In 2007, the Department of Veterans Affairs (VA) introduced a national performance measure requiring suicidal ideation (SI) assessment for all Veterans with positive depression screens. To date, there is little empirical evidence supporting the use of population-based SI assessment for improving outcomes. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans frequently have risk factors for suicide. It is important to know if the VA's structured SI assessment process facilitates delivery of timely and appropriate mental health care.
The main objective of this study was to identify process outcomes among OEF/OIF Veterans with depression who received brief structured assessments for SI in VA facilities. Specifically, our goals were to 1) Identify process outcomes following positive SI assessments, comparing post-assessment care of Veterans with positive assessments to Veterans with negative assessments, 2) Identify key correlates of positive SI assessments, and 3) Evaluate clinician adherence to recommendations for suicide risk assessment following positive SI assessments, 4) Explore Veterans' experiences of SI assessments and their perceptions of clinicians' responses to assessment results. Additional aims included identifying the prevalence of positive assessments among OEF/OIF Veterans who screen positive for depression; comparing accuracy of depression, SI, PTSD, alcohol, and pain screening data in local and regional VA databases; and describing rates and correlates of SI assessments within one day of positive depression screens.
This was a mixed-methods, case-control study.
QUANTITATIVE: We collected data from administrative databases of three VA facilities for all Veterans screened with the Patient Health Questionnaire-2 (PHQ-2) over 18 months (April 1, 2008-September 30, 2009), and determined the prevalence of positive SI assessments (in most cases, endorsement of PHQ-9 9th item or VHA Pocket Card SI assessment) among Veterans meeting criteria for major depression (PHQ-2 3). Because screen-related data storage processes varied across the sites, for VAMC 1 we used a regional data warehouse and for VAMCs 2 and 3, developed computerized text search algorithms to identify depression screens. Using these data sources, we identified our study sample: 1662 Veterans who had positive depression screens in primary care or mental health settings. We compared Veterans with SI to Veterans with no SI on demographics, depression severity, medical morbidity, International Classification of Diseases (ICD-9) psychiatric diagnoses documented prior to or at the time of SI assessment. Multivariate regression was used to identify correlates of receiving assessments and of positive SI assessments. Then, for the 12 months after SI assessment, we identified approaches used to address positive SI assessments and measured healthcare visits, psychiatric diagnoses, and treatment with antidepressants.
QUALITATIVE: We conducted individual interviews with a purposive sample of 34 OEF/OIF Veterans with SI from three study sites to learn about their perceptions of brief SI assessments and the healthcare system's response to screening. A grounded theory approach was used to analyze qualitative data.
QUANTITATIVE: Eighty-one percent of Veterans in our sample received brief structured assessments for SI within 30 days of positive depression screens, and 32% had positive SI assessments. Ninety-four percent were assessed within one day of positive depression screens. In a model adjusted for intra-site correlations, assessment was less likely during months 8-12 and 13-18 of the study period and more likely to occur among Veterans receiving depression or post-traumatic stress disorder (PTSD) diagnoses on the day of SI assessment. The likelihood of positive SI assessments was greater at VAMC 1 and 3 as compared to VAMC 2, and as PHQ-2 scores increased. Positive assessments were more likely for divorced/widowed, but lower for Reserve/Guard and white/non-Hispanic Veterans. Among the subgroup of 694 Veterans with prior-year VA utilization, depressive disorder and bipolar/schizophrenia diagnoses increased the likelihood of positive SI assessments. During the year after SI assessment, Veterans with assessments had fewer primary care visits, but more mental health and emergency department visits; more often received major depression, PTSD, substance use disorder diagnoses; and more often received an antidepressant prescription compared to Veterans who did not have SI assessments or who had negative SI assessments. Within the group of 230 primary care patients who had positive SI assessments, 214 (93%) had providers who documented specific acknowledgement of the positive assessments. For a majority (>65%), clinicians documented exploration for risk factors including hopelessness, past suicide attempts, psychiatric (including substance use) disorders, and pain, as well as relationship and occupational problems. A medication initiation or change was noted for 58% of patients, and mental health follow-up was arranged for 93%. Clinicians documented inquiries about firearms for only 23% of the patients, and recommendations to restrict access to firearms for 6%.
QUALITATIVE: Veterans generally accepted the rationale for brief structured SI assessments and appreciated that the language used was understandable and straightforward, though this was sometimes juxtaposed by frustration with over-simplification of their experiences through "yes/no" questions. A small number had alarming misinterpretations of the rationale for the assessment process. Veterans who trusted their providers were more willing to disclose suicidal thoughts. Many Veterans admitted to being unsure of, or fearful of, what might follow disclosure of suicidal thoughts; they were unaware of what the mental health care process might look like should they become involved. However, the reality of how providers responded was generally felt to be appropriate for the circumstances.
This study identified important correlates of SI among OEF/OIF Veterans with symptoms of depression, described process and utilization outcomes of screening for SI, and improved understanding of the brief structured assessment process for SI from the perspectives of Veterans. The findings will inform future VA policy regarding SI screening and assist clinicians in caring for Veterans who may have suicidal ideation.
External Links for this Project
None at this time.