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

Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans

BACKGROUND

Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk.

OBJECTIVE

To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population.

DESIGN

We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1-30, days 31-365, and days 1-365.

PARTICIPANTS

VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators.

MAIN MEASURES

Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined.

KEY RESULTS

198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1-30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31-365 HR = 1.30 (CI:1.19, 1.43) and days 1-365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1-30 HR = 1.94 (CI:1.51, 2.49), days 31-365 HR = 1.32 (CI:1.20, 1.45) and days 1-365 HR = 1.38 (CI:1.26, 1.51).

CONCLUSIONS

COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.

Suicide Risk Among Military Veterans in the Southwestern United States Before and During the COVID-19 Pandemic

INTRODUCTION

Military Veterans have an increased risk of suicide compared to the general population, but less is known about changes in risk with the onset of the COVID-19 pandemic, or whether any changes have been moderated by psychiatric or demographic factors. The primary objective was to test the hypothesis that the likelihood of suicide attempt or death by suicide was stable during the first year of the pandemic versus the preceding year for the full sample. A second objective was to test the hypothesis that, in contrast, risk increased for Veteran subgroups characterized by traditional risk factors (e.g., psychiatric diagnosis).

MATERIALS AND METHODS

We extracted electronic health record data for 771,570 Veterans who received one or more health care visits between March 13, 2019, and March 12, 2021, at eight VA hospitals across the southwestern United States. Primary outcome measures were suicide attempts and deaths by suicide. Predictor variables included psychiatric diagnoses and demographic factors.

RESULTS

Multivariable models indicated that the odds of death by suicide did not change during the first year of the COVID-19 pandemic, while the odds of making a suicide attempt declined. Veterans treated for major depression were at heightened risk for attempting suicide in both years, but the association was smaller during the pandemic than the year prior. In contrast, the relative risk of attempt for Veterans who were never married and Veterans treated for a non-alcohol, non-opioid substance-use disorder increased during the pandemic.

CONCLUSIONS AND RELEVANCE

The findings suggest that the pandemic has not led to an increase in suicidal behavior, which is consistent with other studies, although the degree of decline varied across diagnostic and demographic groups. Further longitudinal research is needed to evaluate whether the prolonged nature of COVID-19 may lead to changes in risk over time.

Firefighter Suicide: A Theoretical Model for a Population Specific Behavioral Autopsy Program

Some research suggests that firefighters are possibly at greater risk than other at-risk first responder/public service populations for suicidality (e.g., police, Veterans, active duty military non-deployed males; Martin et al., 2017; Stanley et al., 2015; Stanley et al., 2016). Behavioral autopsies have been utilized to elucidate the clinical picture of other at-risk populations; however, to date there is no proposed or applied model for a suicide behavior autopsy in fire personnel. Developing a standardized suicide behavior autopsy will allow for a comprehensive understanding of firefighters who die by suicide and highlight potential areas for intervention. The aim of this paper is to integrate best practices for autopsy procedures from other high-risk populations into a comprehensive theoretical model for a proposed behavioral health autopsy for firefighters. Our recommended protocol is presented along with relevant limitations, clinical implications, and recommendations for future research.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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