BACKGROUND/RATIONALE:
Many veterans receiving treatment in the VHA have risk factors that have been associated with suicide deaths and accidental overdose, including substance use disorders (SUDs). SUDs are highly predictive of both suicide and accidental overdose and VHA SUD treatment programs have the potential to have a major impact in preventing suicide and accidental overdose. Several practice guidelines outline strategies for reducing and managing suicidal risk; however, the degree of adoption of these practices in VHA SUD programs is unknown. Additionally, a greater understanding of current practices for patients at known risk for accidental overdose, such as those receiving SUD treatment, is needed. Developing a measure of utilization of suicide and overdose risk reduction strategies in VHA SUD programs is a first step to understanding potential gaps in the current treatment system.

OBJECTIVE(S):
The objective of this study was to develop a data collection instrument that would allow us to gather information on suicide risk management practices in VA SUD treatment programs. The survey was designed to measure three guideline-concordant, suicide-related practices that include the need to: (a) assess for suicidal behavior risk, (b) integrate information about suicide risk into treatment plans, and (c) monitor at-risk patients for their suicide risk during the course of treatment. We also added an objective to help us assess clinician practices in VA SUD treatment programs that addressed accidental overdose risk.

METHODS:
A total of nine 1.5-hour focus groups via teleconferences were conducted with VHA SUD clinician or director participants (4 to 7 participants per group) from VHA drug and alcohol treatment programs. Each of the focus group transcripts were reviewed by research staff, consistent patterns among respondents, important or emerging themes, and main domains for item development were identified. This process resulted in a refined survey that was pre-tested via telephone interviews with 4 program directors and 4 clinicians randomly selected from VA SUD treatment programs nationally. These interviews were used to examine whether respondents understood the initial set of items and whether additional items were needed. A refined survey was then administered to SUD providers within a single VHA SUD treatment clinic. Chart reviews were conducted on 10 patients to determine if the responses of providers matched with those mentioned in patient records.

FINDINGS/RESULTS:
The study achieved its main goal of developing and evaluating a measure of suicide and overdose related practices in VHA USD treatment programs. This process involved, developing survey items, conducting focus groups, and pilot testing survey items. During the focus groups, the following themes emerged. Participants believed VA providers adequately and routinely assessed for suicide, providing considerable attention to current and past suicidal behaviors and thoughts. They also indicated a need for more staff training across all employment levels (i.e. intake coordinator, therapist, etc.) to handle the increasing number of patients as well as the increased burden of suicide assessment and risk management. When asked about accidental overdose, approximately half the focus group respondents reported that they assess for past non-fatal accidental overdose and the half reported that they did not. One challenge identified by several focus group respondents was that there was no routine education on risk accidental overdose; other respondents stated that training related to accidental overdose was only provided to certain SUD treatment staff (e.g., nurse, prescriber, pharmacy staff) and not others (e.g., addictions therapists, social workers). In order to examine the relationship between responses and provider behavior, the measure was administered to 12 VHA SUD clinicians and then chart reviews were conducted for 10 patients seen by these providers. Pearson's correlation coefficients were used to calculate the agreement between self-report and charts. Correlations between SUD provider responses and the information in the chart were low ranging from -0.23 to 0.33. Assessment of current suicidal thoughts, plan, and attempts had only an agreement of 0.06. Lifetime accidental overdose had the highest correlation of 0.33, and was assessed the least frequently of any of the conditions queried, both in the self-report and chart data.

IMPACT:
The Department of Veterans Affairs has prioritized reducing suicide and accidental death (including death) for VHA patients. The measure of suicide and accidental overdose related practices that was developed during this study provides an important potential tool to help understand current risk management practices. Qualitative data from the focus groups highlight the success of the VA's recent efforts to improve suicide risk management during clinical practice. Yet, responses during focus groups also emphasize the potential to improve VA treatment provider awareness of the risk for accidental overdose in Veterans with substance use disorders.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Burnett-Zeigler I, Zivin K, Islam K, Ilgen MA. Longitudinal predictors of first time depression treatment utilization among adults with depressive disorders. Social psychiatry and psychiatric epidemiology. 2012 Oct 1; 47(10):1617-25. [view]
2. Burnett-Zeigler IE, Pfeiffer P, Zivin K, Glass JE, Ilgen MA, Flynn HA, Austin K, Chermack ST. Psychotherapy utilization for acute depression within the Veterans Affairs health care system. Psychological Services. 2012 Nov 1; 9(4):325-35. [view]
3. Webster L, Eisenberg A, Bohnert AS, Kleinberg F, Ilgen MA. Qualitative evaluation of suicide and overdose risk assessment procedures among veterans in substance use disorder treatment clinics. Archives of suicide research : official journal of the International Academy for Suicide Research. 2013 Jul 29; 16(3):250-62. [view]
4. Burnett-Zeigler I, Ilgen MA, Bohnert K, Miller E, Islam K, Zivin K. The impact of psychiatric disorders on employment: results from a national survey (NESARC). Community mental health journal. 2013 Jun 1; 49(3):303-10. [view]
5. Bohnert AS, Roeder K, Ilgen MA. Unintentional overdose and suicide among substance users: a review of overlap and risk factors. Drug and Alcohol Dependence. 2010 Aug 1; 110(3):183-92. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Substance Use Disorders
DRE: Treatment - Observational, Prevention, Epidemiology
Keywords: Alcohol, Drug abuse, Dual diagnosis – substance abuse and mental health
MeSH Terms: none