Veteran drug overdose mortality, 2010-2019.

BACKGROUND: Prior work documents that Veteran drug overdose mortality increased from 2010 to 2016. The present study assessed trends from 2010 to 2019, by drug type and recent receipt of Veterans Health Administration (VHA) services, and compared rates for Veteran and non-Veteran US adults. METHODS: This retrospective cross-sectional study used data from Veterans Affairs (VA) medical records, the VA/Department of Defense Mortality Data Repository, and CDC WONDER. Trends were compared using Joinpoint regression. RESULTS: From 2010-2019, age-adjusted overdose mortality rates increased 53.2% among Veterans and 79.0% among non-Veterans. Age-adjusted rates of overdose mortality among Veterans rose from 19.8/100,000 in 2010 to 32.6/100,000 in 2017, before falling to 30.3/100,000 in 2019. Despite the decrease from 2017 to 2019 in overall overdose mortality, rates of overdose deaths involving synthetic opioids other than methadone and involving psychostimulants continued to increase through 2019. In 2019, overdose mortality was lower for male Veterans than male non-Veterans (standardized rate ratio (SRR) = 0.81, 95% confidence interval (CI): 0.77-0.84). Among male Veterans, rates were higher in all years for those with recent VHA use than those without (2019: SRR=1.69, 95% CI: 1.56-1.83). From 2010-2019, overdose mortality rates increased faster among female Veterans without VHA use than those with VHA use. CONCLUSIONS: From 2015 onward, Veteran men experienced lower age-adjusted overdose rates than non-Veteran men. In all years, overdose rates were higher among male Veterans with recent VHA use than those without recent use. While overall rates of Veteran overdose deaths declined from 2017 to 2019, rates involving psychostimulants and synthetic opioids continued to rise.

Association of Suicide Risk With Transition to Civilian Life Among US Military Service Members.

Importance: Although interest is high in addressing suicide mortality after the transition from military to civilian life, little is known about the risk factors associated with this transition. To support the ongoing suicide surveillance work of the US Department of Veterans Affairs (VA) Office of Mental Health and Suicide Prevention, examining these factors is important for targeting suicide prevention efforts. Objective: To examine the prevalence, patterns, and associated characteristics of suicide mortality among US service members after separation from military active status. Design, Setting, and Participants: This retrospective population-based cohort study obtained demographic and military service data from the VA/Department of Defense Identity Repository. Individuals who served on active duty in the US Army, Navy, Air Force, Marine Corps, or Coast Guard after September 11, 2001, and who separated from active status between January 1, 2010, and December 31, 2017, were included in the cohort. Data analyses were conducted from September 9, 2019, to April 1, 2020. Main Outcomes and Measures: Suicide mortality within 6 years after separation from military service. Results: A total of 1 868 970 service members (1 572 523 men [84.1%]; mean [SD] age at separation, 30.9 [9.9] years) separated from the military during the study period. Through the end of the study period (December 31, 2017), 3030 suicides (2860 men and 170 women) were identified as having occurred within 6 years of separation from the military. Statistically significant differences in suicide risk were found by demographic and military service characteristics. Suicide rates after separation were time dependent, generally peaking 6 to 12 months after separation and declining only modestly over the study period. Male service members had a statistically significantly higher hazard of suicide than their female counterparts (hazard ratio [HR], 3.13; 95% CI, 2.68-3.69). Younger individuals (aged 17-19 years; HR, 4.46 [95% CI, 3.71-5.36]) had suicide hazard rates that were approximately 4.5 times higher than those who transitioned at an older age (≥40 years). Service branch remained a risk factor for suicide even 6 years after separation; those who separated from the Marine Corps (HR, 1.55; 95% CI, 1.36-1.78) and the Army (HR, 1.48; 95% CI, 1.31-1.67) had a higher hazard than those who transitioned from the Air Force. The hazard for those who separated from the active component was higher than for those who separated from the reserve component (HR, 1.29; 95% CI, 1.18-1.42). Service members with a shorter length of service had a higher hazard (HR, 1.26; 95% CI, 1.11-1.42) than those with a longer service history. Conclusions and Relevance: Results of this study show that not all service members who recently transitioned from military life had the same risk of suicide. The data suggest that awareness of military service and demographic characteristics can help identify those most at risk for suicide to target prevention efforts.

Population metrics for suicide events: A causal inference approach.

Large-scale public health prevention initiatives and interventions are a very important component to current public health strategies. But evaluating effects of such large-scale prevention/intervention faces a lot of challenges due to confounding effects and heterogeneity of study population. In this paper, we will develop metrics to assess the risk for suicide events based on causal inference framework when the study population is heterogeneous. The proposed metrics deal with the confounding effect by first estimating the risk of suicide events within each of the risk levels, number of prior attempts, and then taking a weighted sum of the conditional probabilities. The metrics provide unbiased estimates of the risk of suicide events. Simulation studies and a real data example will be used to demonstrate the proposed metrics.

The Use of Theory-Based Formative Research to Design Suicide Prevention Messaging for U.S. Veterans in Midlife.

BACKGROUND: Communication campaigns offer a viable mechanism to promote suicide prevention and reinforce mental health for U.S. veterans in midlife, a group with a high suicide burden. However, little empirical investigation of this type of messaging has been conducted, with formative campaign research conspicuously missing from the limited literature. AIMS: Using the theory of planned behavior as a guide, formative research was conducted to inform the design of suicide prevention messaging by (a) describing and measuring several theoretical constructs among our audience and (b) modeling associations between constructs and intentions to seek help for suicidal behaviors and mental health more broadly. METHODS: Telephone-based cross-sectional surveys were collected between 2014 and 2016 from a nationally representative sample of veterans with analyses restricted to those aged between 44 and 65 years ( n = 809). Multiple logistic regression was used to identify significant factors associated with intentions to seek help for either suicidal behaviors or mental health. RESULTS: Perceived behavioral control was one of the largest predictors of intentions to seek help for both suicidal behaviors and mental health concerns. Descriptive norms were also significantly associated with suicide-related intentions. Data further suggest several types of attitudes (i.e., discordant beliefs, stereotypes) to consider when designing messages for this group. DISCUSSION: This study represents one of the first efforts to document and describe theoretical constructs and their influence on intentions among veterans in midlife to contribute to the development of evidence-based messaging for veterans informed by a conceptual framework. CONCLUSION: Findings have important implications as the use of communication strategies for suicide prevention grows increasingly popular.

Suicide mortality among male veterans discharged from Veterans Health Administration acute psychiatric units from 2005 to 2010.

PURPOSE: The purpose of this study was to calculate suicide rates and identify correlates of risk in the year following discharge from acute Veterans Health Administration psychiatric inpatient units among male veterans discharged from 2005 to 2010 (fiscal years). METHODS: Suicide rates and standardized mortality ratios were calculated. Descriptive analyses were used to describe suicides and non-suicides and provide base rates for interpretation, and unadjusted and adjusted proportional hazard models were used to identify correlates of suicide. RESULTS: From 2005 to 2010, 929 male veterans died by suicide in the year after discharge and the suicide rate was 297/100,000 person-years (py). The suicide rate significantly increased from 234/100,000 py (95% CI = 193-282) in 2005 to 340/100,000 py (95% CI = 292-393) in 2008, after which it plateaued. Living in a rural setting, HR (95% CI) = 1.20 (1.05, 1.36), and being diagnosed with a mood disorder such as major depression, HR (95% CI) = 1.60 (1.36, 1.87), or other anxiety disorder, HR (95% CI) = 1.52 (1.24, 1.87), were associated with increased risk for suicide. CONCLUSIONS: Among male veterans, the suicide rate in the year after discharge from acute psychiatric hospitalization increased from 2005 to 2008, after which it plateaued. Prevention efforts should target psychiatrically hospitalized veterans who live in rural settings and/or are diagnosed with mood or other anxiety disorders.

Suicide attempts among alcohol-dependent pain patients before and after an inpatient hospitalization.

BACKGROUND: This study examined (1) whether pain diagnoses were risk factors for non-fatal suicide attempts before and after inpatient hospitalizations in alcohol-dependent veterans, and (2) the characteristics of pain patients who attempted suicide. METHOD: Administrative data from the Veterans Health Administration were used to identify veterans with an alcohol use disorder who had an inpatient hospitalization during fiscal year 2011 (n=13,047). Logistic regression analyses were used to examine the associations of suicide attempts before and after hospitalizations with pain diagnoses, demographics, medical comorbidity, and psychiatric comorbidity. RESULTS: Bivariate analyses and analyses controlling for demographics and medical comorbidity, indicated that pain diagnoses were significantly associated with suicide attempts in the 365days before hospitalization (Odds Ratio Adjusted [OR]=1.22). This effect was not significant after controlling for psychiatric disorders. Pain diagnoses were not identified as risk factors of suicide attempts in the 365days following discharge. Subgroup analyses among only those with a pain diagnosis revealed that being younger (OR=2.64), being female (OR=2.28), and having an attempt in the year prior to hospitalization (OR=4.11) were risk factors of suicide attempts in the year following hospitalization. Additionally, younger age (OR=2.13) and depression (OR=3.53) were associated with attempts in the year prior to the hospitalization. CONCLUSIONS: This study suggests that psychiatric disorders account for the relationship between pain diagnoses and past suicide attempts among hospitalized alcohol-dependent veterans. Pain-specific suicide prevention efforts may be better targeted at less intensive levels of care.

Measuring Associations of the Department of Veterans Affairs' Suicide Prevention Campaign on the Use of Crisis Support Services.

Campaigns have become popular in public health approaches to suicide prevention; however, limited empirical investigation of their impact on behavior has been conducted. To address this gap, utilization patterns of crisis support services associated with the Department of Veterans Affairs' Veterans Crisis Line (VCL) suicide prevention campaign were examined. Daily call data for the National Suicide Prevention Lifeline, VCL, and 1-800-SUICIDE were modeled using a novel semi-varying coefficient method. Analyses reveal significant increases in call volume to both targeted and broad resources during the campaign. Findings underscore the need for further research to refine measurement of the effects of these suicide prevention efforts.

Use of ICD-9-CM Diagnosis Code V62.89 (Other Psychological or Physical Stress, Not Elsewhere Classified) Following a Suicide Attempt.

OBJECTIVE: This study examined the demographic, diagnostic, and service characteristics of veterans who received services for "other psychological or physical stress, not elsewhere classified" (ICD-9-CM V62.89) in the month following a suicide attempt. METHODS: An electronic search of a Veterans Health Administration (VHA) suicide event reporting system identified 22,701 veterans who were survivors of a suicide attempt. Their clinical service encounter records were extracted from a VHA administrative database to identify those who received services related to V62.89. RESULTS: Services related to V62.89 were provided to N=2,173 (9.6%) of the sample. Chaplains were the predominant service provider, identified in N=1,745 (80%) of the service encounters. Differences were noted between those who received services related to V62.89 from a chaplain or from another service provider. CONCLUSIONS: V62.89 appears to be a focus of clinical concern for some veteran suicide attempt survivors. Additional research is needed to better understand any implications for suicide "postvention."

VA Suicide Prevention Applications Network: A National Health Care System-Based Suicide Event Tracking System.

OBJECTIVES: The US Department of Veterans Affairs' Suicide Prevention Applications Network (SPAN) is a national system for suicide event tracking and case management. The objective of this study was to assess data on suicide attempts among people using Veterans Health Administration (VHA) services. METHODS: We assessed the degree of data overlap on suicide attempters reported in SPAN and the VHA's medical records from October 1, 2010, to September 30, 2014-overall, by year, and by region. Data on suicide attempters in the VHA's medical records consisted of diagnoses documented with E95 codes from the International Classification of Diseases, Ninth Revision. RESULTS: Of 50 518 VHA patients who attempted suicide during the 4-year study period, data on fewer than half (41%) were reported in both SPAN and the medical records; nearly 65% of patients whose suicide attempt was recorded in SPAN had no data on attempted suicide in the VHA's medical records. CONCLUSION: Evaluation of administrative data suggests that use of SPAN substantially increases the collection of data on suicide attempters as compared with the use of medical records alone, but neither SPAN nor the VHA's medical records identify all suicide attempters. Further research is needed to better understand the strengths and limitations of both systems and how to best combine information across systems.

Veterans Crisis Line Callers With and Without Prior VHA Service Use.

This study examines differences between Veterans with and without prior Veterans Health Administration service use who received a clinical referral from the Veterans' Crisis Line. Differences between groups were identified using data taken from 13,444 calls and medical records. Approximately 91% of Veterans had a history of service use and 9% did not. Callers with prior service use were older, had more mental health disorders, made in-person contact more quickly, and used more outpatient mental healthcare. Those without prior service use were younger, had more mental health problems, and presented for care later. Callers with suicide-related diagnoses had high rates of service contact. These groups represent different subpopulations with unique healthcare needs and practices.

Comorbid depression and alcohol use disorders and prospective risk for suicide attempt in the year following inpatient hospitalization.

OBJECTIVE: The purpose of this study is to identify predictors of nonfatal suicide attempts in veterans discharged from acute hospitalization with depression and/or alcohol use disorder (AUD) diagnoses. We hypothesized that primary depression confers similar risk for attempt whether or not it is accompanied by secondary AUD, and that a suicide attempt in the prior year would confer greatest risk of the variables studied. METHOD: Veteran Health Administration (VHA) patients discharged from acute inpatient hospitalization in 2011 with AUD and/or non-bipolar depression diagnoses (N=22,319) were analyzed using information from the computerized record system and national database on suicidal behavior. Proportional hazard regression models estimated unadjusted and adjusted hazard ratios (AHR) and confidence intervals (95% CI) for risk of a nonfatal attempt within one year following discharge. RESULTS: As hypothesized, primary depression with secondary AUD [AHR (95% CI)=1.41 (1.04, 1.92)] and without secondary AUD [AHR (95% CI)=1.30 (1.00, 1.71)] conferred similar prospective risk for attempt (AUD without depression, reference). Although prior suicide attempt was associated with increased risk, acute care in "general psychiatry" during hospitalization [AHR (95% CI)=6.35 (3.48, 13.00)] conferred the greatest risk among the variables studied. Transfer to another inpatient setting reduced risk [AHR (95% CI=0.53 (0.34, 0.79). LIMITATIONS: Analyses were based on administrative data and did not include information on mortality. CONCLUSION: When primary depression is severe enough to warrant inpatient hospitalization, a secondary diagnosis of AUD may not contribute additional prospective risk for nonfatal attempt. Within VHA, acute psychiatric care during hospitalization is a potential marker for increased risk for nonfatal attempt. Transfer to an additional inpatient setting may reduce risk for nonfatal attempt.

Associations between the Department of Veterans Affairs' suicide prevention campaign and calls to related crisis lines.

OBJECTIVE: The Transit Authority Suicide Prevention (TASP) campaign was launched by the Department of Veterans Affairs (VA) in a limited number of U.S. cities to promote the use of crisis lines among veterans of military service. METHODS: We obtained the daily number of calls to the VCL and National Suicide Prevention Lifeline (NSPL) for six implementation cities (where the campaign was active) and four control cities (where there was no TASP campaign messaging) for a 14-month period. To identify changes in call volume associated with campaign implementation, VCL and NSPL daily call counts for three time periods of equal length (pre-campaign, during campaign, and post-campaign) were modeled using a Poisson log-linear regression with inference based on the generalized estimating equations. RESULTS: Statistically significant increases in calls to both the VCL and the NSPL were reported during the TASP campaign in implementation cities, but were not reported in control cities during or following the campaign. Secondary outcome measures were also reported for the VCL and included the percentage of callers who are veterans, and calls resulting in a rescue during the study period. CONCLUSIONS: Results from this study reveal some promise for suicide prevention messaging to promote the use of telephone crisis services and contribute to an emerging area of research examining the effects of campaigns on help seeking.

Examining the Intersection Between Suicidal Behaviors and Intimate Partner Violence Among a Sample of Males Receiving Services From the Veterans Health Administration.

Veterans comprise 10% of the population, and suicide among Veterans has garnered national media and policy attention. Existing research suggests that intimate partner violence (IPV) is a risk factor for suicidal behaviors among some high-risk populations. This report offers a new perspective: the intersection between Veterans' suicidal thoughts and IPV, both victimization and perpetration. The data were obtained from a northeast telephone survey of Veterans (n = 296) using Veterans Health Administration services and yielded a 27% participation rate. Findings suggest male Veterans who are IPV involved have increased odds of suicidal thoughts and behaviors.

Using media to promote suicide prevention hotlines to Veteran households.

This article presents preliminary evidence that media campaigns are valuable in promoting suicide prevention hotlines to Veteran households by reporting data from 2526 telephone surveys. Findings from this study underscore the need for further investigation of the use of media campaigns to support suicide prevention initiatives aimed at Veteran populations.