Spotlight: Working to Decrease Suicide Rates among Veterans

February 2015

Suicide is the 10^th leading cause of death in the United States, with more than 100 suicides occurring each day and over 40,000 people dying by suicide in 2013. Among Veterans and current military personnel, suicide is a national public health concern, and the rate of suicides among those utilizing VA healthcare, as well as other Veterans, is estimated to be higher than the general population. Concern for rates of suicide among Veterans and other populations has led to several major public health and clinical initiatives and a growth in research funding for suicide prevention.¹

HSR&D continues to support research on suicide, including risk factors, screening, treatment for depression, and prevention. In addition, VA/HSR&D's Mental Health Quality Enhancement Research Initiative (MH-QUERI) works to improve the quality of care, outcomes, and health-related quality of life for Veterans with mental health conditions, with focused research on: serious mental health, recovery-based services for Veterans, PTSD, disparities in mental healthcare, and suicide prevention.

HSR&D and QUERI Research on Suicide Prevention

Following are descriptions of just a few select studies that HSR&D and QUERI investigators conduct on research to improve suicide prevention.

New Program to Help Veterans Coping Long Term with Suicide Risk

The Veteran's Coping Long Term with Active Suicide Program (CLASP-VA) is a unique suicide reduction program that combines individual therapy, case management, and family interventions with the implementation of both individual and telephone-based therapeutic strategies adapted from innovative newer cognitive-behavioral and family approaches. This ongoing study will test the efficacy of CLASP-VA in a sample of 200 Veterans at risk for suicide behavior. If successful, study results could have a significant impact on the care of at-risk Veterans. First, it may decrease the rate of subsequent suicidal behavior and re-hospitalization, and CLASP has the potential to enhance and standardize treatment of suicide within VA by providing a standardized number of treatment contacts and guidelines for each treatment contact. CLASP also is designed to be administered by master's level clinicians, thus cutting the potential financial burden on the VA system.

Mindfulness-Based Cognitive Therapy for Suicide Prevention

Despite VA's comprehensive suicide prevention efforts, VA data show that 11% of Veterans with one suicide attempt make a re-attempt within nine months. The ability of the VA healthcare system to further reduce suicide risk in Veterans is complicated by a lack of specialized evidence-based psychotherapies for suicide, creating a significant gap in VA's otherwise comprehensive prevention approach. In this ongoing randomized controlled trial, investigators will test an innovative psychotherapy – Mindfulness-based Cognitive Therapy for Suicide (MBCT-S), which combines cognitive behavioral techniques with mindfulness meditation to specifically target suicidality. Investigators will determine if MBCT-S is more effective than treatment as usual in reducing suicide events (a broad range of suicide behaviors defined according to VA's Self-Directed Violence Classification System), suicide attempts, and in reducing the severity of suicide ideation, depression, and hopelessness. This ongoing study has the potential to increase the range of cost-effective treatment alternatives for the sizeable number of suicidal Veterans for whom evidence-based psychotherapies are severely limited. If effective, the therapy also will enhance VA's existing array of suicide prevention strategies and reduce the number of Veterans who attempt or complete suicide.

Risk Factors for Suicide-Related Behavior among OEF/OIF Veterans with Polytrauma

Post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) are prevalent conditions among Veterans who served in Iraq and Afghanistan, and studies also have identified high rates of chronic pain in this population. Affecting as many as 42% of Veterans receiving polytrauma care, the co-occurrence of PTSD, TBI, and chronic pain is known as the "Polytrauma Clinical Triad" (PCT). This QUERI study examined the association of these conditions, independently and in interaction with other conditions, with the risk of suicide-related behavior (SRB) among 211,652 OEF/OIF Veterans who received VA healthcare in FY09-FY11. Investigators also examined patient demographics and clinical characteristics, including conditions that are part of the PCT, as well as prior suicidal behavior, insomnia, and other mental health diagnoses (i.e., depression, anxiety, bipolar, substance abuse). Study results show:

• The Polytrauma Clinical Triad was a moderate predictor of suicide-related behavior, but did not appear to increase risk for SRB above that associated with PTSD, depression, or substance abuse alone. Moreover, PTSD comorbid with either depression or substance abuse significantly increased risk for suicidal ideation.
• Veterans with a diagnosis of bipolar disorder, anxiety, substance abuse, schizophrenia, depression, or PTSD were significantly more likely to be diagnosed with SRB.
• Female Veterans were less likely than male Veterans to exhibit suicidal ideation, which contradicts prior research and may suggest that females are less comfortable reporting ideation within the VA healthcare system.

Finley E, Pugh M, Bollinger M, et al. A national cohort study of the association between the polytrauma clinical triad and suicide-related behavior among US Veterans who served in Iraq and Afghanistan. American Journal of Public Health. July 17, 2014;e-pub ahead of print.

Detection of Suicidal Ideation Not Associated with Increased Mental Health Use

The relationship between suicide risk assessment programs and treatment utilization is not well understood. This study evaluated the impact of brief suicidal ideation (SI) assessments on mental healthcare use among new-to-care (no VA healthcare visits during five years prior to study period) OEF/OIF Veterans. Investigators identified 465 Veterans who screened positive for depression between 4/08 and 9/09 in a primary care or mental health outpatient setting at one of three VAMCs that represented the Northwestern, Southwestern, and Northeastern regions of the United States. Study measures included: depression, suicidal ideation, demographics, and healthcare data (i.e., other clinical diagnoses such as PTSD, substance use disorder, anxiety disorder). Study results show:

• Of the 465 Veterans in this study, 147 (32%) had positive SI assessment results. The detection and presence of suicidal ideation was not associated with subsequent mental healthcare use over the following year, when accounting for the severity of depression symptoms. In other words, SI itself was not found to be associated with increased Veteran engagement in specialty mental healthcare over and above depression symptom severity.
• When a Veteran's inaugural visit to VA healthcare included a mental health clinician, the Veteran was more likely to attend more subsequent specialty mental health visits – and to receive an antidepressant medication – than Veterans who were seen by a primary care clinician only.

These results suggest that finding ways to support initiation and continued engagement in mental healthcare may be a more effective means to increase mental health utilization than risk detection efforts in non-mental health settings.

Denneson L, Corson K, Helmer D, et al. Mental health utilization of new-to-care Iraq and Afghanistan Veterans following suicidal ideation assessment. Psychiatry Research. July 2014;217(3):147-153.

Characteristics Associated with Suicide among Male Veterans Treated in VA Primary Care

Approximately half of suicide decedents have contact with primary care clinicians in the month prior to death. However, there are a number of challenges to enhancing suicide prevention in primary care, including a lack of information about Veterans treated in primary care who subsequently die by suicide. This study sought to identify characteristics of Veterans (n=261) who received VA primary care in the six months prior to suicide (in 2009) – and compare these to control patients (n=522) who also received primary care at the same 41 VA facilities in 11 geographically diverse states. All Veterans in this study were male, and the mean age was 63. Study results show:

• Compared to controls, Veterans who died by suicide were significantly more likely to be unmarried, white, and to have major depression, bipolar disorder, anxiety disorder other than PTSD, and/or an alcohol or other substance use disorder diagnosis.
• Veterans who died by suicide also were more likely to have documented functional decline, sleep disturbance, expressions of anger, and suicidal ideation. In multivariable models, the odds of dying by suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline.
• Non-white race and a VA service-connected disability rating were associated with decreased odds of suicide.

The assessment of anxiety disorders and functional decline, in particular, may be important for determining suicide risk among Veterans. The authors suggest continued development of interventions that support identifying and addressing these conditions in primary care.

Dobscha S, Denneson L, Kovas A, et al. Correlates of suicide among Veterans treated in primary care: Case-control study of a nationally representative sample. Journal of General Internal Medicine. December 2014;29(Suppl 4):853-860.

Assessing Risk for Suicide, Violence and Related High-Risk Behaviors among Veterans

Compared to the general population, Veterans are at elevated risk for multiple, inter-related negative outcomes, including suicide and violence. These high-risk behaviors are especially prominent among Veterans with substance use disorder (SUD), who often present with co-morbid mental disorders. As a result, clinicians working in VA must routinely assess the risks clients present to themselves and others. This ongoing QUERI study is working to establish the transportability of the Short-Term Assessment of Risk and Treatability (START) to the VA healthcare system. START evaluates a range of risky behaviors (e.g., self-harm, violence, substance use) with the ultimate goal of improving clinical decision-making and care of Veterans with SUD. Investigators will work to determine whether START can be implemented successfully in VA healthcare facilities, and to evaluate whether START assessments accurately predict suicidality, aggression, and related high-risk behaviors among Veterans with SUD. Investigators will collect data through interviews and surveys, with clinicians conducting START assessments every three months; self-report measures completed by Veterans at study enrollment and 3-month follow-up also will be assessed.

Suicide Prevention Cyberseminar Series

The Suicide Prevention Cyberseminar Series is jointly sponsored by the Center for Information Dissemination and Education Resources (CIDER) and a multi-disciplinary group of VA suicide prevention investigators from various centers across the nation, including the Rocky Mountain MIRECC, the Center of Excellence for Suicide Prevention, the Center to Improve Involvement in Care (CIVIC), and the Patient Safety Center of Inquiry for Suicide Prevention (PSCI-SP). The goal of this series is to disseminate research-based evidence and best practices in the area of suicide prevention. Cyberseminars will be held on the 2^nd Monday of the month at 3:00pm (ET) in March, May, July, September, October, and December. Please visit the HSR&D Cyberseminar web page for more information about upcoming sessions.

References:

1. O'Neil ME, Peterson K, Low A, et al. Suicide Prevention Interventions and Referral/Follow-up Services: A Systematic Review. VA-ESP Project #05-225; 2012

Additional Resources:

• Veterans in emotional crisis and their loved ones can call the free and confidential Veterans Crisis Line at 1-800-273-8255 and press 1, talk online, or send a text message to 838255 to connect with a caring, qualified VA responder.
• Know the warning signs for suicide.

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Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.