Lead/Presenter: Yevgeniy Feyman, PEPReC (Boston)
All Authors: Feyman Y (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health)), Figueroa SM (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Yuan Y (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Price M (Partnered Evidence-Based Policy Resource Center, Boston) Kabidiyeva A (Partnered Evidence-Based Policy Resource Center, Boston) Nebeker J (Department of Health Informatics, Washington DC; University of Utah School of Medicine, Salt Lake City) Ward M (Department of Health Informatics, Washington DC) Shafer P (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Pizer SD (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health) Strombotne KL (Partnered Evidence-Based Policy Resource Center, Boston; Boston University School of Public Health)
Objectives:
In 2018, suicide was the tenth leading cause of death in the United States. While access to care is an important step in reducing suicides, the supply of mental health services is often inadequate. Understanding the causal effects of changes to mental health provider staffing levels on key outcomes can help identify the optimal supply of mental health services. In this analysis, we estimated the effects of changes in Veterans Health Administration (VHA) mental health services staffing levels on suicide-related events among a cohort of Veterans.
Methods:
We used administrative data from the VHA (2013-2017) to identify suicide-related events among a cohort of Veterans separating from service (N = 110,064). Suicide-related events included suicidal self-directed violence, suicide, suicide attempts, and undetermined self-directed violence. We controlled for individual and geographic characteristics. Additionally, we were able to control for pre-existing mental health conditions identified during the Veteran’s military service. Mental health services capacity was measured as the effective number of full-time mental health clinic provider days available at VHA facilities per enrollee in a given pay period. Efficiency was measured as the number of patients seen in a clinic day. We used instrumental variables (IV) methods to account for endogeneity between mental health clinic capacity and patient outcomes. We used federal holidays, clinic-specific leave, non-VA mental health capacity, and the number of non-VHA-enrolled Veterans as instruments for capacity. In addition, we used individual distance from a VHA clinic to instrument for use of VHA mental health services.
Results:
From 2014-2018, the per-pay period probability of a suicide-related event among our cohort was 0.05 percent. We found that a one percent increase in mental health staffing led to a 1.6 percentage point reduction on suicide related events. This effect was largest in the lowest tertile of staffing, suggesting diminishing returns to scale for mental health staffing
Implications:
VHA facilities appear to be staffing-constrained when providing mental health care. Targeted increases in mental health staffing would be likely to reduce suicidality.
Impacts:
Our findings are consistent with the view that broad expansions of mental health staffing are likely to be beneficial. Additionally, to the extent that providers are maldistributed geographically, policies targeting the most understaffed regions or those that make virtual care more accessible are similarly likely to be helpful.