Suicides Among Post-9/11 Veterans Surged from 2006–2020, Exacerbated by TBI
This study examined trends in
suicide rates from 2006–2020 for Veterans with and without TBI compared to the U.S. adult population. Findings showed that
suicide rates among post-9/11 Veterans increased more than 10-fold from 2006–2020, a significantly greater rate of change than in the U.S. adult population. Veterans with TBI had
suicide rates 56% higher than Veterans without TBI and three times higher than the U.S. adult population. From 2006–2020,
suicide rates increased by 15% per year for Veterans with TBI, 14% per year for Veterans without TBI, and 1% per year for the U.S. adult population.
Suicide rates increased above 2006 levels beginning in 2008 through 2020 for Veterans and increased above 2006 levels beginning in 2012 through 2020 for the U.S. adult population.
Date: August 28, 2023
- Most Veterans Endorse Clinician-Initiated Firearm Safety Discussions Based on Veteran/Family Member Risk
This study examined data from the online July-August 2019 National Firearms Survey to assess whether Veteran firearm owners believe clinicians should provide firearm counseling when specific clinical contexts suggest heightened risk of firearm injury to the patient or their family. Findings showed that a large majority (73–88%) of Veteran firearm owners reported that firearm counseling should be delivered as part of routine care when they or someone in their family is at increased risk of firearm injury. Regional differences were minor; regardless of where firearm owners lived, at least two-thirds endorsed routine lethal means counseling “at least sometimes.” Findings should allay concerns among clinicians, healthcare leaders, and policy makers that discussing firearms with Veterans who are—or who have family members who are—at heightened risk of
suicide and other firearm injuries will be viewed as beyond the scope of routine medical care.
Date: June 29, 2023
- Most Veterans Support Integration of Standardized
Suicide Risk Assessment into Routine Primary Care Visits
This study sought to characterize VA primary care patients’ perspectives regarding population-based
suicide risk screening through the Risk ID program – a multi-stage
suicide risk assessment process, which includes initial screening (the focus of this analysis) and subsequent evaluation when indicated (following a positive screen). Findings showed that most Veterans support integration of standardized
suicide risk assessment into routine primary care visits. More than 90% of Veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask Veterans about suicidal thoughts during these visits. And approximately half indicated that Veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most Veterans were generally supportive of VA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm (i.e., repeated screening could turn into “white noise”). They also noted that question wording, body language, and care team role affected whether the process was a positive or negative experience. Additional guidance or training for staff conducting
suicide risk screening may be warranted to ensure Veterans feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes.
Date: March 20, 2023
- Male and Female Veterans Differ in Attitudes to Referral to VA Care after Calling the Veterans Crisis Line
This study described
Suicide Prevention Coordinator (SPC) referral outcomes for Veterans who contacted the Veterans Crisis Line (VCL) with active thoughts of
suicide during calendar years 2018–2019. Reasons given for declining SPC referral suggest that concerns about or discomfort with VA care were a key concern, particularly among women Veterans. Women had a higher rate of declining SPC referrals than men (6% vs. 5%). Men who expressed negative sentiment toward VA appeared to express anger broadly at VA. In contrast, women who expressed negative experiences or views of VA were more likely than men to express frustrations with VA treatment. Compared with men, women who reported a negative experience with or perception of VA care had concerns regarding potentially losing access to their children, being “locked up,” or even fear of retaliation or judgement from VA staff if they pursued an SPC referral. Veterans who called the VCL and were rated as lower risk were more likely to decline referral to future care. This suggests that the VCL interaction itself may have been sufficient in managing the Veteran’s needs at the time – and it helped mitigate an immediate mental health crisis.
Date: January 1, 2023
- Mental Health Staffing Affects Probability of
Suicide-Related Events among Veterans
This study sought to measure the effect of staffing on
suicide-related events (SRE). Findings showed that mental health (MH) staffing had a large causal effect on the probability of a
suicide-related event. From 2014 to 2018, the per-pay period probability of an SRE among this study cohort was 0.05%. A 1% increase in mental health staffing led to a 1.6 percentage point reduction in SREs. This effect was concentrated in the most capacity-constrained facilities, suggesting that staffing increases would have the largest effect in those facilities. There was substantial geographic variation in MH staffing levels across the facilities in this study. For example, in 2018, average mental health provider staffing ranged from 5 standardized clinic days per pay period per 10,000 enrollees to 21 standardized clinic days. There was a similar variation in Veterans’ engagement with VA services. In 2018, the average engagement ranged from virtually no engagement (0%) to 46% by facility-pay period.
Date: September 11, 2022
- PTSD-Multimorbidity in Recently Discharged Veterans Predicts Poor Social Functioning, Increasing Risk for Suicidal Ideation
A growing body of literature suggests that problems experienced by Veterans during their transition from military to civilian life confer significant risk for suicidal ideation (SI). One of these problems is PTSD, which, along with chronic pain and sleep disturbance, can increase risk for SI. Findings from this study showed that at approximately 15 months post-separation, almost 91% of Veterans with probable PTSD also reported sleep disturbance and/or chronic pain. Relative to Veterans with PTSD alone, sleep disturbance and chronic pain did not confer greater risk for SI. Relative to Veterans without probable PTSD, Veterans with all three conditions (PTSD-multimorbidity: PTSD, chronic pain, and sleep disturbance) experienced the poorest social functioning and had greater risk for suicidal ideation. The impact of PTSD-multimorbidity on risk for SI was partially explained by its negative effect on social functioning. Given the additional risk for suicidal ideation associated with poor social functioning, clinicians should be mindful to not only support Veterans’ efforts to seek social support, but also to monitor the quality of support received and integrate social functioning aims into treatment planning.
Date: June 2, 2022
- Predictive Tool Associated with 22% Lower Odds of All-Cause Mortality among High-Risk Veterans Taking Opioids
In 2018, VA mandated a case review intervention that targeted patients who had been prescribed opioid analgesics and who were at high risk of adverse outcomes. The Stratification Tool for Opioid Risk Mitigation (STORM), a provider-facing dashboard that uses predictive analytics to stratify patients prescribed opioids based on their risk for overdose/
suicide, was developed to identify these patients and assist providers in determining whether a patient needed a revised treatment plan or augmented care. Investigators then evaluated the impact of the case review mandate on serious adverse events (SAEs) and all-cause mortality among Veterans designated as high-risk between 2018-2020. Findings showed that identifying high-risk patients and mandating they receive an interdisciplinary case review was associated with 22% lower odds of all-cause mortality relative to control patients. This kind of impact is on par with interventions such as common medications for heart disease. Mandated review patients were five times more likely to receive a case review than non-mandated patients with similar risk – and they received more risk mitigation strategies.
Date: May 2, 2022
- Palliative Care Consultation Associated with Lower Odds of
Suicide among Veterans at High Risk of One-Year Mortality
This study examined the association between the number of palliative care consultations (PCCs) and documented
suicide in a cohort of Veterans at high risk of short-term mortality. Findings showed that receipt of PCC within 90 days of death was associated with a 71-78% decrease in the odds of
suicide compared to other causes among Veterans at high risk of one-year mortality. The largest reduction in odds of death by
suicide was among those who had received two or more PCCs. Among Veterans who died by
suicide, 5% received at least one PCC in the 90 days prior to death compared to 16% who died from other causes.
Date: April 27, 2022
- Receipt of Video Tablets among Rural Veterans Associated with Increased Use of Mental Health Care and Less Suicidal Behavior
This study sought to evaluate the association between the escalated distribution of VA’s video-enabled tablets during the COVID-19 pandemic and rural Veterans’ mental health service use and
suicide-related outcomes. Findings showed that receipt of a video tablet was associated with the increased use of mental healthcare via video and increased psychotherapy visits across all modalities. Tablets also were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of a
suicide-related ED visit, and a 22% reduction in the likelihood of
suicide behavior. VA and other health systems should consider leveraging video-enabled tablets for improving access to mental healthcare via telehealth and for preventing
suicides among rural residents.
Date: April 6, 2022
- Rapid Response to Executive Order by HSR&D Investigators Leads to Widespread Adoption of
Suicide Prevention Strategies
As part of the response to Presidential Executive Order #13861, this study analyzed a large body of text responses collected as a federal Request for Information (RFI) to uncover gaps in policy and practice across the U.S. in order to more effectively address and prevent
suicide among Veterans. Findings identified unique barriers to care, in addition to ways in which data and research could be better aligned to improve outcomes. For example, Veterans need a greater connection to the community when they transition from military service and they want healthcare professionals who understand and/or have experience with military culture. Metrics for evidence-based risk prevention and treatment methods need to incorporate Veterans’ perspectives to ensure
suicide prevention efforts address their needs and concerns. VA used the findings and policy opportunities identified from this RFI analysis to contribute to the development of The PREVENTS Roadmap with recommendations and implementation steps for
suicide prevention. Thus far, the governors of 42 states and territories have submitted state proclamations to support the PREVENTS campaign and follow strategies outlined within the report. The HSR&D “QUICk: A Qualitative Interdisciplinary Collaboration” method developed for this study has been submitted for VA invention disclosure and could be useful for other researchers to address similar public requests for information or to help analyze other types of qualitative data to fulfill research mandates.
Date: March 3, 2022
- Excess Mortality Rates among Post-9/11 Veterans Compared with General US Population, Particularly among Veterans with TBI
This study sought to assess the total all-cause and cause-specific mortality burden – and to estimate the total number of excess deaths among post-9/11 Veterans with and without exposure to traumatic brain injury (TBI) compared with the total US population. Findings showed that post-9/11 Veterans experienced excess all-cause and cause-specific mortality compared with the total US population, which was exacerbated by exposure to TBI. While Veterans exposed to moderate/severe TBI accounted for only 3% of the total post-9/11 Veteran population, they accounted for 34% of total excess deaths observed, which was 11-fold higher than would otherwise be expected. The top five causes of death for Veterans were: 1) accident, 2)
suicide, 3) cancer, 4) cardiovascular disease, and 5) homicide. Adjusted mortality rates for each were higher among Veterans with mild and moderate/severe TBI, compared with Veterans with no TBI. While excess accident,
suicide, and homicide mortality was greater among those with TBI across all age groups, excess mortality from cardiovascular disease and cancer was primarily in Veterans >55 years with moderate/severe TBI. After 20 years of war, it is vital to focus attention on what puts Veterans at risk for accelerated aging and increased mortality, and how it can be mitigated.
Date: February 11, 2022
- Suicidal Ideation among Post-9/11 Veterans Recently Separated from Military Service
This study sought to identify unique trajectories of change in suicidal ideation (SI) frequency among a sample of post-9/11 Veterans (7,823 men and 1,743 women) during the first three years after their separation from military service. Findings showed that the majority of Veterans do not experience substantial SI in the first three years after service (90%), demonstrating that most Veterans are resilient to this experience and suggesting that
suicide-focused interventions should be targeted for the minority of Veterans with symptomatic trajectories (10%). Three symptomatic SI trajectories, that were similar across genders, were identified: delayed onset (low initial SI that increased with time; 5%), remitting (moderate-to-high initial SI that decreased with time; 3%) and chronic (moderate-to-high SI throughout the study time period; 2%). Key correlates of symptomatic SI trajectories included: younger age, racial/ethnic minority groups, other than honorable or medical separation, enlisted rank, and early connection with VA healthcare. Continued service in the National Guard/Reserves and officer rank were associated with lower odds of assignment to a symptomatic trajectory. Understanding trends and drivers of SI during the military transition period can inform: 1) treatment of SI itself, to reduce Veterans’ distress and improve health and functioning during this challenging time; and 2) upstream
suicide prevention services for reintegrating Veterans.
Date: January 23, 2022
- Impact of COVID-19 Pandemic on Healthcare Workers and First Responders
This study examined the relationships between COVID-19 related occupational stressors, psychiatric symptoms, and occupational outcomes (likelihood of leaving current field and occupational functioning). Findings showed high levels of psychiatric symptoms and distress in healthcare workers during the COVID-19 pandemic. Half of the healthcare workers in this study – and 59% of all nurses – indicated a decreased likelihood of staying in their current occupation due to the pandemic. Nurses and emergency medical service workers reported the greatest burdens: more than 40% had PTSD symptoms and more than 80% had depression symptoms. Among all respondents, more than one-third (38%) had PTSD symptoms, and nearly three-quarters had depression (74%) and anxiety (75%) symptoms. More than 15% of participants reported thoughts of
suicide or self-harm in the preceding two weeks. More than 18% of respondents reported trouble completing work-related tasks. The volume of critically ill patients, risk of COVID-19 exposure, and factors promoting demoralization were associated with psychiatric distress. Distress was associated with increased odds of planning to leave the profession. Demoralizing factors (e.g., feeling unsupported by one’s workplace, being asked to take unnecessary risks) were most strongly associated with distress. Healthcare staffing shortages are in and of themselves a COVID-19 stressor, so turnover could exponentially worsen HCW’s wellbeing and professional retention.
Date: December 16, 2021
- High Acute Inpatient Psychiatric Bed Occupancy Associated with Increased Rates of
Suicide among Veterans
This study examined the relationship between the incidence of
suicide among Veterans and acute inpatient psychiatric bed availability using occupancy as a measure of hospital strain and access. Findings showed that high acute VA psychiatric bed occupancy (>95%), not beds per capita, was associated with a 10% higher incidence of death by
suicide. Extrapolated over the 6-year study across 145 hospital quarters with occupancy >95%, this hospital strain contributed to an estimated excess of 64.5
suicides. The absolute number of acute VA inpatient psychiatric beds decreased by 13% from 4,419 in 2011 to 3,860 in 2016, while mean occupancy decreased from 68% to 65% over the same time period; the number of deaths by
suicide increased from 2,193 in 2011 to 2,464 in 2016. The VA national average of 65.5 acute psychiatric beds per 100,000 Veterans was three times the US national average of 22/100,000 in 2016. Changes in VA acute psychiatric beds, non-VA (i.e., community) psychiatric beds, spending on community mental health per capita, and the proportion of Veterans with a mental health diagnosis were not associated with the incidence of
suicide among Veterans enrolled in VA care. Measuring hospital occupancy and establishing occupancy benchmarks should be included in patient safety reports as psychiatric bed overcrowding joins overall hospital, emergency department, and intensive care unit occupancy as a risk for higher mortality.
Date: August 16, 2021
- Brief Training Increases Discussions between VA Providers and Veterans on Firearm Safety to Reduce
This study evaluated the impact of a one-hour educational seminar for VA clinicians on lethal means safety, “A Public Health Approach to Talking About Firearms and Death by
Suicide.” Findings showed that the webinar was effective in providing clinicians with the skills to talk with Veterans about firearm safety, and it continued to impact their practice four months after training. After the training, participants reported that they felt that it was very important to speak to all Veterans about firearm safety and believed that harm reduction was important in reducing death by
suicide. Importantly, they felt more confident in their ability to have the discussion after the webinar. In the four-month evaluation, participants responded that they had been successful with speaking with Veterans about firearm safety, with 71% percent of respondents reporting being moderately to very successful. On average, clinicians asked more than half of Veterans they had treated about firearm safety. Clinicians also felt it was important to let others know that Veterans were open to talking about firearm safety.
Date: July 1, 2021
- Veterans Receiving Buprenorphine for Opioid Use Disorder Have Lower Risk of
This study sought to determine the association between buprenorphine pharmacotherapy and
suicide, overdose, and all-cause mortality among Veterans initiating buprenorphine within VA. Findings showed that Veterans who were not receiving buprenorphine pharmacotherapy on any given day had more than a four-fold increase in
suicide/overdose death compared to those who received buprenorphine, even when accounting for time periods on other medication for opioid use disorder. Over the 5-year follow-up from the initial buprenorphine prescription, 3% died from
suicide or overdose, and 8% died of any cause. Among
suicide/overdose deaths, the majority (90%) were due to overdose and 71% of overdoses involved a prescription or illicit opioid.
Date: May 19, 2021
- VA Workgroup Consensus Statement on
Suicide among Homeless Veterans and What We Still Need to Learn
This article serves as a consensus statement by the recently formed VA
Suicide Prevention among Veterans Experiencing Homelessness Workgroup – and provides a brief overview of current initiatives to prevent
suicide among homeless Veterans. This consensus statement also discusses methods of conducting research within this complex subset of the Veteran population, as well as future research endeavors necessary to inform gaps in knowledge. While VA has implemented several initiatives to prevent
suicide among homeless Veterans, there is a continued need to understand how best to tailor these initiatives. Further, because homeless Veterans often access various community services (e.g., homeless shelters, community emergency departments), an effective collaboration between VA and the community is needed.
Date: April 1, 2021
- Food Insecurity in Veterans is Associated with Increased Depression Symptoms and Suicidal Ideation
This study sought to investigate the association between food insecurity and suicidal ideation. Findings showed that food insecurity in Veterans was associated with increased depression symptoms and suicidal ideation. The odds for suicidal ideation among Veterans with very low food security – the most severe level of food insecurity – increased by nearly four-fold compared to those who were food secure. Adjusted results show that Veterans with marginal, low, or very low food security had statistically significant increased depression screening scores compared to Veterans who had full food security. Veterans with low or very low food security had statistically significant increased odds for suicidal ideation compared to Veterans with full food security. Food insecurity affected 12% of the Veterans surveyed and 4% of Veterans endorsed suicidal ideation. Given this evidence supporting the relationship between food insecurity and depression, organizations serving Veterans should integrate prevention, mitigation and treatment efforts for food insecurity, depression, and suicidal ideation.
Date: March 26, 2021
- Some Combat Experiences May Increase Risk of Attempting
Suicide among Service Members
This study sought to determine the association of combat exposure with
suicide attempts among active-duty US service members who were deployed in Iraq and Afghanistan. Findings showed that when defined broadly, combat was not associated with
suicide attempts after adjusting for demographic and military-specific factors. High combat severity was associated with an increased risk for
suicide attempts, although this association was partly mediated by mental health disorders, specifically PTSD. Some individual combat experiences were associated with
suicide attempts, but these associations were largely accounted for by mental disorders. Exceptions included being attacked or ambushed, seeing dead bodies or human remains, and being directly responsible for the death of a non-combatant, which showed significant associations with
suicide attempts even after adjustment for mental disorders. Results suggest that certain types of combat experiences may have different implications for service members compared to other combat experiences, increasing individuals’ risk of attempting
Date: February 2, 2021
Suicide Prevention for Women Veterans
The articles in this supplement highlight the value of a wide range of data sources, from the macro-level surveillance data available through the DoD, VA, and the US National Violent Death Reporting System to the depth of qualitative data of individual experiences with
suicide attempts. They also illustrate the complexities of studying gender and
suicide, while generating a new understanding of important areas for
suicide prevention among women. Articles included suggest that younger age, mental health concerns, experiencing violence, and medical comorbidities may all contribute to
suicide risk among women.
Date: February 1, 2021
- Veterans Open to Discussing Firearms Storage Safety in Primary Care Setting
This quality improvement project – part of a larger study to develop a training program on firearms storage safety (FSS) for VA primary care teams – describes Veterans’ perspectives on discussing FSS during primary care visits. Most Veterans in the study agreed that primary care is an acceptable setting for FSS discussions, but staff need to build rapport and trust by using a personal, caring, and non-judgmental approach. Veterans noted concerns about the legal consequences of disclosing firearm ownership and most did not support direct questioning about this, e.g., “Do you own a firearm?,” which may trigger fears of having firearms being taken away or limitations being placed on access to firearms. Veterans also noted the need to provide a clear reason for why a discussion on FSS was happening, such as promoting mental health or concern for household safety and wellbeing. Discussing FSS with Veterans in primary care settings is a promising upstream approach that can complement other
suicide prevention efforts but must be conducted in a Veteran-centric manner.
Date: January 26, 2021
- Significantly Higher Rates of
Suicide among Sexual Minority Veterans Compared to Other Veterans and the General Public
This study assessed
suicide mortality among Veterans who had documentation of sexual minority sexual orientation status recorded in VA’s electronic health record (EHR). Findings showed that risk of death from
suicide was more than four-fold higher for sexual minority Veterans compared to the general US population – and more than twice as high as what has been found among the general Veteran population. The most common method of
suicide was by firearm (40%) with men more likely than women (41% vs. 35%, respectively) to use firearms. For both sexual minority men and women,
suicide was the most common cause of death among those 18–29 years of age, accounting for approximately 40% of all deaths.
Date: December 28, 2020
- Use of VHA Homeless Programs Decreases
This study assessed whether participation in VHA Homeless Programs is associated with reduced risk of all-cause and
suicide mortality among Veterans with housing instability. Findings showed that the use of VHA Homeless Programs among Veterans reporting housing instability was significantly associated with reduced hazards of all-cause and
suicide mortality. More than one-half of Veterans reporting unstable housing on the Homelessness Screening Clinical Reminder accessed homeless services during the observation period, and the use of any homeless service was associated with a 6% reduction in risk for all-cause mortality. The risk of both all-cause and
suicide mortality was reduced significantly with each additional service used. With each additional VHA Homeless Program accessed, the risk of dying by
suicide was lowered by 19%. Veterans who accessed 4 or more VHA Homeless Programs had 78% reduced hazards of
suicide death compared with those who did not access any VHA Homeless Programs. Veterans’ receipt of interventions to address housing instability may be particularly important for reducing
suicide risk, perhaps by addressing unmet basic human needs such as housing.
Date: November 18, 2020
- Gender Differences in Thought Processes among Veterans who Attempted
This study sought to better understand gender differences in the development of suicidal behaviors among U.S. Veterans to inform future research and gender-tailored prevention efforts. Findings revealed two gendered narratives of
suicide attempts that incorporated the primary themes of self-concept, social power, relationships, coping, and stress. When discussing reasons for their
suicide attempts, women described feelings of worthlessness, saying they felt “nonexistent in an existing world,” and that they “don’t deserve to be anything.” Women appeared to internalize negative experiences and evaluations from others into negative assessments of their worth (i.e., ‘I am bad’). In contrast to women, men discussed feeling like the world had let them down and that they no longer had any fight left to obtain the life they want to live. In the moments prior to their attempts, men Veterans recalled thinking, “I’ve had enough,” and, “this is just exhausting and pointless.” These feelings primarily reflected their interpretations of failed actions (i.e., ‘What I did was bad.’) rather than assessments of their worth. Thus, in
suicide prevention, women Veterans may benefit from methods to increase self-worth through positive social relationships, while men Veterans may benefit from methods that increase their sense of purpose in life and help them achieve their ideal selves through successful experiences.
Date: September 1, 2020
- Methods of
Suicide Differ Between Stably and Unstably Housed Veterans
This study examined whether Veterans’ methods of
suicide varied by housing status. Findings showed that across the study period, 3% of Veterans in the study population were unstably housed. Among the 7,005 Veterans who died by
suicide, 4% were unstably housed. After accounting for demographic and health factors, unstably housed Veterans had an 86% increased hazard of
suicide from self-poisoning from exposure to drugs and other biological substances, compared to stably housed Veterans. Unstably housed Veterans also were more than 3 times more likely to die by
suicide from jumping from a height and more than 2.5 times more likely to die by
suicide from unspecified means than stably housed Veterans. Among stably housed Veterans, nearly 3 of 4
suicides involved firearms; in contrast, for unstably housed Veterans, less than half of
suicides involved firearms. Understanding methods of
suicide can inform prevention and intervention efforts, allowing VA to tailor
suicide prevention programs for unstably housed Veterans. In particular, lethal means safety efforts (i.e., counseling and public health approaches) to
suicide prevention should consider unstably housed Veterans at greater risk for using different means of
Date: April 12, 2020
- Possible Impact of Measures to Curb COVID-19 Spread on
Suicide Prevention Efforts
Social distancing and other public health actions intended to curb the spread of COVID-19 have the potential for adverse outcomes on
suicide risk. However, concerns about negative secondary outcomes of COVID-19 prevention efforts should not imply that that these public health actions should not be taken. Implementation should include a comprehensive approach that considers the public health priority of
suicide prevention as well.
Date: April 10, 2020
- Veterans at Higher Risk of Overdose/
Suicide Death After Stopping Opioid Treatment; Increasing Risk with Duration on Opioids
This study examined the associations between stopping outpatient opioid treatment, length of opioid treatment, and overdose/
suicide death among VA patients. Findings showed that Veterans were at a higher risk of overdose/
suicide death after stopping opioid treatment, with increasing risk the longer they had been treated before stopping. Even patients treated for up to 30 days had a rise in risk of death after treatment was stopped. Factors independently associated with a higher risk for overdose/
suicide death included: receiving prescriptions for long-acting or short-acting opioids compared to tramadol; maximum daily morphine milligram equivalents; number of medical diagnoses; and having a mental health disorder diagnosis or substance use disorder diagnosis. Older age, female gender, and being currently married were independently associated with a lower risk for overdose/
suicide death. Risk of death from overdose or
suicide was increased for 3 months after starting or stopping treatment with opioids, highlighting these vulnerable risk periods.
Date: March 4, 2020
- All-Cause Deaths and Those Due to Poisoning,
Suicide, and Alcoholic Liver Disease Higher among White Veterans Ages 55-64
After years of declining mortality rates across all age groups in the United States, increasing rates in White non-Hispanic Americans ages 45–54 were reported. This study sought to determine whether White non-Hispanic middle-aged male Veterans enrolled in VA primary care experienced similar increases in all-cause and select-cause death rates as was observed in the general population. Findings showed that White non-Hispanic male Veterans ages 55-64 had a significant increase in all-cause death rates from 2003 through 2014, accompanied by increases in deaths due to
suicide, poisoning, and alcoholic liver disease. Changes were not evident in the younger (45-54) Veteran age group. For White non-Hispanic males ages 55–64 who were not Veterans, all-cause mortality decreased slightly from 2003-2014. However, there were increases in death rates due to poisoning, alcoholic liver disease, and
suicide. For all three race/ethnicity groups in the 55–64 age category, trends in death rates for alcoholic liver disease, poisoning, and
suicide did not differ according to rural or urban location. Findings suggest the critical importance of
suicide prevention programs, as well as the importance of high-quality integrated healthcare, for both Veteran and non-Veteran white men.
Date: January 31, 2020
- Past Year Opioid Misuse Associated with Past-Year
Suicide Attempt among High-Risk Veterans
The main objective of this study was to test the relationship between past-year
suicide attempt and past-year opioid misuse among Veterans at high risk of
suicide who also reported using at least one illicit substance or alcohol in the past year. Findings showed that past-year opioid misuse was associated with past-year, but not lifetime,
suicide attempt in high
suicide-risk Veterans: 82% of opioid misusers had attempted
suicide in the past year versus 56% of those who misused other substances. The relationship between past-year opioid misuse and past-year
suicide attempt remained significant when psychosocial factors associated with
suicide attempt and opioid misuse were included as covariates.
Suicide attempt rates did not differ among those who misused different types of opioids. Among Veterans with past-year
suicide attempt, those who misused opioids in the past year were more likely to use overdose as a method to attempt
suicide compared to those who misused other substances. Opioid misuse may be a marker of more lethal near-term
suicide behavior, supporting current VA opioid therapy guidelines in which
suicide risk assessment during opioid therapy is recommended. Lethal means restriction of toxic substances among Veteran opioid misusers also may be important.
Date: December 1, 2019
- Social Stressors Strongly Associated with
Suicide Ideation and Attempt among Veterans
This study examined documented social stressors in VA’s electronic health record (EHR) and how these stressors were associated with suicidal ideation and
suicide attempt. Seven types of social stressors were included: 1) experiences of violence, 2) housing instability, 3) employment or financial problems, 4) legal problems, 5) social or familial problems, 6) lack of access to care or transportation, and 7) non-specific psychological needs. Findings showed that social stressors were strongly associated with suicidal ideation and
suicide attempt. For example, compared with Veterans who had no social stressors, those with one social stressor had nearly 2.5 times the odds of suicidal ideation, two social stressors had over four times the odds, three social stressors had nearly five times the odds, and four or more social stressors had over eight times the odds – after adjusting for numerous socio-demographic factors and mental illness diagnoses. Social stressors are as relevant as biological factors (e.g., depression) for
suicide prevention and treatment. Systematic assessment of a more complete set of these stressors may improve the ability to identify patients at highest risk of
Date: November 19, 2019
- Healthcare Processes Linked to
Suicide Risk Following Discharge from VA Residential Substance Abuse
This study examined 39 root-cause analysis (RCA) reports of
suicide in Veterans occurring within three months of discharge from a residential drug treatment program that were reported to any one of 140 VA medical centers between 2001 and 2017. RCA is a well-known and robust approach to elucidating the contribution of systems and organizational processes to adverse events such as
suicide after hospital discharge. Findings showed that most
suicides occurred in close proximity to discharge from a treatment program, with 56% occurring within seven days of discharge and 36% occurring within 48 hours of discharge. The most common method of
suicide was overdose (33%), followed by hanging (28%). Categories of root causes ranged from problems with
suicide risk assessment to non-engagement in treatment. The largest number of root causes of
suicide pertained to problems with risk assessment, breakdowns in communication, and problems with the discharge process. This was followed by problems with treatment of mental health disorders and non-engagement with treatment during the residential stay – and after discharge. Lack of patient engagement was related to willingness to participate in treatments that might mitigate
suicide risk – and to involve family or loved ones in discharge planning. Efforts to prevent
suicide after discharge from a treatment program should focus on addressing
suicide risk factors during admission and helping patients engage more fully in SUD treatment.
Date: June 28, 2019
- Post 9/11 Veterans Less Likely to Delay Mental Health Treatment
This study compared delay of treatment for PTSD, major depressive disorder (MDD), and/or alcohol-use disorder (AUD) among post-9/11 Veterans relative to pre-9/11 Veterans and civilians. Findings showed that post-9/11 Veterans were less likely than both pre-9/11 Veterans and civilians to delay mental health treatment for PTSD and depression. Median time to PTSD treatment was 2.5 years for post-9/11 Veterans compared to 16 years and 15 years, for pre-9/11 Veterans and civilians, respectively. Median time to depression treatment was 1 year for post-9/11 Veterans compared to 7 years and 5 years, for pre-9/11 Veterans and civilians, respectively. No differences in treatment delay were observed between post-9/11 Veterans and pre-9/11 Veterans or civilians for alcohol-use disorder. Increased engagement in PTSD and depression treatment for post- vs. pre-9/11 Veterans could be attributable to a host of recent historic, cultural, and policy changes, including: DoD’s universal post-deployment mental health screening; educational public health initiatives; enhanced eligibility for VA benefits for post-9/11 Veterans; VA’s
suicide prevention hotline; VA mobile health resources (e.g., PTSD Coach); and VA’s integration of mental health services into primary care settings.
Date: March 7, 2019
- Brief Cognitive Behavioral Therapy Reduces Suicidal Ideation among Veterans with Chronic Illness
Brief cognitive behavioral therapy (bCBT) intervention delivered by VA mental health providers in primary care settings is effective for depression, anxiety, and improves physical health quality of life. Investigators in the current study determined the effect of bCBT on suicidal ideation among Veterans with cardiopulmonary chronic illness receiving mental health treatment in a VA primary care setting. Findings showed that bCBT in primary care reduced suicidal ideation in Veterans with chronic medical illness. Veterans in the bCBT group were less likely to have high suicidal ideation than Veterans in the EUC group post-treatment and at 8-month follow-up after accounting for baseline suicidal ideation. Results suggest that exposure to a brief evidence-based psychotherapy intervention in primary care may significantly reduce distress and suicidal ideation over a prolonged period of time, potentially reducing future
suicide-related distress and/or attempts among a high-risk Veteran population.
Date: February 8, 2019
- Links Between Opioid Use and
This review describes what is known about the links between
suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and
suicide are highlighted. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
Date: January 3, 2019
- Unique Link between Homelessness and
suicide rates are much higher among those who are homeless or have been homeless. This study sought to replicate these previous findings with a larger, national population cohort. After controlling for common risk factors, results suggest a unique link between homelessness and
suicide. Veterans with a history of homelessness were 8.8 times more likely to have attempted
suicide than Veterans with no history of homelessness (25% vs. 3%). In the total study cohort (Veterans and non-Veterans), lifetime homelessness was significantly and independently associated with lifetime
suicide attempts. The association between homelessness and
suicide was stronger among Veterans than non-Veterans.
Date: January 2, 2019
- Medical Records Flag for
Suicide Risk Increases VA Healthcare Visits among Veterans with Substance Use Disorder
VA has identified
suicide prevention as a top priority and established policies to include high-risk
suicide patient record flags (PRFs) in the electronic medical record to alert providers of patient risk and increase healthcare contacts. This study sought to identify predictors of new PRFs and to describe healthcare use before and after PRF initiation among VA patients who had received a substance use disorder (SUD) diagnosis. Findings showed that consistent with VA policy, 62% of Veterans with new
suicide risk flags attended the recommended number of visits in months 1 to 3, with an additional 14% meeting recommended targets in month 1 only. Further, outpatient contacts in mental health and substance use disorder clinics increased 2 and 4 times, respectively, over the three-month follow-up period, with mean contacts in these services exceeding the minimum required one contact per week in month one. ED visits decreased by 45% in the three months following initiation of a PRF. Demographic predictors of PRF initiation included being younger than 35, White, and homeless. Clinical predictors were cocaine, opioid and sedative use disorders, PTSD, psychotic, bipolar, and depressive disorders, and
Suicide risk PRFs in an electronic medical record and subsequent follow-up increased service use for those Veterans with flags initiated.
Date: June 8, 2018
- Evaluating Care Coordination Program for Pregnant Veterans
The VA Maternity Care Coordinator Telephone Care Program (MCC-TCP) was created to support MCCs and includes outlines to guide up to eight calls with Veterans on topics such as VA maternity care benefits, chronic health problems, substance use cessation, and depression and
suicide screening. Investigators evaluated the program and assessed its feasibility, as well as facilitators and barriers to its implementation in 11 VA facilities. Findings showed that the VA Maternity Care Coordinator Telephone Care Program was successfully implemented and was perceived by the maternity care coordinators as valuable in meeting the care coordination needs of pregnant Veterans. MCC-TCP implementation barriers included limited information and communication technology tools to support the program – and lack of coordinator time for delivering telephone care. Consistent with prior research, pregnant women Veterans using VA maternity care had a high need for care coordination services due to their substantial burden of physical and mental health problems: 41% had pre-pregnancy chronic physical problem(s); 34% had mental health problem(s), particularly depression (28%) and PTSD/anxiety (21%); and 18% actively or recently smoked. Given the substantial and growing maternity care coordination needs among pregnant Veterans, especially those with chronic medical and mental illness, further investments in programs such as the Maternity Care Coordinator Telephone Care Program should be prioritized.
Date: May 23, 2018
- Medical Record Alert Associated with Reduced Opioid and Benzodiazepine Co-prescribing
This implementation project evaluated the effectiveness of an advanced medication alert designed to reduce opioid and benzodiazepine co-prescribing among Veterans with high-risk conditions (substance use disorder, sleep apnea,
suicide risk, and age =65) at one VA healthcare system (VA Puget Sound). Findings showed that the proportions of patients with concurrent prescriptions decreased significantly post-alert launch among Veterans with substance use (25%), sleep apnea (39%), and
suicide risk (62%), with greater decreases at the alert site relative to the comparison site in sleep apnea and
suicide-risk cohorts. Significant decreases in benzodiazepine prescribing were observed at the alert site only.
Date: December 28, 2017
- Systematic Review: Patient Outcomes in Dose Reduction or Discontinuation of Long-term Opioid Therapy Suggest Utility of Multimodal Care
Investigators examined the evidence on the effectiveness of strategies to reduce or discontinue long-term opioid therapy (LTOT) prescribed for chronic pain – and the effect of dose reduction or discontinuation on important patient outcomes, including pain severity and pain-related function. Findings showed that there are multiple strategies to reduce or discontinue long-term opioid treatment for chronic pain, however the quality of the evidence for effectiveness was very low. In 3 good-quality trials of behavioral interventions and 11 fair-quality studies of interdisciplinary pain programs, patients received multimodal care that emphasized non-pharmacologic and self-management strategies. Sixteen fair-quality studies reported improvement in pain severity (8/8 studies), function (5/5 studies), and quality of life (3/3 studies) following opioid dose reduction. However, few studies examined the potential risks of opioid dose reduction such as adverse events (i.e., opioid overdose), illicit substance abuse, or
Date: July 18, 2017
- Higher Risk of Suicidal Ideation and Suicidal Self-Directed Violence following Discontinuation of Long-term Opioid Therapy
The primary objective of this study was to identify predictors of suicidal ideation (SI) and non-fatal suicidal self-directed violence (SSV) following clinician-initiated discontinuation of long-term opioid therapy. Findings showed that a substantial proportion of Veterans with substance use disorder diagnoses and similar matched patients experienced suicidal ideation or suicidal self-directed violence following discontinuation of long-term opioid therapy by their opioid-prescribing clinicians, most of whom represent new onset cases. Approximately 12% of patients in this sample had SSV and/or SI documented in the medical record in the 12 months following discontinuation of opioid therapy: 47 patients had SI only, while 12 had SSV. Half of patients with SSV attempted
suicide by overdose, most commonly with benzodiazepines. Mental health diagnoses associated with having SI/SSV included PTSD and psychotic disorders. The majority of patients (75%) were discontinued from opioid therapy due to aberrant behaviors. Healthcare providers should pay special attention to safety when patients are discontinued from long-term opioid therapy, particularly patients with PTSD or psychotic disorders.
Date: July 1, 2017
- Systematic Review of
Suicide Risk Assessment and Prevention
This systematic review evaluated studies assessing the accuracy of methods to identify individuals at increased risk for
suicide, and the effectiveness and adverse effects of healthcare interventions relevant to Veteran and military populations in reducing
suicide attempts. Findings showed that
suicide rates were reduced in 6 of 8 observational studies of various types of multiple-component population-level interventions, including two studies in Veteran and military populations. Only 2 of 10 trials of individual-level psychotherapy reported statistically significant differences between treatment and usual care, however, most trials were inadequately designed to detect differences. No studies described the adverse effects of risk assessment methods or interventions for
suicide prevention. Risk assessment methods are sensitive predictors of subsequent
suicide attempts in studies, but the frequency of false positives limits their clinical utility. Future research should continue to refine these methods and examine their clinical applications.
Date: June 15, 2017
- Factors Associated with
Suicide within One Week of Discharge from VA Psychiatric Facilities
To better understand system and organizational factors associated with post-discharge
suicide, this study reviewed root-cause analysis (RCA) reports of death by
suicide within seven days of discharge from all VA inpatient mental health units between FY2002 and FY2015. Findings showed that risk for
suicide in the week following hospital discharge may be highest during the first few days after discharge. There were 141 reports of
suicide within seven days of discharge: 40% occurred during the first day of discharge; 67% within 72 hours of discharge, and nearly 80% within four days of discharge. Further, 43% of
suicides followed an unplanned discharge. Root causes for
suicide fell into three major categories: 1) challenges for clinicians and patients following the established process of care, 2) awareness and communication of
suicide risk, and 3) flaws in the established process of care. No association was found between length of hospital stay and days to
suicide. Authors suggest that current VA policies mandating mental health follow-up within 7 days of discharge may be insufficient and that other methods of intervention to better reach this vulnerable patient population may need to be considered (e.g., tele-monitoring). The authors also suggest that inpatient teams be aware of the potentially heightened risk for
suicide in patients whose discharge is unplanned.
Date: June 1, 2017
- Meta-Analysis of Interventions to Prevent
This study conducted a meta-analysis of randomized controlled trials (RCTs) that compared the efficacy of various interventions versus control to prevent death by
suicide among adults. Of the studies included in this review, 29 RCTs reported on complex psychosocial interventions, with 3 reporting on the WHO Brief Intervention and Contact (BIC) intervention, which includes an educational session on
suicide prevention followed by regular contact with a trained provider (phone or in-person) for up to 18 months. The WHO BIC intervention was associated with significantly lower odds of death by
suicide. No other
suicide prevention intervention showed a statistically significant effect in reducing death by
Date: June 1, 2017
- “Virtual Hope Box” Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to
Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. They then assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of
suicide and self-harm. Findings showed that VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures. The most frequently cited reasons for using VHB by Veterans were for distress, when emotions were overwhelming, when they felt like hurting themselves, and for relaxation, distraction, and/or inspiration. Data suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills. Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare.
Date: November 15, 2016
- Higher Risk of Suicidal Ideation among Veterans Seeking Mental Health Treatment from both VA and non-VA Facilities
VA researchers developed the Veterans Health Module (VHM) to be implemented within the Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance System (BRFSS). This report presents data from the 2011-2012 VHM telephone survey. Findings showed that after adjusting for sociodemographic and VHM variables, Veterans who sought mental health treatment from both VA and non-VA facilities had more than four-fold increased odds of suicidal ideation than Veterans who sought mental health treatment from VA facilities only. Overall, 5% of the study cohort reported recent suicidal ideation, and 1% reported attempting
suicide. There were no sex differences in prevalence of suicidal ideation or attempt. In the overall sample, lifetime diagnosis of depression, anxiety, or PTSD was the strongest correlate of both suicidal ideation and attempt.
Date: June 24, 2016
- Use of Clozapine for Veterans with Treatment-Resistant Schizophrenia Could Result in Significant Cost Savings
This cost-benefit analysis sought to simulate potential cost savings for VA that would result from increasing the use of clozapine among Veterans with treatment-resistant schizophrenia. Findings showed that modest increases in clozapine use could result in significant cost savings for VA. Among Veterans with treatment-resistant schizophrenia, VA would save $22,444 per Veteran over the first year of treatment, primarily from 18.6 fewer inpatient hospitalization days per patient. Given this finding, if current clozapine use was doubled from 20% of patients with treatment-resistant schizophrenia to 40%, VA would accrue an estimated cost savings of $80 million over the first year. Moreover, full utilization of clozapine would save VA $320 million over the first year. Findings suggest VA should strongly consider initiatives to substantially increase clozapine use among Veterans with treatment-resistant schizophrenia. Deaths from clozapine-related adverse events are more than balanced out by decreased incidence of
suicide attempts, with a net result of slightly fewer deaths with increased use of clozapine.
Date: June 15, 2016
- Central Nervous System Polypharmacy May Increase Risk of Overdose and
Suicide-Related Behavior among OEF/OIF Veterans
This study examined the prevalence of central nervous system (CNS) polypharmacy and its association with drug/alcohol overdose and
suicide-related behaviors in a national cohort of OEF/OIF Veterans. Findings showed that of the Veterans in this study, 8% had received five or more CNS-acting medications in 2011. CNS polypharmacy was most strongly associated with PTSD, depression, and TBI – and was independently associated with overdose and
suicide-related behaviors after controlling for known risk factors. Women and Veterans between ages 31 and 50 years were more likely to have CNS polypharmacy. Findings suggest that CNS polypharmacy may be used as a “trigger tool” to identify individuals who may benefit from referral to a tailored inter-disciplinary treatment team comprised of experts from relevant fields. Ideally, these teams would work together to optimize medication profiles and treatment plans, and to examine non-pharmacological treatment options.
Date: March 1, 2016
- Increased Dose of Prescription Opioids Raises Risk of
Suicide among Veterans with Chronic Non-Cancer Pain
This study examined the association between prescribed opioid dose and
suicide in a national sample of VA patients with a chronic non-cancer pain condition who received opioid therapy. Findings showed that increased dose of opioids was found to be a marker of increased
suicide risk, even when relevant demographic and clinical factors were statistically controlled. Type of opioid dosing schedule (i.e., regularly scheduled, as needed, or both) did not significantly affect
suicide risk after accounting for other factors. Similar to the U.S. population and other large studies of VA patients, the vast majority of
suicides involved firearms (64%), with overdose accounting for 20% of all
Date: January 5, 2016
- Sexual Trauma during Military Service Increases Risk of Subsequent
Suicide among Veterans
This was the first large-scale, population-based study of sexual trauma and
suicide mortality that examined risks associated with military sexual trauma (MST) among both male and female Veterans receiving VA care. Findings showed that women and men who reported MST had an increased risk of
suicide, and MST remained an independent risk factor even after adjusting for other known risk factors for
suicide among Veterans, including mental health conditions, medical morbidity, and demographic characteristics. Among Veterans who reported MST, those who died by
suicide were significantly more likely to be treated for mental health conditions determined by their provider to be related to MST experiences: men 50% vs. 36%, and women 67% vs. 48%. Overall, 2% of the Veterans in this study reported MST when screened (1% of men, and 21% of women), with 97% reporting no MST, and 0.3% declining to complete the screen.
Date: December 14, 2015
- Individual and Facility-Level Factors Associated with Higher Risk of
Suicide Attempt among Veterans Receiving Opioid Therapy
This study examined the associations between the receipt of guideline-recommended care for opioid therapy and risk of
suicide-related events, assessing associations between individual-level and facility-level delivery of recommended care, and individual-level
suicide-related events. Findings showed that within 180 days following opioid prescription, 1.6% of the study population on chronic short-acting opioids and 2.1% of the study population on long-acting opioids experienced
suicide-related events. At the individual level, Veterans who received opioid therapy and had medical frailty, drug, alcohol, or mood disorder, and/or traumatic brain injury had a higher risk of
suicide-related events. Patients on opioid therapy within VA facilities that ordered more drug screens were associated with a decreased risk of
suicide-related events. Patients on long-acting opioid therapy within facilities that provided more follow-up after new prescriptions also were associated with decreased risk of
suicide-related events. Patients on long-acting opioid therapy within facilities having higher sedative co-prescription rates had an increased risk of
suicide -related events. Among the sub-population of patients with a substance use disorder and a short-acting opioid prescription, the facility rate use of specialty substance use disorder treatment was associated with lower risk of
suicide-related events. Encouraging facilities to make more consistent use of drug screening, providing follow-up within four weeks for patients initiating new opioid prescriptions, avoiding sedative co-prescription in combination with long-acting opioids, and engaging patients with substance use disorders in specialty substance use treatment, may help prevent
Date: July 1, 2015
- Rates of
Suicide Higher among Transgender Veterans
This study sought to document all-cause and
suicide mortality among VA healthcare users with an ICD-9-CM diagnosis consistent with transgender status. Findings showed that the crude
suicide rate among Veterans with transgender-related diagnoses across the 10-year study period was approximately 82/100,000 person-years, which approximated the crude
suicide death rates for Veterans with serious mental illness (e.g., depression, schizophrenia). However, this rate was higher than in both the general VA and U.S. populations. Comparisons of age at time of death suggest Veterans with transgender-related diagnoses may be dying by
suicide at younger ages than Veterans without such diagnoses. The average age of transgender Veterans at the time of death by
suicide was 49 years compared with studies that show the average age of death among non-transgender Veterans who die from
suicide was between 55 and 60 years.
Diseases of the circulatory system and neoplasms were the first and second leading causes of death among transgender Veterans, however, the other ranked causes of death differed somewhat from patterns among the general U.S. population for the same time period. For example, certain infectious and parasitic diseases were the 6th leading cause of death among transgender Veterans, whereas they ranked 9th among the general U.S. population. Authors suggest future research is needed to examine how transgender Veterans seek or receive mental health services and that programs aimed at
suicide prevention may benefit from clinical education and training about transgender populations.
Date: December 1, 2014
- Characteristics Associated with
Suicide among Male Veterans Treated in VA Primary Care
This study sought to identify characteristics of Veterans who received VA primary care in the six months prior to
suicide (in 2009) – and compare these to control patients who also received primary care at the same 41 VA facilities in 11 geographically diverse states. Findings showed that 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. The odds of dying by
suicide were greatest among Veterans with anxiety disorder diagnoses and functional decline. A diagnosis of PTSD was not significantly associated with
suicide, nor was a pain diagnosis or general medical comorbidity. Also, 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.
Date: December 1, 2014
- JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management,
suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
- Risk Factors for
Suicide-Related Behavior among OEF/OIF Veterans with “Polytrauma Clinical Triad”
The co-occurrence of PTSD, TBI, and chronic pain is known as the “Polytrauma Clinical Triad” (PCT). This study examined the association of these conditions, independently and in interaction with other conditions, with the risk of
suicide-related behavior (SRB) among OEF/OIF Veterans. Findings showed that the PCT 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 all three categories of 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 VA. Risk for SRB was highest in the 18-25 year old age group.
Date: July 17, 2014
- “Virtual” Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for
Tools that assist patients in accessing and affirming their reasons for living can enable them to mitigate suicidal thoughts. One such tool has been labeled a “hope box”: a physical representation of the patient’s reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a “Virtual” Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Compared with a CHB, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use. Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
Date: May 15, 2014
- Risk of
Suicide-Related Behavior among Older Veterans Receiving Antiepileptic Drugs
This study examined the temporal relationship between new antiepileptic drug (AED) monotherapy exposure and
suicide-related behavior (SRB) in older Veterans. Findings showed that Veterans receiving their first AED during the study period were more likely to have
suicide-related behavior during the 30 days prior to AED exposure than at any other time period in the year before and after exposure, even after controlling for psychiatric comorbidity. There were 106 SRB events among 92 Veterans in the year after exposure, with approximately 22% (n=16) of those Veterans also having an SRB event before their first AED exposure. Moreover, the rate of SRB after starting on an AED was gradually reduced over time. Results suggest that the peak in
suicide-related behavior is prior to AED exposure. However, as the risk for recurrent SRB was 22% in individuals with SRB prior to exposure to AED therapy, these Veterans should be followed closely to prevent recurrent SRB.
Date: November 26, 2013
- Non-Cancer Pain Associated with
This study evaluated associations between non-cancer, pain-related clinical diagnoses (arthritis, back pain, migraine, tension headache or headache symptom, psychogenic pain, neuropathy, fibromyalgia) and
suicide. Findings showed that, after controlling for demographics, most clincial diagnoses of non-cancer pain conditions were associated with risk of
suicide in this large national cohort of Veterans. After further controlling for co-occuring psychiatric conditions, the associations between pain conditions and
suicide death were reduced; however, significant associations remained for back pain, migraine, and psychogenic pain. In Veterans with a pain condition who died by
suicide, the two most common methods of
suicide were firearms (68%) and poisoning (17%). There was no relationship between the number of pain conditions and
suicide risk. The authors suggest that there is a need for increased awareness of
suicide risk among Veterans with back pain, migraine, and psychogenic pain, which may not be fully explained by comorbid psychiatric diagnoses.
Date: July 1, 2013
- Suicidal Ideation is Common among OEF/OIF Veterans who Receive VA Healthcare
This study sought to determine the prevalence and correlates of suicidal ideation among OEF/OIF Veterans who screened positive for depression following implementation of required brief assessments. Findings showed that suicidal ideation is common among OEF/OIF Veterans who receive VA healthcare: one in three Veterans who screened positive for depression acknowledged possible suicidal ideation. High PHQ-2 scores (> 5) nearly doubled the odds of suicidal ideation, even when controlling for diagnoses of depression. Depression and bipolar or schizophrenia diagnoses significantly increased the odds of suicidal ideation. In addition, having a single diagnosed psychiatric disorder did not significantly increase the odds of suicidal ideation, but two disorders were associated with a 60% increase, and three or more disorders more than doubled the odds. In contrast to previous reports, this study found no increase in suicidal ideation for Veterans with PTSD, substance use disorders, anxiety disorders, or traumatic brain injury. However, the authors note that a recently published evidence-based synthesis concluded that despite mixed results, PTSD should be considered a risk factor for
suicide attempts and completion among Veterans.
Date: July 1, 2013
- Association between Several Common Antiepileptic Drugs and
Suicide-Related Behavior in Older Veterans
This retrospective study examined the relationship between antiepileptic drugs (AEDs) and
suicide-related behaviors among Veterans aged 65 years and older who received VA healthcare. Findings showed that, within the study sample of 2 million older Veterans, there were 332 cases of
suicide-related behavior (SRB). Exposure to antiepileptic drugs was significantly associated with
suicide-related behavior, even after controlling for psychiatric comorbidity and prior SRB. Individuals who received AEDs were significantly more likely to have prior diagnoses of
suicide-related behavior, depression, anxiety, bipolar disorder, PTSD, schizophrenia, substance abuse/dependence, conditions associated with chronic pain, and dementia. Veterans who received prescriptions for several specific AEDs – valproate, gabapentin, lamotrigine, levetiracetam, phenytoin, and topiramate – were at greater risk of diagnosed
suicide-related behavior than Veterans with no AED exposure. Findings indicated that
suicide-related behavior may occur as early as one week following AED use.
Date: October 30, 2012
- Risk of
Suicide and Mental Disorder Comorbidity among Male Veterans Using VA Healthcare
This study examined mental disorder comorbidity and
suicide in a large national cohort of Veterans who use VA healthcare, particularly the association between differing two-way combinations of mental disorders and
suicide risk. Findings showed that among Veterans who died by
suicide between FY00 and FY06 (0.25% of the study cohort), 47% had been diagnosed with a mental disorder(s) including 19% with one mental disorder and 27% with two or more. Each mental disorder was associated with increased risk for
suicide. However, nearly all two-way combinations of mental disorders showed a smaller increase in risk for
suicide than would be expected by considering the risk associated with each disorder separately, which is interpreted to indicate sub-additive risk. Depression was the most common diagnosis among Veterans who died by
suicide (31%), followed by substance use disorder (21%), anxiety disorder (15%), PTSD (12%), schizophrenia (9%), and bipolar disorder (9%).
Date: October 22, 2012
- Pre-Military Trauma Associated with Post-Recruit Training
Suicide Attempts among Marines
This study examined pre- and post-Marine recruit training risk factors for
suicide attempts among current and former Marines in the 10 years following training. Findings showed that stressful and traumatic life events (e.g., childhood physical, sexual and emotional abuse, sexual harassment during recruit training) and
suicide attempts made before recruit training had strong associations with
suicide attempts after recruit training. Those who experienced at least one life stressor prior to joining the Marines had 4 times the odds of
suicide attempt compared to those who did not report any life stressors prior to joining. Half of the Marines in this study who died by
suicide (per death certificate) in the 10 years following recruit training (n=3) reported at least one significant life stressor prior to joining the Marines. Marines who experienced military sexual harassment during recruit training had 3 times the odds of
suicide attempt in the 10 years following training compared with those who did not report this experience. Marines with PTSD symptoms consistent with a diagnosis had about double the odds of
suicide attempts compared with those without PTSD symptoms.
Date: October 20, 2012
- Prescription Drug and Alcohol Misuse Associated with Higher
Suicide Deaths among Veterans with Depression
This study sought to assess the association between factors noted in the electronic medical record and
suicide mortality for a cohort of Veterans who had received treatment for depression. Findings showed that suicidal behaviors and substance-related variables were the strongest independent predictors of
suicide. Compared with Veterans without a
suicide attempt or ideation, those with a
suicide attempt in the prior year were 7 times more likely to die of
suicide, and Veterans with suicidal ideation without an attempt were 3 times more likely to die of
suicide. Veterans with prescription drug misuse and those with alcohol abuse were 7 times and 3 times, respectively, more likely to die of
suicide than those without. Based on these findings, the authors suggest that prescription drug and alcohol misuse assessments should be prioritized in
suicide assessments among Veterans diagnosed with a depressive disorder. Veterans for whom providers considered a hospitalization for psychological issues had 3 times higher risk of
suicide death than those for whom hospitalization was not considered.
Date: October 1, 2012
- Promoting Gun Safety and Delayed Gun Access to High-Risk Patients is Acceptable to Veterans and Providers
This study explored VA stakeholders’ perceptions about gun safety and interventions to delay gun access among Veterans with a mental health diagnosis during high-risk periods. Findings showed that several measures to promote gun safety and to delay access to guns for high-risk patient groups are acceptable to VA patients and providers, if judiciously applied. For example, most patients and clinicians in this study indicated that routine screening for gun access was acceptable, particularly for patients receiving mental healthcare. Clinicians and patients reported having very little discussion regarding gun ownership during the course of routine treatment. Both groups indicated that gun access was typically discussed only during
suicide or homicide risk assessments, and then only if the patient expressed suicidal/homicidal ideation that involved guns. However, nearly all patients felt that clinicians should routinely speak to their patients about guns. One of the most widely suggested and accepted interventions – across all stakeholders – was further education on
suicide, including risks related to guns, for VA patients, family members, and clinicians.
Date: September 5, 2012
- QI Intervention for VA Programs Serving Homeless Veterans
Through the Getting To Outcomes (GTO) intervention, staff members at three homeless programs were able to make noticeable improvements in their programming. Although none of the improvements incorporated the wholesale adoption of a specific evidence-based program, most improvements involved programs becoming more evidence-based; e.g., using evidence-based guidelines to manage high-risk patients (i.e., Veterans at risk of
suicide) and supporting additional substance abuse treatment for Veterans who had relapsed, while keeping them in their current VA housing. Many staff members experienced some challenges adding GTO activities to their already busy workload, and some felt the process could be more transparent and inclusive. Staff members stated that high levels of communication, commitment to the program, and technical assistance were critical to the success of the intervention.
Date: August 1, 2012
- Warning Signs Associated with
Suicide among Veterans Receiving VA Healthcare
Of the 381 Veterans in this study who used VA healthcare in their last year of life, 67 (18%) died by
suicide within one week of contact. Among these Veterans, documented suicidal ideation was the strongest predictor of
suicide. Psychotic symptoms noted during the last VA healthcare visit also were associated with
suicide. Of the 381 Veterans who used VA healthcare in their last year of life, 174 (46%) died within one month of contact. Among these Veterans, the warning signs noted above (suicidal ideation and psychotic symptoms) were also risk factors that predicted
suicide within a month of contact. Authors note that assessment of suicidal ideation is critical to identifying Veterans at immediate risk, but that both suicidal ideation and psychotic symptoms may also suggest ongoing risk.
Date: July 13, 2012
- Review Supports One-to-One Peer Mentorship among Veterans
Across a broad range of populations, peer mentors appeared to be acceptable, credible sources of information. This may be particularly true among current and former members of the Armed Forces, who are accustomed to a culture of mutual support. The literature suggests that peers are capable of conducting assessment and triage, coaching and teaching, and providing direct social support. A White Paper identified three areas where peer mentorship (PM) might play a unique role for military/Veteran populations: coping with combat and operational stress,
suicide prevention, and recovery-related issues downstream from combat/injury. In addition, the review suggests PM might play a role in reducing stigma, improving treatment adherence, increasing knowledge of treatment resources, and augmenting or teaching self-management skills.
Date: July 1, 2012
- Killing Experiences Independently Associated with Suicidal Ideation among Vietnam Veterans
Vietnam Veterans in this study with war-related killing experiences were twice as likely to report suicidal ideation as those who did not kill, even after accounting for PTSD, depression, substance use disorder diagnoses, and combat exposure. This is the first study demonstrating that killing experiences are independently associated with suicidal ideation, after taking mental health diagnoses into account. In regression analyses that included demographic variables, PTSD, depression, substance use disorders, combat experiences, and killing experiences, PTSD was the only variable significantly associated with
suicide attempts. Nearly 14% of Veterans in this study met diagnostic criteria for current PTSD.
Date: April 13, 2012
- AJPH Features Articles on Veterans and
This special supplement of AJPH focuses on Veterans and mental health, and includes four articles on
suicide among Veterans.
Date: January 1, 2012
- Less than One-Quarter of Veterans who Complete
Suicide Access VA Healthcare in Year Prior to Death
This study sought to determine the number of Veterans who completed
suicide and who had accessed VA healthcare in the Pacific Northwest Region in the year prior to death. Findings show that of the 968 Veterans in this study who completed
suicide, less than one-quarter (22%) accessed VA healthcare in the year prior to death, and a minority of those Veterans visited mental health providers. These numbers are consistent with current estimates of the number of Veterans accessing care at VA hospitals and clinics, and suggest that Veterans who go on to complete
suicide may access VA healthcare at similar rates as Veterans who do not commit
suicide. Of those Veterans who completed
suicide, 57% did not have a mental health diagnosis, and 58% had not seen a mental health professional, suggesting that it is perhaps equally important to understand patients with general medical conditions who also may be likely to complete
suicide. Of those who completed
suicide, 55 were hospitalized during the year prior to death. Of these, 39% with a psychiatric hospitalization and 22% with a medical/surgical hospitalization completed
suicide within 30 days. A large number of Veterans (73% of men; 36% of women) completed
suicide by use of a firearm, supporting concerns from earlier studies over firearm access as a key risk factor in Veteran
Date: April 4, 2011
- Rates of Accidental Poisoning among VA Patients Higher than General Population
This study describes the rate of accidental poisoning mortality among Veterans who used VA healthcare services, compares this rate to the general U.S. population, and describes the drugs/medications involved. Findings show that for FY05, VA patients had nearly twice the rate of fatal accidental poisoning compared to adults in the general population. Among VA patients who died from accidental poisoning, opioid medications (including methadone) made up 32% of the reported deaths; cocaine also was common at 23%. In both the VA and U.S. general populations, the rate of accidental poisoning mortality was higher for men than women, and higher for individuals ages 30 to 64 as compared to those ages 18 to 29, or ages 65 and older. Although VA patients have a greater risk of
suicide than death by accidental poisoning, their risk for accidental poisoning death relative to the general population is larger than that of
Date: April 1, 2011
Suicide Risk Factors for OIF Veterans
This study examined combat and mental health as risk factors for suicidal ideation among OIF Veterans. Findings show that, overall, 2.8% of the OIF Veterans in the study reported suicidal thinking, the desire for self-harm, or both. Post-deployment depression symptoms were associated with suicidal thoughts, while post-deployment PTSD symptoms were associated with current desire for self-harm. Post-deployment depression and PTSD symptoms mediated the association between killing in combat and suicidal thinking, while post-deployment PTSD symptoms mediated the association between killing in combat and the desire for self-harm. These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning Veterans.
Date: January 22, 2011
- Veterans who Commit
Suicide May Not Show Apparent Emotional Distress During Last Healthcare Contact
This retrospective study examined VA healthcare contacts (by phone or in person) by Veterans in the year prior to their deaths by
suicide. The majority of Veterans in this study were seen for routine VA medical care in the year prior to committing
suicide, and did not show apparent signs of emotional distress at their last healthcare visit. In the year prior to death, nearly 50% of the Veterans had one or more mental health contacts, and 63% had one or more primary care contacts. Just over half of the Veterans received care in the 30 days prior to death, with 20% receiving mental health care and 15% receiving primary care. Forty percent of these Veterans were assessed for suicidal ideation during the year prior to death, and 16% were assessed during their last contact. Nearly three-quarters of those who were specifically asked about thoughts of
suicide in the year prior to death denied having such thoughts. The median number of days between final VA healthcare contact and date of death was 42. Of the 26 Veterans whose final contacts were with mental health, 87% were assessed for depression, substance use disorder, or PTSD, and 54% were assessed for suicidal ideation. Of the 22 Veterans whose final contacts were with primary care, 55% were assessed for depression, substance use disorder, or PTSD, and 9% were assessed for suicidal ideation.
Date: December 1, 2010
- Link between Psychiatric Diagnosis and Higher Risk of
Suicide among Veterans
As part of VA’s ongoing evaluation of
suicide risk among Veterans being treated in VA facilities, this study examined the impact of different psychiatric diagnoses on the risk of
suicide. Findings show that a clinical diagnosis of a psychiatric disorder increased the risk of subsequent
suicide by 160%. Psychiatric diagnoses were an especially strong risk factor for
suicide among women, increasing their risk of
suicide more than 5-fold. Bipolar disorder was the least common diagnosis (only 3% of all Veterans studied), but was diagnosed in approximately 9% of all Veterans who died by
suicide. A diagnosis of bipolar disorder increased the risk of
suicide nearly 3-fold in men and 6-fold in women. Authors suggest this makes bipolar disorder particularly appropriate for targeted interventions (e.g., improving medication adherence). Overall,
suicides were more than three times as common in men than in women and were 37% to 77% more common in Veterans ages 30 and older than among those ages 18 to 29.
Date: November 1, 2010
- Most VA Patients with Substance Use Disorders Who Die from
Suicide Use Violent Means
Most VA patients with substance use disorders (SUDs) who died from
suicide used violent means (70%, n=600), and the majority were carried out with firearms. No specific SUD was associated with increased risks of violent
suicide, but several SUD diagnoses (e.g., cocaine use and opiate use) were associated with a higher risk of non-violent
suicide. Alcohol use was associated with a lower likelihood of non-violent
suicide. While many psychiatric disorders (e.g., major depression, PTSD, schizophrenia) were associated with increased risk of both violent and non-violent
suicide, the strength of the association between the disorder and type of
suicide was greater for non-violent than violent
suicide. The authors suggest that by linking data on risk factors to information about the specific methods used, future interventions designed to decrease access to lethal means could be tailored to focus on those at greatest risk of dying by specific means.
Date: July 1, 2010
- Checklist Successfully Identifies VA Environmental Hazards for Inpatient
This is the first study to examine the implementation and effectiveness of the Mental Health Environment of Care Checklist to improve patient safety. Findings show that between 2007 and 2008, 7,642 environmental
suicide hazards had been identified and 5,834 (76.3%) had been abated. Approximately 2% of these
suicide hazards were identified as critical, and another 27% were rated as serious. The most common hazard was anchor points for hanging (44%); anchor points also presented the greatest risk level, followed by suffocation and poison. High-risk locations included bedrooms and bathrooms.
Date: February 1, 2010
- Prior Violence Associated with Greater Risk of Suicidal Thoughts and Attempts in Patients Seeking SUD Treatment
Even after accounting for other known risk factors, such as symptoms of depression or childhood victimization, a history of violent behavior was consistently associated with a higher likelihood of lifetime suicidal thoughts and behaviors. Suicidal thoughts and attempts are common in those with substance use disorders (SUD): more than 43% of the participants in this study reported either prior
suicide attempts or suicidal ideation at some point in their lives. A history of either suicidal ideation or
suicide attempt(s) was more common among substance users who were female and those with a history of depression or childhood abuse.
Date: February 1, 2010
- Affective Disorders Strongest Predictor of Suicidal Behavior in Elderly Veterans Receiving Anti-Epileptic Medication
In January 2008, the FDA issued an alert indicating that anti-epileptic drug (AED) treatment is associated with increased risk for suicidal ideation, attempt, and completion. This study sought to assess variation in
suicide-related behaviors in a population not well-represented by the data used for the FDA analysis – individuals 66 years and older with new exposure to AEDs. Findings show that in older Veterans who were started on AED monotherapy, the strongest reliable predictor of
suicide-related behaviors was the diagnosis of an affective disorder prior to AED treatment. Increased
suicide-related behaviors were not associated with individual AEDs. However, while most Veterans in this study received AED prescriptions for gabapentin (76.8%), a trend for increased
suicide-related behaviors was found among those prescribed levetiracetam or lamotrigine, but interpretation was difficult since few Veterans received either drug (0.6%). The associations between
suicide-related behaviors and chronic pain or chronic disease burden were not statistically significant, but dementia was significantly associated with
suicide-related behaviors (42.2% with dementia vs. 25.8% without).
Date: January 11, 2010
- Substance Abuse is Strongest Predictor of
Suicide among Veterans with Depression
This study was an analysis designed to derive an empirically-based set of interactions related to rates of
suicide in a national sample of VA patients diagnosed with depression. Findings show that among Veterans with depression those at highest risk for
suicide have the combined risk factors of a substance use disorder (SUD), non-African American race, and a psychiatric inpatient stay in the past 12 months. Substance use disorder was also identified as the strongest single risk factor for
suicide. Among Veterans without a substance use disorder, gender was the strongest predictor of
suicide risk – rates were significantly higher for men than for women. Ethnicity also was related to
suicide risk in this group. African American Veterans without an SUD were less likely to die by
suicide compared to non-African American Veterans. The authors suggest that providers treating patients with these characteristics should be aware of these risks and consider target strategies to screen for current suicidal ideation.
Date: November 1, 2009
Suicide Risk Significantly Higher for VHA Patients Compared to the General Population
Suicide rates among the Veterans enrolled in the VA healthcare system during FY00 and FY01 were found to be significantly higher than those in the general population. However, the differentials between
suicide rates for VA patients and the general population were less than what might be expected given previous comparisons. Overall, for men and women combined,
suicide risks among Veterans were 66% higher than those observed in the general population. Among male Veterans,
suicide rates were highest for those aged 30-49 years and lowest among Veterans aged 18-29 and 60-69. Among women Veterans,
suicide rates were highest among those aged 50-59 years. It is important to emphasize that this study compares a general population to users of a health care system where the prevalence of all conditions would be expected to be higher. Also, the study population precedes current conflicts in Iraq and Afghanistan.
Date: April 15, 2009
- Study Suggests Additional Interventions for Veterans with SUD and History of Abuse
Men with a history of physical or sexual abuse had more severe drug problems at intake, but by six months there were no group differences in drug use. However, veterans with a history of sexual abuse had more severe psychiatric problems at all time points and were more likely to report significant suicidality at intake and 6 month follow-up. This suggests that additional interventions may be warranted for veterans with SUD and a history of sexual abuse. Also, routine screening for suicidality in SUD treatment programs may be warranted given the prevalence of lifetime sexual abuse among SUD patients and the relationship between sexual abuse and attempted
Date: December 1, 2008
- Improving the Environment of Care to Reduce Inpatient
Suicide Attempts in VA Facilities
Authors provide 5 recommendations for reducing environmental hazards for
suicide on inpatient psychiatric units.
Date: August 1, 2008