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Stecker T, Allan NP, Hoge C, Ashrafioun L, Conner KR. Efficacy of CBT for Treatment Seeking (CBT-TS) in Untreated Veterans and Service Members at Risk for Suicidal Behavior. J Gen Intern Med 2023; 38:2639-2646. [PMID: 36964422 PMCID: PMC10506992 DOI: 10.1007/s11606-023-08129-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 03/01/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVE Military members and Veterans at-risk for suicide are often unlikely to seek behavioral health treatment. The primary aim of this study was to test the efficacy of brief CBT for Treatment Seeking (CBT-TS) to improve behavioral health treatment utilization among U.S. military service members and Veterans at-risk for suicide. METHODS A total of 841 participants who served in the U.S. military since 9/11 and who reported suicidality but were not in behavioral health treatment were recruited to participate in this trial. Participants were randomly assigned to either brief CBT-TS delivered by phone or an assessment-only control condition. Follow-up assessments were conducted at baseline and months 1, 3, 6, and 12 to track treatment utilization and symptoms. RESULTS CBT-TS resulted in significantly greater behavioral health treatment initiation within 1 month compared to the control condition (B = .93, p < .001); and the higher treatment initiation persisted for 12 months post intervention. CONCLUSIONS This study employed a low-cost, easily implementable one-session intervention administered by phone. The study provides evidence that CBT-TS is efficacious in promoting behavioral health treatment initiation in an adult population at risk for suicidal behavior and showed enduring benefits for 6-12 months. CBT-TS provides a unique strategy for treatment engagement for at-risk adults unlikely to seek treatment. TRIAL REGISTRATION Clinicaltrials.gov NCT05077514.
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Affiliation(s)
- Tracy Stecker
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA.
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Health Care System, Canandaigua, NY, USA.
| | - Nicholas P Allan
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Health Care System, Canandaigua, NY, USA
- Department of Psychology, Ohio State University, Columbus, OH, USA
| | - Charles Hoge
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Lisham Ashrafioun
- VA Center of Excellence for Suicide Prevention, VA Finger Lakes Health Care System, Canandaigua, NY, USA
- Departments of Emergency Medicine and Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kenneth R Conner
- Departments of Emergency Medicine and Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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2
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Nichter B, Hill M, Norman S, Haller M, Pietrzak RH. Mental health treatment utilization among U.S. military veterans with suicidal ideation: Results from the National Health and Resilience in Veterans Study. J Psychiatr Res 2020; 130:61-67. [PMID: 32783995 DOI: 10.1016/j.jpsychires.2020.07.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/14/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Despite advances in the treatment of suicidality over the last decade, a significant proportion of veterans with suicidal ideation do not utilize mental health treatment. To date, however, few population-based studies have examined factors that may facilitate or impede mental healthcare engagement among veterans currently contemplating suicide. This study examined barriers and facilitators of current mental healthcare utilization in a nationally representative sample of U.S. military veterans who endorsed current suicidal ideation. METHODS Using data from the National Health and Resilience in Veterans Study (n = 3157), collected in 2011, multivariable analyses were conducted to identify predisposing (e.g., age), enabling (e.g., social support), and need (e.g., psychiatric history) characteristics, as well as perceptions of stigma and barriers to care, associated with current mental healthcare utilization. RESULTS A total of 7.3% (n = 231) of veterans endorsed current suicidal ideation, of which 36.1% (n = 84) were engaged in current mental health treatment. Younger age, female sex, current depression, lifetime suicide attempt(s), and number of lifetime traumas and medical problems were associated with treatment utilization. Mistrust of mental health providers and fear of treatment harming one's reputation were associated with lower likelihood of treatment engagement, over and above the effects of these predisposing, enabling, and need characteristics. DISCUSSION More than 3 of 5 U.S. veterans endorsing current suicidal ideation are not engaged in mental health treatment. Results underscore the importance of multi-modal suicide prevention and treatment engagement efforts that target need-based factors, and perceptions of stigma and negative beliefs about mental healthcare in this population.
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Affiliation(s)
- Brandon Nichter
- Department of Psychiatry, University of California, San Diego, 92093, CA, USA.
| | - Melanie Hill
- Department of Psychiatry, University of California, San Diego, 92093, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Sonya Norman
- Department of Psychiatry, University of California, San Diego, 92093, CA, USA; National Center for PTSD, White River Junction, VT, USA; VA Center of Excellence for Stress and Mental Health, San Diego, CA, USA
| | - Moira Haller
- Department of Psychiatry, University of California, San Diego, 92093, CA, USA; VA San Diego Healthcare System, San Diego, CA, USA
| | - Robert H Pietrzak
- National Center for PTSD, VA Connecticut Healthcare System, West Haven, CT, USA; Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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3
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Simons K, Van Orden K, Conner KR, Bagge C. Age Differences in Suicide Risk Screening and Management Prior to Suicide Attempts. Am J Geriatr Psychiatry 2019; 27:604-608. [PMID: 30799168 DOI: 10.1016/j.jagp.2019.01.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study examined differences by age in suicide risk screening and clinical actions to reduce suicide risk among patients with visits to Veterans Health Administration (VHA) medical facilities in the year prior to an attempt. METHODS Ninety-three VHA patient records were reviewed specific to the last visit before an attempt. Information was extracted regarding documentation of individual suicide risk factors and provider actions to reduce risk. RESULTS The authors examined differences by patient age (≥50 versus 18-49). Older patients' medical records were less likely to have evidence of 1) screening for impulsivity and firearms access and 2) engagement in safety planning, referrals for mental health services, and consideration of psychiatric hospitalization. General medical providers were less likely to document these risk factors and action steps in comparison with mental health clinicians. CONCLUSION Lethal means education and collaborative care are universal strategies that may improve identification of and lower suicide risk in older veterans.
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Affiliation(s)
- Kelsey Simons
- VISN 2 Center of Excellence for Suicide Prevention (KS, KVO), Canandaigua VA Medical Center, Canandaigua, NY; Department of Psychiatry (KS, KVO, KRC), University of Rochester School of Medicine and Dentistry, Rochester, NY.
| | - Kimberly Van Orden
- VISN 2 Center of Excellence for Suicide Prevention (KS, KVO), Canandaigua VA Medical Center, Canandaigua, NY; Department of Psychiatry (KS, KVO, KRC), University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Kenneth R Conner
- Department of Psychiatry (KS, KVO, KRC), University of Rochester School of Medicine and Dentistry, Rochester, NY; Department of Emergency Medicine (KRC), University of Rochester Medical Center, Rochester, NY
| | - Courtney Bagge
- Department of Psychiatry and Human Behavior (CB), University of Mississippi Medical Center, Jackson, MS
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4
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Ribeiro JD, Gutierrez PM, Joiner TE, Kessler RC, Petukhova MV, Sampson NA, Stein MB, Ursano RJ, Nock MK. Health care contact and suicide risk documentation prior to suicide death: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). J Consult Clin Psychol 2017; 85:403-408. [PMID: 28333538 PMCID: PMC5364817 DOI: 10.1037/ccp0000178] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Prior research has shown that a substantial portion of suicide decedents access health care in the weeks and months before their death. We examined whether this is true among soldiers. METHOD The sample included the 569 Regular Army soldiers in the U.S. Army who died by suicide on active duty between 2004 and 2009 compared to 5,690 matched controls. Analyses examined the prevalence and frequency of health care contacts and documentation of suicide risk (i.e., the presence of prior suicidal thoughts and behaviors) over the year preceding suicide death. Predictors of health care contact and suicide risk documentation were also examined. RESULTS Approximately 50% of suicide decedents accessed health care in the month prior to their death, and over 25% of suicide decedents accessed health care in the week prior to their death. Mental health encounters were significantly more prevalent among suicide decedents (4 weeks: 27.9% vs. 7.9%, χ2 = 96.2, p < .001; 52 weeks: 59.4% vs. 33.7%, χ2 = 120.2, p < .001). Despite this, risk documentation was rare among suicide decedents (4 weeks: 13.8%; 52 weeks: 24.5%). Suicide decedents who were male, never married, and non-Hispanic Black were less likely to access care prior to death. Number of mental health encounters was the only predictor of suicide risk documentation among decedents at 4 weeks (OR = 1.14) and 52 weeks (OR = 1.05) prior to their death. CONCLUSIONS Many soldiers who die by suicide access health care shortly before death, presenting an opportunity for suicide prevention. However, in most cases, there was no documentation of prior suicidal thoughts or behaviors, highlighting the need for improvements in risk detection and prediction. Increasing the frequency, scope, and accuracy of risk assessments, especially in mental health care settings, may be particularly useful. (PsycINFO Database Record
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Affiliation(s)
| | - Peter M. Gutierrez
- Department of Psychiatry, University of Colorado School of Medicine
- Denver Veterans Affairs Medical Center, Rocky Mountain Mental Illness Research, Education, and Clinical Center
| | | | | | | | | | - Murray B. Stein
- University of California, San Diego
- Veterans Affairs San Diego Healthcare System
| | - Robert J. Ursano
- Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of Health Sciences
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5
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Schaffer A, Sinyor M, Kurdyak P, Vigod S, Sareen J, Reis C, Green D, Bolton J, Rhodes A, Grigoriadis S, Cairney J, Cheung A. Population-based analysis of health care contacts among suicide decedents: identifying opportunities for more targeted suicide prevention strategies. World Psychiatry 2016; 15:135-45. [PMID: 27265704 PMCID: PMC4911782 DOI: 10.1002/wps.20321] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The objective of this study was to detail the nature and correlates of mental health and non-mental health care contacts prior to suicide death. We conducted a systematic extraction of data from records at the Office of the Chief Coroner of Ontario of each person who died by suicide in the city of Toronto from 1998 to 2011. Data on 2,835 suicide deaths were linked with provincial health administrative data to identify health care contacts during the 12 months prior to suicide. Sub-populations of suicide decedents based on the presence and type of mental health care contact were described and compared across socio-demographic, clinical and suicide-specific variables. Time periods from last mental health contact to date of death were calculated and a Cox proportional hazards model examined covariates. Among suicide decedents, 91.7% had some type of past-year health care contact prior to death, 66.4% had a mental health care contact, and 25.3% had only non-mental health contacts. The most common type of mental health contact was an outpatient primary care visit (54.0%), followed by an outpatient psychiatric visit (39.8%), an emergency department visit (31.1%), and a psychiatric hospitalization (21.0%). The median time from last mental health contact to death was 18 days (interquartile range 5-63). Mental health contact was significantly associated with female gender, age 25-64, absence of a psychosocial stressor, diagnosis of schizophrenia or bipolar disorder, past suicide attempt, self-poisoning method and absence of a suicide note. Significant differences between sub-populations of suicide decedents based on the presence and nature of their health care contacts suggest the need for targeting of community and clinical-based suicide prevention strategies. The predominance of ambulatory mental health care contacts, often close to the time of death, reinforce the importance of concentrating efforts on embedding risk assessment and care pathways into all routine primary and specialty clinical care, and not only acute care settings.
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Affiliation(s)
- Ayal Schaffer
- Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada,Department of Psychiatry, Faculty of MedicineUniversity of TorontoTorontoCanada
| | - Mark Sinyor
- Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada,Department of Psychiatry, Faculty of MedicineUniversity of TorontoTorontoCanada
| | - Paul Kurdyak
- Department of Psychiatry, Faculty of MedicineUniversity of TorontoTorontoCanada,Health Systems Research, Centre for Addiction and Mental HealthTorontoCanada
| | - Simone Vigod
- Department of Psychiatry, Faculty of MedicineUniversity of TorontoTorontoCanada,Department of PsychiatryWomen's College HospitalTorontoCanada
| | - Jitender Sareen
- University of ManitobaWinnipegCanada,Winnipeg Regional Health Authority Adult Mental Health ProgramWinnipegCanada
| | - Catherine Reis
- Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada
| | - Diane Green
- Institute for Clinical Evaluative SciencesTorontoCanada
| | - James Bolton
- Department of PsychiatryUniversity of ManitobaWinnipegCanada,Mood and Anxiety Disorders Program, Health Sciences CentreWinnipegCanada
| | - Anne Rhodes
- Department of Psychiatry and Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada,Offord Centre for Child StudiesHamiltonCanada,McMaster UniversityHamiltonCanada,Institute for Clinical Evaluative SciencesTorontoCanada
| | - Sophie Grigoriadis
- Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada,Department of Psychiatry, Faculty of MedicineUniversity of TorontoTorontoCanada
| | - John Cairney
- Department of Family MedicineMcMaster UniversityHamiltonCanada
| | - Amy Cheung
- Department of PsychiatrySunnybrook Health Sciences CentreTorontoCanada,Department of Psychiatry, Faculty of MedicineUniversity of TorontoTorontoCanada
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Denneson LM, Kovas AE, Britton PC, Kaplan MS, McFarland BH, Dobscha SK. Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide. Suicide Life Threat Behav 2016; 46:363-74. [PMID: 26833711 DOI: 10.1111/sltb.12226] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 10/11/2015] [Indexed: 11/28/2022]
Abstract
A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow-up (n = 168; 57%). Fifty-three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.
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Affiliation(s)
- Lauren M Denneson
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Anne E Kovas
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA
| | - Peter C Britton
- VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA.,Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Mark S Kaplan
- Department of Social Welfare, University of California - Los Angeles Luskin School of Public Affairs, Los Angeles, CA, USA
| | - Bentson H McFarland
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Steven K Dobscha
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, OR, USA.,Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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7
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Denneson LM, Cromer R, Jacobson LE, Teo A, Dobscha SK. Female Veterans Who Died by Suicide: Qualitative Analysis of Medical Records. ACTA ACUST UNITED AC 2016. [DOI: 10.1080/21635781.2016.1153537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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8
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Treatment of veterans with mental health symptoms in VA primary care prior to suicide. Gen Hosp Psychiatry 2016; 38:65-70. [PMID: 26412146 DOI: 10.1016/j.genhosppsych.2015.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/21/2015] [Accepted: 08/26/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We describe Veterans Affairs (VA) primary care received by veterans with mental health symptoms in the year prior to suicide to identify opportunities to improve care. METHOD Death certificate data from 11 states were linked to VA national patient care data for veterans who died by suicide in 2009 and had received VA care. We identified 118 age-, sex- and clinician-matched case-control pairs (suicide decedents and living controls) with mental health symptoms. Using McNemar's chi-square and paired t tests, we compare primary care follow-up received during the year prior to death. RESULTS Cases and controls received similar primary care clinician follow-up and treatment for mental health symptoms. Cases were less likely than controls to fill 90 or more total days of an antidepressant during the year (P=.02), despite no differences in prescription orders from clinicians (P=.05). Cases and controls were equally likely to fill 90 or more consecutive days of an antidepressant (P=.47). Across both groups, 48% (n=113) received assessment for suicidal ideation in primary care. CONCLUSION We identified two areas to improve primary care for veterans at risk for suicide: monitoring antidepressant treatment adherence and improving suicidal ideation assessment and follow-up for veterans with mental health symptoms.
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Dobscha SK, Denneson LM, Kovas AE, Teo A, Forsberg CW, Kaplan MS, Bossarte R, McFarland BH. Correlates of suicide among veterans treated in primary care: case-control study of a nationally representative sample. J Gen Intern Med 2014; 29 Suppl 4:853-60. [PMID: 25355088 PMCID: PMC4239287 DOI: 10.1007/s11606-014-3028-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death. OBJECTIVE Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care. DESIGN This was a retrospective case-control study. SUBJECTS The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician. MAIN MEASURES Demographic, diagnosis, and utilization data were obtained from VA's Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide. KEY RESULTS Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27-0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36-0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79-6.92), functional decline (OR = 2.52; 95 % CI = 1.55-4.10), depression (OR = 1.82; 95 % CI = 1.07-3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07-4.83) were associated with greater odds of suicide. CONCLUSIONS Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.
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Affiliation(s)
- Steven K Dobscha
- Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, P.O. Box 1034 (R&D 66), Portland, OR, 97207, USA,
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10
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Clouston SAP, Rubin MS, Colen CG, Link BG. Social inequalities in suicide: the role of selective serotonin reuptake inhibitors. Am J Epidemiol 2014; 180:696-704. [PMID: 25167863 DOI: 10.1093/aje/kwu191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We aimed to examine the relationship between socioeconomic status (SES) and suicide associated with the introduction and diffusion of selective serotonin reuptake inhibitors (SSRIs). Negative binomial regression was used to estimate county-level suicide rates among persons aged 25 years or older using death certificate data collated by the National Center for Health Statistics from 1968 to 2009; SES was measured using the decennial US Census. The National Health and Nutrition Examination Survey and the Medical Expenditure Panel Survey were used to measure SSRI use. Once SSRIs became available in 1988, a 1% increase in SSRI usage was associated with a 0.5% lower suicide rate. Prior to the introduction of SSRIs, SES was not related to suicide. However, with each 1% increase in SSRI use, a 1-standard deviation (SD) higher SES was associated with a 0.6% lower suicide rate. In 2009, persons living in counties with SES 1 SD above the national average were 13.6% less likely to commit suicide than those living in counties with SES 1 SD below the national average--a difference of 1.9/100,000 adults aged ≥25 years. Higher SSRI use was associated with lower suicide rates among US residents aged ≥25 years; however, SES inequalities modified the association between SSRI use and suicide.
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11
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Ahmedani BK, Simon GE, Stewart C, Beck A, Waitzfelder BE, Rossom R, Lynch F, Owen-Smith A, Hunkeler EM, Whiteside U, Operskalski BH, Coffey MJ, Solberg LI. Health care contacts in the year before suicide death. J Gen Intern Med 2014; 29:870-7. [PMID: 24567199 PMCID: PMC4026491 DOI: 10.1007/s11606-014-2767-3] [Citation(s) in RCA: 386] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/23/2013] [Accepted: 12/20/2013] [Indexed: 01/17/2023]
Abstract
BACKGROUND Suicide prevention is a public health priority, but no data on the health care individuals receive prior to death are available from large representative United States population samples. OBJECTIVE To investigate variation in the types and timing of health services received in the year prior to suicide, and determine whether a mental health condition was diagnosed. DESIGN Longitudinal study from 2000 to 2010 within eight Mental Health Research Network health care systems serving eight states. PARTICIPANTS In all, 5,894 individuals who died by suicide, and were health plan members in the year before death. MAIN MEASURES Health system contacts in the year before death. Medical record, insurance claim, and mortality records were linked via the Virtual Data Warehouse, a federated data system at each site. KEY RESULTS Nearly all individuals received health care in the year prior to death (83 %), but half did not have a mental health diagnosis. Only 24 % had a mental health diagnosis in the 4-week period prior to death. Medical specialty and primary care visits without a mental health diagnosis were the most common visit types. The individuals more likely to make a visit in the year prior to death (p < 0.05) tended to be women, individuals of older age (65+ years), those where the neighborhood income was over $40,000 and 25 % were college graduates, and those who died by non-violent means. CONCLUSIONS This study indicates that opportunities for suicide prevention exist in primary care and medical settings, where most individuals receive services prior to death. Efforts may target improved identification of mental illness and suicidal ideation, as a large proportion may remain undiagnosed at death.
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Affiliation(s)
- Brian K Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, 1 Ford Place, 3A, Detroit, MI, 48202, USA,
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12
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Dobscha SK, Denneson LM, Kovas AE, Corson K, Helmer DA, Bair MJ. Primary care clinician responses to positive suicidal ideation risk assessments in veterans of Iraq and Afghanistan. Gen Hosp Psychiatry 2014; 36:310-7. [PMID: 24650585 DOI: 10.1016/j.genhosppsych.2013.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 11/21/2013] [Accepted: 11/25/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To examine primary care clinician actions following positive suicide risk assessments administered to Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans. METHODS We identified OEF/OIF veterans with positive templated suicide risk assessments administered in primary care settings of three Veterans Affairs (VA) Medical Centers. National VA datasets and manual record review were used to identify and code clinician discussions and actions following positive assessments. Bivariate analyses were used to examine relationships between patient characteristics and discussions of firearms access and alcohol/drug use. RESULTS Primary care clinicians documented awareness of suicide risk assessment results for 157 of 199 (79%) patients with positive assessments. Most patients were assessed for mental health conditions and referred for mental health follow-up. Clinicians documented discussions about firearms access for only 15% of patients. Among patients whose clinicians assessed for substance abuse, 34% received recommendations to reduce alcohol or drug use. Depression diagnoses and suicidal ideation/behavior severity were significantly associated with firearms access discussions, while patient sex, military service branch, and substance abuse diagnoses were significantly associated with recommendations to reduce substance use. CONCLUSION Greater efforts are needed to understand barriers to clinicians' assessing, documenting and counseling once suicidal ideation is detected, and to develop training programs and systems changes to address these barriers.
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Affiliation(s)
- Steven K Dobscha
- VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC), Portland Veterans Affairs Medical Center, Portland, OR, USA; Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA.
| | - Lauren M Denneson
- VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC), Portland Veterans Affairs Medical Center, Portland, OR, USA; Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Anne E Kovas
- VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC), Portland Veterans Affairs Medical Center, Portland, OR, USA; Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Kathryn Corson
- VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC), Portland Veterans Affairs Medical Center, Portland, OR, USA; Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Drew A Helmer
- War-Related Illness and Injury Study Center, VA New Jersey Health Care System, East Orange, NJ, USA; Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Matthew J Bair
- Richard L. Roudebush Veteran Affairs Medical Center, Indianapolis, IN, USA
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13
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Smith EG, Kim HM, Ganoczy D, Stano C, Pfeiffer PN, Valenstein M. Suicide risk assessment received prior to suicide death by Veterans Health Administration patients with a history of depression. J Clin Psychiatry 2013; 74:226-32. [PMID: 23561227 PMCID: PMC4055158 DOI: 10.4088/jcp.12m07853] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To examine the quality of suicide risk assessment provided to veterans with a history of depression who died by suicide between 1999 and 2004. METHOD We conducted a case-control study of suicide risk assessment information recorded in 488 medical charts of veterans previously diagnosed with major depression, depression not otherwise specified, dysthymia, or other, less common ICD-9-CM depression codes. Patients dying by suicide from April 1999 through September 2004 or comparison patients (n = 244 pairs) were matched for age, sex, entry year, and region. RESULTS Seventy-four percent of patients with a history of depression received a documented assessment of suicidal ideation within the past year, and 59% received more than 1 assessment. However, 70% of those who died of suicide did not have a documented assessment for suicidal ideation at their final Veterans Health Administration (VHA) visit, even if that visit occurred within 0 through 7 days prior to suicide death. Most patients dying by suicide denied suicidal ideation when assessed (85%; 95% CI, 75%-92%), even just 0 through 7 days prior to suicide death (73%; 95% CI, 39%-94%). Suicidal ideation was assessed more frequently during outpatient final visits with mental health providers (60%) than during outpatient final visits with primary care (13%) or other non-mental health providers (10%, P < .0001). CONCLUSIONS Most VHA patients with a history of depression received some suicide risk assessment within the past year, but suicide risk assessments were infrequently administered at the final visit of patients who eventually died by suicide. Among patients who had assessments, denial of suicidal ideation appeared to be of limited value. Practice changes are needed to improve suicide risk assessment among patients with histories of depression, including the development of assessment and prevention strategies that are less dependent on the presence or disclosure of suicidal ideation at scheduled medical visits.
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Helping elderly patients to avoid suicide: a review of case reports from a National Veterans Affairs database. J Nerv Ment Dis 2013; 201:12-6. [PMID: 23274289 DOI: 10.1097/nmd.0b013e31827ab29c] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examines the health system factors associated with completed suicide among veterans older than 65 years. All root cause analysis reports of suicides that occurred between 2008 and 2010 in the Veterans Health Administration were reviewed; of those, 46 reports were for those 65 years or older. The average age in the sample was 76.96 years; all were men. Method of suicide, stressors, previous attempts, root causes, and action plans designed to address the root causes are reported. Based on these results, recommendations are made for the assessment and treatment of suicide in elderly men.
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Britton PC, Ilgen MA, Rudd MD, Conner KR. Warning signs for suicide within a week of healthcare contact in Veteran decedents. Psychiatry Res 2012; 200:395-9. [PMID: 22796102 PMCID: PMC5064427 DOI: 10.1016/j.psychres.2012.06.036] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 05/16/2012] [Accepted: 06/23/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVES This study examined warning signs for suicide observed in the final day(s) of life in Veteran decedents who received healthcare from Veterans Health Administration (VHA) (N=381), using data obtained from detailed chart reviews. METHODS Veterans who died within a week (7 days) of healthcare contact (18%) were compared to those who died later (82%). Multivariate logistic regression was used to examine differences in suicidal thoughts, psychiatric symptoms, and somatic symptoms as documented at the last visit, after controlling for demographic variables. A second multivariate regression examined whether the identified warning signs were also risk factors for suicide within a month (30 days) of contact. RESULTS Documented suicidal ideation, OR (95% CI)=3.46 (1.15-10.38), and psychotic symptoms, OR (95% CI)=2.67 (1.11-6.42), at the last visit increased the likelihood of suicide within a week of healthcare contact. Both variables also increased the odds of suicide within a month of contact. CONCLUSIONS The assessment of suicidal ideation is critical to identify Veterans at immediate risk. However, recognition of psychotic symptoms may also improve identification. In addition to indicating immediate risk, some warning signs may also suggest on-going risk.
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Affiliation(s)
- Peter C. Britton
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs Medical Center, Canandaigua, NY, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY, Peter C. Britton, Ph.D. is the corresponding author located at the VISN 2 Center of Excellence for Suicide Prevention at the Department of Veteran Affairs Medical Center, Canandaigua, 400 Fort Hill Avenue, Canandaigua, NY 14424, USA ()
| | - Mark A. Ilgen
- VISN 11 Serious Mental Illness Treatment Resource and Evaluation (SMITREC), Department of Veteran Affairs Medical Center, Ann Arbor, MI, U.S.A., Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI
| | - M. David Rudd
- Department of Psychology, University of Utah, Salt Lake City, UT
| | - Kenneth R. Conner
- VISN 2 Center of Excellence for Suicide Prevention, Department of Veteran Affairs Medical Center, Canandaigua, NY, Department of Psychiatry, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Abstract
Military veterans represent a unique, heterogeneous population with suicide prevalence rates, risk factors and preventative management needs that differ from those of the rest of community. Veterans worldwide receive high proportions of their healthcare from community providers, and sensitivity to these distinct needs is required for optimized care. An overview of the recent prevalence-study literature, with a focus upon statistical design, is presented in order to provide a critical orientation within this field with high levels of popular media attention. Attention to psychiatric comorbidity, subthreshold symptomology, select signature disorders of contemporary conflicts (namely, post-traumatic stress disorder and traumatic brain injury), and veteran life narratives before, within and beyond military service will guide our review of risk factor assessment and management strategies. This critical review of the literature provides an overview of this active field of neuropsychiatric research with a select focus upon these topics of special interest.
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Affiliation(s)
- Timothy R Rice
- Department of Psychiatry, The Mount Sinai School of Medicine, 1425 Madison Avenue, Box 1230, New York, NY 10029, USA.
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Ilgen MA, Conner KR, Roeder KM, Blow FC, Austin K, Valenstein M. Patterns of treatment utilization before suicide among male veterans with substance use disorders. Am J Public Health 2012; 102 Suppl 1:S88-92. [PMID: 22390610 DOI: 10.2105/ajph.2011.300392] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to describe the extent and nature of contact with the health care system before suicide among veterans with substance use disorders (SUDs). METHODS We examined all male Veterans Health Administration patients who died by suicide between October 1, 1999, and September 30, 2007, and who had a documented SUD diagnosis during the 2 years before death (n = 3132). RESULTS Over half (55.5%; n = 1740) of the male patients were seen during the month before suicide, and 25.4% (n = 796) were seen during the week before suicide. In examining those with a medical visit in the year before suicide (n = 2964), most of the last visits before suicide (56.6%; n = 1679) were in a general medical setting, 32.8% (n = 973) were in a specialty mental health setting, and 10.5% (n = 312) were in SUD treatment. CONCLUSIONS Men with SUDs who died from suicide were frequently seen in the month before their death. Most were last seen in general medical settings, although a substantial minority of those with SUDs was seen in specialty mental health settings.
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Affiliation(s)
- Mark A Ilgen
- Serious Mental Illness Treatment Research and Evaluation Center (SMITREC), Department of Veterans Affairs, Ann Arbor, MI, USA.
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Sani G, Tondo L, Koukopoulos A, Reginaldi D, Kotzalidis GD, Koukopoulos AE, Manfredi G, Mazzarini L, Pacchiarotti I, Simonetti A, Ambrosi E, Angeletti G, Girardi P, Tatarelli R. Suicide in a large population of former psychiatric inpatients. Psychiatry Clin Neurosci 2011; 65:286-95. [PMID: 21507136 DOI: 10.1111/j.1440-1819.2011.02205.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIMS The aim of this study was to identify predictors of completed suicide in a wide sample of psychiatric inpatients receiving retrospective and prospective DSM-IV diagnoses. METHODS We followed up 4441 severe psychiatric patients who were hospitalized for some time during a 35-year period in a private hospital setting. We collected sociodemographic, clinical and temperamental data. RESULTS Ninety-six patients from the sample committed suicide. There were no sex differences in suicide completion and no differences between major psychiatric disorders, but people who had been hospitalized for anxiety disorders did not commit suicide and people with bipolar disorders were more likely to commit suicide than people with unipolar major depression. Shorter-term treatment with lithium and anticonvulsants, longer-term treatment with antidepressants, history of suicide attempts, suicidal thinking, and single status positively predicted completed suicide. Suicide tended to occur after a mean period of about 14 years of duration of disease. Patients' symptoms during the period preceding suicide were assessed through interviewing patients' physicians or family members. Symptoms occurring in >10% of cases were, in decreasing order, inner tension, racing/crowded thoughts, aggressive behavior, guilt, psychomotor agitation, persecutory ideation, anxiety, and hallucinations. Surprisingly, cyclothymic temperament was less associated with completed suicide as compared to other temperaments. CONCLUSIONS Suicide is likely to occur in a milieu of agitation, mixed anxiety and depression, and psychosis. Longer-term mood stabilizer treatment may reduce the rate of completed suicide.
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