Current Programs and Incentives to Overcome Rural Physician Shortages in the United States: A Narrative Review.

Access to healthcare continues to be a top priority and prominent challenge in rural communities, with 20% of the total U.S. population living in rural areas while only 10% of physicians practice in rural areas. In response to physician shortages, a variety of programs and incentives have been implemented to recruit and retain physicians in rural areas; however, less is known about the types and structures of incentives that are offered in rural areas and how that compares to physician shortages. The purpose of our study is to conduct a narrative review of the literature to identify and compare current incentives that are offered by rural physician shortage areas to better understand how resources are being allocated to vulnerable areas. We reviewed published peer-reviewed articles from 2015-2022 to identify incentives and programs designed to address physician shortages in rural areas. We augment that review by examining the gray literature, including reports and white papers on the topic. Identified incentive programs were aggregated for comparison and translated into a map that depicts high, medium, and low levels of geographically designated Health Professional Shortage Areas (HPSAs) and the number of incentives offered by state. Surveying current literature regarding different types of incentivization strategies while comparing to primary care HPSAs provides general insights on the potential influence of incentive programs on shortages, allows easy visual review, and may provide greater awareness of available support for potential recruits. Providing a broad overview of the incentives offered in rural areas will help illuminate whether diverse and appealing incentives are offered in the most vulnerable areas and guide future efforts to address these issues.

A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder.

OBJECTIVE: Mortality from opioid use disorder (OUD) can be reduced for patients who receive opioid agonist treatment (OAT). In the United States (US), OATs have different requirements including nearly daily visits to a dispensing facility for methadone but weekly to monthly prescriptions for buprenorphine. Our objective was to compare mortality rates for buprenorphine and methadone treatments among a large sample of US patients with OUD. METHODS: We measured all-cause mortality, overdose mortality, and suicide mortality among US Department of Veterans Affairs patients with a diagnosis of OUD who received OAT from 2010 through 2019. We leveraged substantial and sustained regional variation in prescribing buprenorphine versus methadone as an instrumental variable (IV) and used inverse propensity of treatment weighting to balance relevant covariates across treatment groups. We compared mortality with true two-stage IV using both probit and linear probability models, as well as a reduced form IV model, adjusting for demographics and health status. RESULTS: Our cohort consisted of 61,997 patients with OUD who received OAT, of whom 92.7% were male with a mean age of 47.9 (SD = 14.1) years. Patients were followed for a median of 2 (IQR = 1,4) calendar years. Across regional terciles, mean methadone prescribing was 4.8%, 19.5%, and 75.1% of OAT patients. All models identified significant reductions in all-cause and suicide mortality for buprenorphine relative to methadone. For example, predicted all-cause mortality from the probit model was 169.7 per 10,000 person years (95% CI, 157.8, 179.6) in the lowest tercile of methadone prescribing compared with 206.1 (95% CI, 196.0, 216.3) in the highest tercile. No difference was identified for overdose mortality. CONCLUSION: We found significantly lower all-cause mortality and suicide mortality rates for buprenorphine compared with methadone. Our results support the less restrictive prescribing practices for buprenorphine as OAT in the US.

Comparative Effectiveness of Direct-Acting Antivirals for Posttraumatic Stress Disorder in Veterans Affairs Patients With Hepatitis C Virus Infection.

We recently conducted an exploratory study that indicated that several direct-acting antivirals (DAAs), highly effective medications for hepatitis C virus (HCV) infection, were also associated with improvement in posttraumatic stress disorder (PTSD) among a national cohort of US Department of Veterans Affairs (VA) patients treated between October 1, 1999, and September 30, 2019. Limiting the same cohort to patients with PTSD and HCV, we compared the associations of individual DAAs with PTSD symptom improvement using propensity score weighting. After identifying patients who had available baseline and endpoint PTSD symptom data as measured with the PTSD Checklist (PCL), we compared changes over the 8-12 weeks of DAA treatment. The DAAs most prescribed in conjunction with PCL measurement were glecaprevir/pibrentasvir (GLE/PIB; n = 54), sofosbuvir/velpatasvir (SOF/VEL; n = 54), and ledipasvir/sofosbuvir (LDV/SOF; n = 145). GLE/PIB was superior to LDV/SOF, with a mean difference in improvement of 7.3 points on the PCL (95% confidence interval (CI): 1.1, 13.6). The mean differences in improvement on the PCL were smaller between GLE/PIB and SOF/VEL (3.0, 95% CI: -6.3, 12.2) and between SOF/VEL and LDV/SOF (4.4, 95% CI: -2.4, 11.2). While almost all patients were cured of HCV (92.5%) regardless of the agent received, PTSD outcomes were superior for those receiving GLE/PIB compared with those receiving LDV/SOF, indicating that GLE/PIB may merit further investigation as a potential PTSD treatment.

Association between post-traumatic stress disorder severity and death by suicide in US military veterans: retrospective cohort study.

BACKGROUND: There is mixed evidence regarding the direction of a potential association between post-traumatic stress disorder (PTSD) and suicide mortality. AIMS: This is the first population-based study to account for both PTSD diagnosis and PTSD symptom severity simultaneously in the examination of suicide mortality. METHOD: Retrospective study that included all US Department of Veterans Affairs (VA) patients with a PTSD diagnosis and at least one symptom severity assessment using the PTSD Checklist (PCL) between 1 October 1999 and 31 December 2018 (n = 754 197). We performed multivariable proportional hazards regression models using exposure groups defined by level of PTSD symptom severity to estimate suicide mortality rates. For patients with multiple PCL scores, we performed additional models using exposure groups defined by level of change in PTSD symptom severity. We assessed suicide mortality using the VA/Department of Defense Mortality Data Repository. RESULTS: Any level of PTSD symptoms above the minimum threshold for symptomatic remission (i.e. PCL score >18) was associated with double the suicide mortality rate at 1 month after assessment. This relationship decreased over time but patients with moderate to high symptoms continued to have elevated suicide rates. Worsening PTSD symptoms were associated with a 25% higher long-term suicide mortality rate. Among patients with improved PTSD symptoms, those with symptomatic remission had a substantial and sustained reduction in the suicide rate compared with those without symptomatic remission (HR = 0.56; 95% CI 0.37-0.88). CONCLUSIONS: Ameliorating PTSD can reduce risk of suicide mortality, but patients must achieve symptomatic remission to attain this benefit.

Is It Time for the Mental Health Field to Consider Unplanned Discharge a Key Metric of Patient Safety?

ABSTRACT: Mental health lacks robust measures to assess patient safety. Unplanned discharge is common in mental health populations and associated with poor outcomes. Clarifying whether unplanned discharge varies across settings may highlight the need to develop measures to reduce harms associated with this event. Unplanned discharge rates were compared across the Department of Veterans Affairs' acute inpatient and residential mental health treatment settings from 2009 to 2019. Logistic regression was used to create facility-level, adjusted unplanned discharge rates stratified by setting. Results were described using central tendency. Among 847,661 acute inpatient discharges, the mean unplanned discharge rate was 3.3% (range, 0%-18%). Among 358,117 residential discharges, the mean unplanned discharge rate was 17.9% (range, 1%-48.3%). Unplanned discharge is a marked problem in mental health, with large variation across treatment settings. Unplanned discharge should be measured as part of patient safety efforts.

Changes in Alcohol Consumption following Direct-Acting Antiviral Treatment for Hepatitis C in VA Patients with Comorbid Alcohol Use Disorder and PTSD.

OBJECTIVE: To investigate whether direct-acting antivirals (DAA) for hepatitis C viral infection (HCV): glecaprevir/pibrentasvir (GLE/PIB), ledipasvir/sofosbuvir (LDV/SOF), and sofosbuvir/velpatasvir (SOF/VEL) are associated with reduced alcohol consumption among veterans with alcohol use disorder (AUD) and co-occurring post-traumatic stress disorder (PTSD). METHODS: We measured change in Alcohol Use Disorder Identification Test-Consumption Module (AUDIT-C) scores in a retrospective cohort of veterans with PTSD and AUD receiving DAAs for HCV. RESULTS: One thousand two hundred and eleven patients were included (GLE/PIB n = 174, LDV/SOF n = 808, SOF/VEL n = 229). Adjusted frequencies of clinically meaningful improvement were 30.5% for GLE/PIB, 45.5% for LDV/SOF, and 40.5% for SOF/VEL. The frequency was lower for GLE/PIB than for LDV/SOF (OR = 0.59; 95% CI [0.40, 0.87]) or SOF/VEL (OR = 0.66; 95% CI [0.42, 1.04]). CONCLUSIONS: DAA treatment for HCV was associated with a substantial reduction in alcohol use in patients with AUD and co-occurring PTSD. Further exploration of the role of DAAs in AUD treatment is warranted.

The Regional Distribution of Psychiatric Residency Positions Funded by the Department of Veterans Affairs and Its Relationship to Rural Veteran Populations.

OBJECTIVE: The authors evaluated the distribution of psychiatry residency positions funded by the Department of Veterans Affairs between 2014 and 2020 with respect to geographic location and hospital patient population rurality. METHODS: The authors collected data on psychiatry residency positions from the Veterans Affairs' Office of Academic Affiliations Support Center and data on hospital-level patient rurality from the Veterans Health Administration Support Service Center. They examined the chronological and geospatial relationships between the number of residency positions deployed and the size of the rural patient populations served. RESULTS: Between 2014 and 2020, the Department of Veterans Affairs has substantially increased the number of rural hospitals hosting psychiatry residency programs, as well as the number of residency positions at those hospitals. However, several geographic regions serve high numbers of rural veterans with few or no psychiatry resident positions. CONCLUSIONS: While the VA efforts to increase psychiatry residency positions in rural areas have been partially successful, additional progress can be made increasing support for psychiatry trainees at Veterans Affairs hospitals and community-based outpatient clinics that serve large portions of the rural veteran population.

Invited Commentary: Baby Steps to a Learning Mental Health-Care System-Can We Do the Work?

There are an infinite number of small decisions to be made in routine clinical practice, and most will never be the subject of prospective research studies. Rather than making these decisions arbitrarily, learning health-care systems leverage experience represented by electronic health record data and other sources to inform decision-making and improve clinical practice. While this approach has been elusive in mental health, Coulombe et al. (Am J Epidemiol. 2021;190(7):1210-1219) use UK National Health Service data to evaluate a decision rule for antidepressant choice created using dynamic weighted survival modeling. Although the results are equivocal in this use case, the work suggests a path forward for data-driven decision-making in routine mental health care. Such approaches will be required to set the stage for a learning mental health care system.

Mortality after electroconvulsive therapy.

BACKGROUND: There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths. AIMS: We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year. METHOD: We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching. RESULTS: Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79-1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66-0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65-1.73) for all-cause mortality, and 1.02 (95% CI 0.58-1.8) for all-cause mortality excluding suicide deaths. CONCLUSIONS: There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.

Natural language processing of clinical mental health notes may add predictive value to existing suicide risk models.

BACKGROUND: This study evaluated whether natural language processing (NLP) of psychotherapy note text provides additional accuracy over and above currently used suicide prediction models. METHODS: We used a cohort of Veterans Health Administration (VHA) users diagnosed with post-traumatic stress disorder (PTSD) between 2004-2013. Using a case-control design, cases (those that died by suicide during the year following diagnosis) were matched to controls (those that remained alive). After selecting conditional matches based on having shared mental health providers, we chose controls using a 5:1 nearest-neighbor propensity match based on the VHA's structured Electronic Medical Records (EMR)-based suicide prediction model. For cases, psychotherapist notes were collected from diagnosis until death. For controls, psychotherapist notes were collected from diagnosis until matched case's date of death. After ensuring similar numbers of notes, the final sample included 246 cases and 986 controls. Notes were analyzed using Sentiment Analysis and Cognition Engine, a Python-based NLP package. The output was evaluated using machine-learning algorithms. The area under the curve (AUC) was calculated to determine models' predictive accuracy. RESULTS: NLP derived variables offered small but significant predictive improvement (AUC = 0.58) for patients that had longer treatment duration. A small sample size limited predictive accuracy. CONCLUSIONS: Study identifies a novel method for measuring suicide risk over time and potentially categorizing patient subgroups with distinct risk sensitivities. Findings suggest leveraging NLP derived variables from psychotherapy notes offers an additional predictive value over and above the VHA's state-of-the-art structured EMR-based suicide prediction model. Replication with a larger non-PTSD specific sample is required.

Recent trends in the rural-urban suicide disparity among veterans using VA health care.

There is an elevated risk of suicide among people living in rural areas, and the rural-urban disparity in death by suicide is growing in the general United States population. The department of Veterans Affairs (VA) implemented programs targeting rural health in 2007 and suicide prevention in 2008. Rural-urban differences in suicide rates among VA users have not been examined since 2010. We sought to understand whether the rural-urban disparity in suicide risk among VA users decreased during a time of contemporaneous VA efforts to improve access to mental health care for rural Veterans and to improve the effectiveness of mental health services at preventing suicide. We performed a retrospective cohort study examining differences in the raw and adjusted annual suicide rate among rural and urban VA users between 2003 and 2017. All VHA users 2003-2017. Descriptive statistics are presented for all VHA users in 2017. This includes 6,120,355 unique VA users, 32.0% (n = 1,955,935) of whom lived at a rural address. Raw rates of death by suicide were higher in rural VA users than urban VA users overall (33.3 vs. 29.1 deaths per 100,000 population) and across years, but the age, sex, and race-adjusted rates converged in 2005. White VA users had over triple the rate of death by suicide as black VA users, and lived disproportionally in rural areas. The rural-urban suicide disparity among VA users persists. However, the disparity appears to be driven by differences in the racial composition of rural and urban patients, which were not accounted for in prior studies.

Measurement Strategies for Evidence-Based Antidepressants for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

We sought to develop a quality standard for the prescription of antidepressants for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting antidepressants as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified antidepressant initiation during the first year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users, and compared outcomes in a subgroup who completed patient-reported outcome measurement (PROM) as part of routine practice. We added progressively stringent measurement requirements. Prescribing quality for PTSD in the VA was stable over time. Use of PROM was rare in the case of antidepressant treatment, limiting our assessment of outcomes.

Effects of Electroconvulsive Therapy on Short-Term Suicide Mortality in a Risk-Matched Patient Population.

OBJECTIVE: Although evidence has suggested that electroconvulsive therapy (ECT) is effective in reducing suicidal ideation, research establishing the effectiveness of ECT in reducing short-term risk of death by suicide is less conclusive. This study assessed whether receipt of ECT reduced suicide mortality among patients seeking healthcare in Veterans Health Administration hospitals. METHODS: Annual cohorts of patients who received ECT between 2006 and 2015 were propensity score matched with mental health patients who did not receive ECT. After matching, population averaged adjusted odds were calculated to assess the risk of suicide in the year after receipt of ECT, compared with a control group. RESULTS: The study population consisted of 14,810 patients in the ECT cohort and 58,369 matched controls. Matching successfully reduced clinical and demographic differences between cohorts of patients who received ECT and those who did not (asymptotic Kolmogorov-Smirnov statistic = 0.02, P > 0.99). After matching and controlling for remaining between-group differences in an adjusted logistic regression, the odds of suicide in the year after receipt of ECT were not statistically different from those of matched patients who did not receive the procedure (odds ratio = 1.31, 95% confidence interval = 0.94-1.96, P = 0.095). CONCLUSIONS: Patients who received ECT were at a high risk for suicide. Electroconvulsive therapy did not seem to have a greater effect on decreasing short-term risk for suicide than other types of mental health treatment provided to patients with similar baseline risk.

Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics.

OBJECTIVES: The body of large-scale, epidemiological research on electroconvulsive therapy (ECT) in the United States is limited. To address this gap, we assessed demographic, clinical, pharmacological, and mental health treatment history as well as 2-year mortality outcomes associated with ECT use in the largest U.S. health care system. METHODS: Among all patients who sought mental health care at Veterans Health Administration (VHA) hospitals in 2012, we used bivariate analyses to compare patients who did and not receive ECT during 2 years of follow-up. Among the population who received ECT, descriptive statistics were calculated to characterize prior mental health treatment patterns and ECT receipt. RESULTS: 0.11% (N = 1616) of all VHA mental health patients in 2012 (N = 1,457,053) received ECT in 2 years of follow-up. There was significant regional variation in provision of ECT. Those who received ECT were more likely to have diagnoses of major depressive, bipolar, and personality disorders and were significantly more likely to have had a recent mental health inpatient stay (risk ratio, 6.94). Receipt of ECT was not associated with a difference in all-cause mortality (risk ratio, 0.88). Thirty-two percent of those who received ECT had no substantial antidepressant or therapy trial in the year before index mental health encounter. CONCLUSIONS: Use of ECT in the VHA is rare. Patients who receive ECT have a complex and high-risk profile, not necessarily consistent with the most common indications for ECT.

Associations between Medication Assisted Therapy Services Delivery and Mortality in a National Cohort of Veterans with Posttraumatic Stress Disorder and Opioid Use Disorder.

Objective: Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. Methods: We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. Results: A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years (SD = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). Conclusions: In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.

Correction to: Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

The original version of this article unfortunately contained a mistake. The co-author name was incorrectly published with the middle initial in the author list.

Measurement Strategies for Evidence-Based Psychotherapy for Posttraumatic Stress Disorder Delivery: Trends and Associations with Patient-Reported Outcomes.

We sought to develop a quality standard for the delivery of psychotherapy for posttraumatic stress disorder (PTSD) that is both consistent with the underlying evidence supporting psychotherapy as a treatment for PTSD and associated with the best levels of symptom improvement. We quantified psychotherapy receipt during the initial year of PTSD treatment in a 10-year national cohort of Department of Veterans Affairs (VA) users who completed patient-reported outcome measurement as part of routine practice. We added progressively stringent measurement requirements. The most stringent requirement was associated with superior outcomes. Quality of psychotherapy for PTSD in the VA improved over time.

A Pilot Study of an Intervention to Prevent Suicide After Psychiatric Hospitalization.

A prior meta-analysis found that the World Health Organization Brief Intervention and Contact Program (WHO BIC) significantly reduces suicide risk. WHO BIC has not been studied in high-income countries. We piloted an adapted version of WHO BIC on an inpatient mental health unit in the United States. We assessed the feasibility and acceptability. We also evaluated changes in suicidal ideation, hopelessness, and connectedness using a repeated measures analysis of variance. Of 13 eligible patients, 9 patients enrolled. Patients experienced significant improvements in suicidal ideation, hopelessness, and connectedness at 1 and 3 months (Beck Scale for Suicidal Ideation, F(2,16) = 14.96, p < 0.01; Beck Hopelessness Scale, F(2,16) = 5.88, p < 0.05; perceived burdensomeness subscale, F(2,16) = 10.97, p < 0.013; and thwarted belongingness subscale, F(2,16) = 4.77, p < 0.03). Patients were highly satisfied. An adapted version of WHO BIC may be feasible to implement in a high-resource setting, but trials need to confirm efficacy.

How Well Do Incident Reporting Systems Work on Inpatient Psychiatric Units?

BACKGROUND: Adverse events and medical errors have been shown to be a persistent issue in health care. However, little research has been conducted regarding the efficacy of incident reporting systems, particularly within an inpatient psychiatry setting. METHODS: The medical records from a random sample of 40 psychiatric units within Veterans Health Administration (VHA) medical centers were screened and evaluated by physicians for 9 types of safety events. The abstracted safety events were then evaluated to assess if they were caused by an error and if they caused harm to the patient. These safety events were then matched to incidents that were reported to the VHA Adverse Event Reporting System (AERS), which includes all reported adverse events, close calls, and root cause analyses that occur within the VHA health system. RESULTS: Overall, 37.4% (95% confidence interval [CI] = 33.5%-41.5%) of safety events detected in the medical record were reported to the AERS. Among the patient safety events identified, the most commonly reported to the AERS were patient falls (52.3%), assaults (46.2%), and elopements (42.3%). Reporting rates increased when the patient safety event resulted in harm to the patient (48.2%; CI = 41.6%-55.0%). CONCLUSION: The majority of patient safety events that occur on VHA inpatient psychiatric units do not get reported to the VHA's Adverse Event Reporting System. These findings suggest that self-reporting is not a reliable method of tracking patient safety events. Future efforts should target the barriers to inpatient psychiatric reporting and develop mechanisms to overcome these barriers.

Health Care Processes Contributing to Suicide Risk in Veterans During and After Residential Substance Abuse Treatment.

Objective: Substance use disorders are an important risk factor for suicide. While residential drug treatment programs improve clinical outcomes for substance use disorders, less is known about the role of related health care processes in contributing to suicide risk. These data may help to inform strategies to prevent suicide during and after residential treatment.Methods: A retrospective analysis was conducted on root-cause analysis (RCA) reports of suicide in veterans occurring within 3 months of discharge from a residential drug treatment program that were reported to a Veterans Affairs facility between 2001 and 2017. Demographic information such as age, gender, and psychiatric comorbidity were abstracted from each report. In addition, an established codebook was used to code root causes from each report. Root causes were grouped into categories in order to characterize the key system and organizational-level processes that may have contributed to the suicide.Results: A total of 39 RCA reports of suicide occurring within 3 months after discharge from a residential drug treatment program were identified. The majority of decedents were men and the average age was 42.9 years (SD = 11.2). The most common method of suicide was overdose (33%) followed by hanging (28%). Most suicides occurred in close proximity to discharge, with 56% (n = 22) occurring within seven days of discharge and 36% (n = 14) occurring within 48 hours of discharge. The most common substances used by decedents prior to admission were alcohol or opiates. RCA teams identified a total of 140 root causes and the majority were due to problems with suicide risk assessment (n = 32, 22.9%). Non-engagement with treatment during (n = 20, 14.3%) and after the residential stay (n = 18, 12.9%) was also highlighted as an important concern. Finally, several reports raised concerns that a discharge prior to treatment completion or a precipitous discharge due to program violation negatively impacted treatment outcomes.Conclusions: Efforts to prevent suicide in the period following discharge from a residential drug treatment program should focus on addressing suicide risk factors during admission and helping patients engage more fully in substance use disorder treatment.