Association between suicide, external-cause and all-cause mortality and irregular mental health discharge among the US veteran population

An Analysis of Irregular Discharges From Residential Treatment Programs in the Department of Veterans Affairs Health Care System

INTRODUCTION

Veteran populations are frequently diagnosed with mental health conditions such as substance use disorder and PTSD. These conditions are associated with adverse outcomes including a higher risk of suicide. The Veterans Health Administration (VHA) has designed a robust mental health system to address these concerns. Veterans can access mental health treatment in acute inpatient, residential, and outpatient settings. Residential programs play an important role in meeting the needs of veterans who need more structure and support. Residential specialty types in the VHA include general mental health, substance use disorder, PTSD, and homeless/work programs. These programs are affiliated with a DVA facility (i.e., medical center). Although residential care can improve outcomes, there is evidence that some patients are discharged from these settings before achieving the program endpoint. These unplanned discharges are referred to using language such as against medical advice, self-discharge, or irregular discharge. Concerningly, unplanned discharges are associated with patient harm including death by suicide. Although there is some initial evidence to locate factors that predict irregular discharge in VHA residential programs, no work has been done to examine features associated with irregular discharge in each residential specialty.

METHODS

We conducted a retrospective cohort study of patients who were discharged from VHA residential treatment programs between January 2018 and September 2022. We included the following covariates: Principal diagnosis, gender, age, race/ethnicity, number of physical health conditions, number of mental health diagnostic categories, marital status, risk of homelessness, urbanicity, and service connection. We considered two discharge types: Regular and irregular. We used logistic regression to determine the odds of irregular discharge using models stratified by bed specialty as well as combined odds ratios and 95% CIs across program specialties. The primary purposes are to identify factors that predict irregular discharge and to determine if the factors are consistent across bed specialties. In a secondary analysis, we calculated facility-level adjusted rates of irregular discharge, limiting to facilities with at least 50 discharges. We identified the amount of residual variation that exists between facilities after adjusting for patient factors.

RESULTS

A total of 279 residential programs (78,588 patients representing 124,632 discharges) were included in the analysis. Substance use disorder and homeless/work programs were the most common specialty types. Both in the overall and stratified analyses, the number of mental health diagnostic categories and younger age were predictors of irregular discharge. In the facility analysis, there was substantial variation in irregular discharge rates across residential specialties even after adjusting for all patient factors. For example, PTSD programs had a mean adjusted irregular discharge rate of 15.3% (SD: 7.4; range: 2.1-31.2; coefficient of variation: 48.4%).

CONCLUSIONS

Irregular discharge is a key concern in VHA residential care. Patient characteristics do not account for all of the observed variation in rates across residential specialty types. There is a need to develop specialty-specific measures of irregular discharge to learn about system-level factors that contribute to irregular discharge. These data can inform strategies to avoid harms associated with irregular discharge.

Pilot randomized controlled trial of a brief strategy to prevent suicide after discharge from residential addiction treatment

INTRODUCTION

Veterans are at greater risk for suicide and veterans with substance use disorder (SUD) have an even greater risk. Little research has looked into brief interventions to prevent suicide in this population in residential substance use treatment programs.

METHOD

We conducted a pilot, randomized controlled trial of a brief suicide prevention strategy called Veterans Affairs Brief Intervention and Contact Program (VA BIC) in patients participating in the Residential Recovery Center (RRC) SUD 28-day program and deemed at risk for suicide. We measured changes in symptoms at 1-, 3-, and 6-months. We looked at social connectedness, suicidal ideation, hopelessness, thwarted belongingness, perceived burdensomeness, and treatment engagement.

RESULTS

The study enrolled twenty patients. One participant withdrew immediately after baseline. We found that adherence to VA BIC components was high, as 100 % of patients (N = 10) completed 70 % or more of the VA BIC visits. Furthermore, 80 % of intervention group patients (N = 8) completed all VA BIC components. During the six-month follow-up, suicidal ideation improved in patients assigned to VA BIC, while it worsened in the standard care arm. Similarly, patients assigned to VA BIC reported a reduction in perceived burdensomeness over the six-month follow-up period while it worsened in the standard care arm. Additionally, VA BIC may modestly improve treatment engagement in the first month postdischarge.

CONCLUSION

We were able to recruit and enroll patients from a residential SUD treatment program into a clinical trial of the VA BIC intervention. Our preliminary results suggest that VA BIC may be useful in reducing suicidal ideation and perceived burdensomeness in patients who are discharged from residential SUD treatment programs and increasing treatment engagement. Future trials of VA BIC should determine whether VA BIC can reduce the risk of suicide in patients who are discharged from residential SUD treatment programs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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