presented as clinically worse across the outcomes. However, the relationship between insomnia and suicidal responses was stronger for active duty military compared to veterans. Continued research on TBIs and insomnia severity across groups will improve quality of care for those at risk of suicide.

Changing Trends in Opioid Overdose Deaths and Prescription Opioid Receipt Among Veterans

INTRODUCTION

To inform overdose prevention, this study assessed both recent trends in opioid overdose mortality across opioid categories and receipt of prescription opioid analgesics among Veterans who died from overdose in the Veterans Health Administration.

METHODS

Using Veterans Health Administration records linked to National Death Index data, annual cohorts (2010-2016) of Veterans who received Veterans Health Administration care were obtained and were examined by opioid overdose categories (natural/semisynthetic opioids, heroin, methadone, and other synthetic opioids) on (1) overdose rates and changes in rates adjusted for age, sex, and race/ethnicity; and (2) Veterans Health Administration prescription opioid receipt. Analyses were conducted in 2018.

RESULTS

The overall rate of opioid overdose among Veterans increased from 14.47 per 100,000 person-years in 2010 to 21.08 per 100,000 person-years in 2016 (adjusted rate ratio=1.65, 95% CI=1.51, 1.81). There was a decline in methadone overdose (adjusted rate ratio=0.66, 95% CI=0.51, 0.84) and no significant change in natural/semisynthetic opioid overdose (adjusted rate ratio=1.08, 95% CI=0.94, 1.24). However, the synthetic opioid overdose rate (adjusted rate ratio=5.46, 95% CI=4.41, 6.75) and heroin overdose rate (adjusted rate ratio=4.91, 95% CI=3.92, 6.15) increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016.

CONCLUSIONS

Opioid overdose rates among Veterans Health Administration Veterans increased because of increases in heroin and synthetic opioid overdose rates. Prescriptions of opioids declined among patients who died from all categories of opioid overdose; by 2016, only a minority received an opioid analgesic from Veterans Health Administration within 3 months of overdose. Future prevention efforts should extend beyond patients actively receiving opioid prescriptions.

Social isolation as a promising animal model of PTSD comorbid suicide: neurosteroids and cannabinoids as possible treatment options

Post-traumatic stress disorder (PTSD) is a psychiatric condition characterized by drastic alterations in mood, emotions, social abilities and cognition. Notably, one aspect of PTSD, particularly in veterans, is its comorbidity with suicide. Elevated aggressiveness predicts high-risk to suicide in humans and despite the difficulty in reproducing a complex human suicidal behavior in rodents, aggressive behavior is a well reproducible behavioral trait of suicide. PTSD animal models are based on a peculiar phenotype, including exaggerated fear memory and impaired fear extinction associated with neurochemical dysregulations in the brain circuitry regulating emotion. The endocannabinoid and the neurosteroid systems regulate emotions and stress responses, and recent evidence shows these two systems are interrelated and critically compromised in neuropsychiatric disorders. For instance, levels of the neurosteroid, allopregnanolone, as well as those of the endocannabinoids, anandamide and its congener, palmitoylethanolamide are decreased in PTSD. Similarly, the endocannabinoid system and neurosteroid biosynthesis are altered in suicidal individuals. Selective serotonin reuptake inhibitors (SSRIs), the only FDA-approved treatments for PTSD, fail to help half of the treatment-seeking patients. This highlights the need for developing biomarker-based efficient therapies. One promising alternative to SSRIs points to stimulation of allopregnanolone biosynthesis as a treatment and a valid end-point to predict treatment response in PTSD patients. This review highlights running findings on the role of the endocannabinoid and neurosteroid systems in PTSD and suicidal behavior both in a preclinical and clinical perspective. A specific focus is given to predictive PTSD/suicide animal models. Ultimately, we discuss the idea that disruption of neurosteroid and endocannabinoid biosynthesis may offer a novel promising biomarker axis to develop new treatments for PTSD and, perhaps, suicidal behavior.

Suicide Rates Among Active Duty Service Members Compared with Civilian Counterparts, 2005-2014

The objective of this study was to compare military suicide rates with civilian suicide rates, adjusting for age and sex differences that exist between the two populations. The number of active component (AC) service members whose manner of death was certified as suicide was determined for specific age and sex groups for each year from 2005 to 2014. Indirect standardization was then used to determine the expected number of suicides for each age/sex group, based on the U.S. suicide rates for the corresponding age/sex groups obtained from the Centers for Disease Control and Prevention's Web-based Injury Statistics Query and Reporting System. Although suicide rates among U.S. active duty Service Members were found to increase between 2005 and 2009, overall age- and sex-adjusted AC suicide rates were lower than or comparable to civilian rates every year of the study period. When suicide numbers were analyzed within specific age and sex categories, there was a significant association between higher suicide incidence and AC military status for 17-29-yr-old females in 2010, 2012, and 2014, and a significant association between lower suicide incidence and AC military status for 25-49 -yr-old males in some years.

A National Comparison of Suicide Among Medicaid and Non-Medicaid Youth

INTRODUCTION

In the U.S., youth enrolled in Medicaid experience more risk factors for suicide, such as mental illness, than youth not enrolled in Medicaid. To inform a national suicide prevention strategy, this study presents suicide rates in a sample of youth enrolled in Medicaid and compares them with rates in the non-Medicaid population.

METHODS

Data sources were death certificate data matched with Medicaid data from 16 states, and the Web-based Injury Statistics Query and Reporting System. Deaths by suicide that occurred between 2009 and 2013 by youth aged 10 to 18 years were identified for Medicaid and non-Medicaid groups. Age-, gender-, and cause-specific mortality rates were calculated separately for both groups. Standardized mortality ratios were calculated to compare rates, and standardized mortality ratio 95% CIs were estimated with Poisson regressions. The data were analyzed in 2018.

RESULTS

A substantial proportion (39%) of the total number of deaths by suicide (N=4,045) in youth occurred among those enrolled in Medicaid. The overall suicide rate did not significantly differ between groups (standardized mortality ratio=0.96, 95% CI=0.90, 1.03). However, compared with the non-Medicaid group, the suicide rate in the Medicaid group was significantly higher among youth aged 10 to 14 years (standardized mortality ratio=1.28, 95% CI=1.11, 1.47), females (regardless of age; standardized mortality ratio=1.14, 95% CI=1.01, 1.29), and those who died by hanging (standardized mortality ratio=1.26, 95% CI=1.16, 1.38).

CONCLUSIONS

The population-based profile of suicide among youth enrolled in Medicaid differs from the profile of youth not enrolled in Medicaid, confirming the importance of Medicaid as a "boundaried" suicide prevention setting.

Health coverage types and their relationship to mental and physical health in U.S. veterans

OBJECTIVE

To examine sociodemographic characteristics and chronic health conditions in veterans across health coverage types including those without coverage.

DESIGN

The sample included cross-sectional data from veterans aged 18 years and over, collected in the 2016 National Health Interview Survey (n = 3487). Chronic health conditions and sociodemographic variables were examined across eleven health coverage types and combinations of health coverage types, as follows: No coverage, Medicare, Medicaid, Private, TRICARE (formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS)), TRICARE and Medicare, Veteran's Administration, Veteran's Administration and Medicare, Veteran's Administration and Private, Veteran's Administration and Private and Medicare.

RESULTS

Approximately 3.9% of veterans did not have coverage. The greatest proportion had private coverage (28.2%), then private coverage plus Medicare (19.6%). Only 5.9% had Veterans Administration coverage solely. Among the veterans not covered, the majority were young, lived alone, had less than a high school education and resided in the South. The most common chronic health conditions among non-covered veterans were obesity and migraine. Regional differences were observed in the types of chronic health conditions. Veterans in the Northeast were less likely to report serious psychological distress. In a logistic regression, younger age (18-44 years), living alone and having less than a high school education were predictive of no coverage, but number of chronic health conditions was not.

CONCLUSION

A population of veterans without health coverage may be undeserved and at risk for poor mental and physical health due to non-health related factors.

Carbon monoxide poisoning surveillance in the Veterans Health Administration, 2010-2017

BACKGROUND

Exposure to carbon monoxide (CO), the odorless, colorless gas resulting from incomplete combustion of hydrocarbons, is preventable. Despite the significant risk of morbidity and mortality associated with CO poisoning, there currently exists no active national CO surveillance system in the United States (U.S.). Our study aims to use electronic health record data to describe the epidemiology of CO poisoning in the Veterans Health Administration healthcare population.

METHODS

We identified unique inpatient and outpatient encounters coded with International Classification of Diseases (ICD) codes for CO poisoning and analyzed relevant demographic, laboratory, treatment, and death data from January 2010 through December 2017 for Veterans across all 50 U.S. states and Puerto Rico. Statistical methods used were 95% CI calculations and the two-tailed z test for proportions.

RESULTS

We identified 5491 unique patients with CO poisoning, of which 1755 (32%) were confirmed/probable and 3736 (68%) were suspected. Unintentional poisoning was most common (72.9%) overall. Age less than 65 years, residence in Midwest U.S. Census region versus South or West, and winter seasonal trend were characteristics associated with confirmed/probable CO poisoning. Twenty-six deaths (1.5%) occurred within 30 days of confirmed/probable CO poisoning and were primarily caused by cardiovascular events (42%) or anoxic encephalopathy (15%).

CONCLUSIONS

Our findings support the use of ICD-coded data for targeted CO poisoning surveillance, however, improvements are needed in ICD coding to reduce the percentage of cases coded with unknown injury intent and/or CO poisoning source. Prevalence of CO poisoning among Veterans is consistent with other U.S. estimates. Since most cases are unintentional, opportunities exist for provider and patient education to reduce risk.

Suicide risk among Veteran primary care patients with current anxiety symptoms

BACKGROUND

Although anxiety is prevalent in primary care, the association between anxiety symptoms and suicide risk remains understudied.

OBJECTIVES

This cross-sectional study aimed to (i) assess the prevalence of suicide risk among Veteran primary care patients with anxiety symptoms and (ii) compare suicide risk between patients with a positive (versus negative) depression screen.

METHODS

Participants were 182 adult primary care patients (84.6% male, Mage = 58.3 years) with current anxiety symptoms, but no psychotherapy in specialty care in the past year, at a Veterans Health Administration medical center in New York. Participants completed self-report measures of anxiety, depression and suicide risk via telephone.

RESULTS

Forty percent endorsed ≥1 suicide risk item. Suicide risk was more common among those screening positive (versus negative) for depression (50.5% versus 26.5%, χ2 (1) = 10.88; P = 0.001). Participants with a negative depression screen constituted 31% of all those with any suicide risk. Logistic regression revealed that anxiety symptom severity was not associated with suicide risk (P = 0.14) after controlling for age, sex and depression screen status (P = 0.01).

CONCLUSIONS

A substantial proportion of primary care patients with anxiety was classified as at risk for suicide, even in the absence of a positive depression screen. Primary care providers should assess suicide risk among patients with anxiety symptoms, even if the patients are not seeking specialty mental health treatment, the anxiety symptoms are not severe or do not rise to the level of an anxiety disorder, and comorbid depressive symptoms are not present.