Mental Health Care Utilization and Psychiatric Diagnoses in a Sample of Military Suicide Decedents and Living Matched Controls

External Validation and Updating of a Statistical Civilian-Based Suicide Risk Model in US Naval Primary Care

Importance

Suicide remains an ongoing concern in the US military. Statistical models have not been broadly disseminated for US Navy service members.

Objective

To externally validate and update a statistical suicide risk model initially developed in a civilian setting with an emphasis on primary care.

Design, Setting, and Participants

This retrospective cohort study used data collected from 2007 through 2017 among active-duty US Navy service members. The external civilian model was applied to every visit at Naval Medical Center Portsmouth (NMCP), its NMCP Naval Branch Health Clinics (NBHCs), and TRICARE Prime Clinics (TPCs) that fall within the NMCP area. The model was retrained and recalibrated using visits to NBHCs and TPCs and updated using Department of Defense (DoD)-specific billing codes and demographic characteristics, including expanded race and ethnicity categories. Domain and temporal analyses were performed with bootstrap validation. Data analysis was performed from September 2020 to December 2022.

Exposure

Visit to US NMCP.

Main Outcomes and Measures

Recorded suicidal behavior on the day of or within 30 days of a visit. Performance was assessed using area under the receiver operating curve (AUROC), area under the precision recall curve (AUPRC), Brier score, and Spiegelhalter z-test statistic.

Results

Of the 260 583 service members, 6529 (2.5%) had a recorded suicidal behavior, 206 412 (79.2%) were male; 104 835 (40.2%) were aged 20 to 24 years; and 9458 (3.6%) were Asian, 56 715 (21.8%) were Black or African American, and 158 277 (60.7%) were White. Applying the civilian-trained model resulted in an AUROC of 0.77 (95% CI, 0.74-0.79) and an AUPRC of 0.004 (95% CI, 0.003-0.005) at NBHCs with poor calibration (Spiegelhalter P < .001). Retraining the algorithm improved AUROC to 0.92 (95% CI, 0.91-0.93) and AUPRC to 0.66 (95% CI, 0.63-0.68). Number needed to screen in the top risk tiers was 366 for the external model and 200 for the retrained model; the lower number indicates better performance. Domain validation showed AUROC of 0.90 (95% CI, 0.90-0.91) and AUPRC of 0.01 (95% CI, 0.01-0.01), and temporal validation showed AUROC of 0.75 (95% CI, 0.72-0.78) and AUPRC of 0.003 (95% CI, 0.003-0.005).

Conclusions and Relevance

In this cohort study of active-duty Navy service members, a civilian suicide attempt risk model was externally validated. Retraining and updating with DoD-specific variables improved performance. Domain and temporal validation results were similar to external validation, suggesting that implementing an external model in US Navy primary care clinics may bypass the need for costly internal development and expedite the automation of suicide prevention in these clinics.

Characteristics of suicide decedents with no federally funded mental health service contact in the 12 months before death in a population-based sample of Australians 45 years of age and over

INTRODUCTION

More than half of suicide decedents have no contact with mental health services 12 months before death. It is uncertain if they have different characteristics than decedents who use mental health services.

METHODS

A case-series design. Participants 45 years and older, who died by suicide (2006-2018). Comparisons were made between those who did and did not have contact with mental health services, using individually linked data from federal services in the Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS).

RESULTS

Of 186 cases, 71% had no contact with mental health services. Physical health services were used equally by 75%. Psychiatric medication use was uncommon, except for antidepressants, 50% with mental health service contact and 20% with no contact. Older age, lower income, involuntarily unemployed, firearms as suicide method, greater physical disability, less functional impairment due to emotional problems and lesser proportions with mental illness, were associated with no contact with mental health services.

CONCLUSIONS

For suicide prevention, middle-older aged adults may have less requirement for mental health intervention, and greater requirement for the development of complementary interventions focused on physical health and social issues, which are not necessarily best delivered by clinical mental health services.

Contact with the health care system prior to suicide: A nationwide population-based analysis using linkage national death certificates and national health insurance data

This study aimed to discover the proportion of people dying by suicide who had non-psychiatric medical contact alone or any mental health contact in the year, month, and week prior to suicide. Data on suicide deaths (n = 74,741) of all South Koreans from 2009 to 2013 were linked with National Health Insurance (NHI) data by social security number to identify health care contact during the 12 months prior to suicide. The NHI data includes records on inpatient or outpatient service and type of health care institutes which the decedents have contacted. Among the 74,741 individuals who died by suicide, the proportion of individuals who contacted non-psychiatric health care alone was 60.1%, 46.1%, and 35.5%; and the proportion of those who had any mental health contact was 27.9%, 18.0%, and 7.9% in the year, four weeks, and week before death, respectively. Psychiatric care visits in the year, four weeks and weeks prior to death occurred most frequently in psychiatric local clinics. Non-psychiatric care visits in the year and four weeks prior to death were most common in local clinics at the primary care level, but in the one week before death, non-psychiatric care visits were common in tertiary hospital departments. This study indicates that the majority of suicide cases are not diagnosed and managed preceding death despite high general medical contact rates. It implies that suicide prevention strategy should be applied to non-psychiatric medical settings in countries with high suicide rates like South Korea.

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual

Suicide rates have been steadily increasing in both the U.S. general population and military, with significant psychological and economic consequences. The purpose of the current study was to examine the economic costs and cost-benefit of the suicide-focused Collaborative Assessment and Management of Suicidality (CAMS) intervention versus enhanced treatment as usual (ETAU) in an active duty military sample using data from a recent randomized controlled trial of CAMS versus ETAU. The full intent-to-treat sample included 148 participants (mean age 26.8 years ± 5.9 SD years, 80% male, 53% White). Using a micro-costing approach, the cost of each condition was calculated at the individual level from a healthcare system perspective. Benefits were estimated at the individual level as cost savings in past-year healthcare expenditures based on direct care reimbursement rates. Cost-benefit was examined in the form of cost-benefit ratios and net benefit. Total costs, benefits, cost-benefit ratios, and net benefit were calculated and analyzed using general linear mixed modeling on multiply imputed datasets. Results indicated that treatment costs did not differ significantly between conditions; however, CAMS was found to produce significantly greater benefit in the form of decreased healthcare expenditures at 6-month follow-up. CAMS also demonstrated significantly greater cost-benefit ratios (i.e., benefit per dollar spent on treatment) and net-benefit (i.e., total benefit less the cost of treatment) at 12-month follow-up. The current study suggests that beyond its clinical effectiveness, CAMS may also convey potential economic advantages over usual care for the treatment of suicidal active duty service members. Our findings demonstrate cost savings in the form of reduced healthcare expenditures, which theoretically represent resources that can be reallocated toward other healthcare system needs, and thus lend support toward the overall value of CAMS.

People Who Die by Suicide Without Receiving Mental Health Services: A Systematic Review

Introduction

The majority of people who die by suicide have never seen a mental health professional or been diagnosed with a mental illness. To date, this majority group has largely been ignored, with most existing research focusing on predictors of suicide such as past suicide attempts. Identifying the characteristics of people who die by suicide without receiving services, often with a fatal first attempt, is crucial to reduce suicide rates through guiding improvements to service pathways and “just in time” interventions.

Methods

In this systematic review, PsycInfo, PubMed, CINAHL, and Web of Science were searched for peer-reviewed articles published from 1980 to 1st March 2021. Included studies examined predictors of non-receipt of formal mental health services among people who died by suicide. Data were extracted from published reports and the quality of included studies was assessed using a modified version of the Joanna Briggs Institute Checklist for Analytical Cross Sectional Studies. This review was registered with PROSPERO, CRD 42021226543.

Results

Sixty-seven studies met inclusion criteria, with sample sizes ranging from 39 to 193,152 individuals. Male sex, younger or older age, and rural location were consistently associated with non-receipt of mental health services. People not receiving mental health services were also less likely to have a psychiatric diagnosis, past suicidal behavior or contact with general health services, and more likely to use violent means of suicide. There was some evidence that minority ethnicity and psychosocial stressors were associated with service non-receipt.

Conclusion

People who die by suicide without receiving mental health services are likely to have diverse profiles, indicating the need for multifaceted approaches to effectively support people at risk of suicide. Identifying the needs and preferences of individuals who are at risk of suicide is crucial in developing new support pathways and services, and improving the quality of existing services.

Systematic Review Registration

http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42021226543.