Technology-Facilitated Depression Self-Management Linked with Lay Supporters and Primary Care Clinics: Randomized Controlled Trial in a Low-Income Sample.

Purpose: To test whether technology-facilitated self-management support improves depression in primary care settings. Methods: We randomized 204 low-income primary care patients who had at least moderate depressive symptoms to intervention or control. Intervention participants received 12 months of weekly automated interactive voice response telephone calls that assessed their symptom severity and provided self-management strategies. Their patient-nominated supporter (CarePartner) received corresponding guidance on self-management support, and their primary care team received urgent notifications. Those randomized to enhanced usual care received printed generic self-management instructions. Results: One-year attrition rate was 14%. By month 6, symptom severity on the Patient Health Questionnaire-9 (PHQ-9) decreased 2.5 points more in the intervention arm than in the control arm (95% CI -4.2 to -0.8, p = 0.003). This benefit was similar at month 12 (p = 0.004). Intervention was also over twice as likely to lead to ≥50% reduction in symptom severity by month 6 (OR = 2.2 (1.1, 4.7)) and a decrease of ≥5 PHQ-9 points by month 12 (OR = 2.3 (1.2, 4.4)). Conclusions: Technology-facilitated self-management guidance with lay support and clinician notifications improves depression for primary care patients. Subsequent research should examine implementation and generalization to other chronic conditions. clinicaltrials.gov, identifier NCT01834534.

The Cost-Effectiveness of Cognitive Behavioral Therapy Versus Second-Generation Antidepressants for Initial Treatment of Major Depressive Disorder in the United States: A Decision Analytic Model.

Background: Most guidelines for major depressive disorder recommend initial treatment with either a second-generation antidepressant (SGA) or cognitive behavioral therapy (CBT). Although most trials suggest that these treatments have similar efficacy, their health economic implications are uncertain. Objective: To quantify the cost-effectiveness of CBT versus SGA for initial treatment of depression. Design: Decision analytic model. Data Sources: Relative effectiveness data from a meta-analysis of randomized controlled trials; additional clinical and economic data from other publications. Target Population: Adults with newly diagnosed major depressive disorder in the United States. Time Horizon: 1 to 5 years. Perspectives: Health care sector and societal. Intervention: Initial treatment with either an SGA or group and individual CBT. Outcome Measures: Costs in 2014 U.S. dollars, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. Results of Base-Case Analysis: In model projections, CBT produced higher QALYs (3 days more at 1 year and 20 days more at 5 years) with higher costs at 1 year (health care sector, $900; societal, $1500) but lower costs at 5 years (health care sector, -$1800; societal, -$2500). Results of Sensitivity Analysis: In probabilistic sensitivity analyses, SGA had a 64% to 77% likelihood of having an incremental cost-effectiveness ratio of $100 000 or less per QALY at 1 year; CBT had a 73% to 77% likelihood at 5 years. Uncertainty in the relative risk for relapse of depression contributed the most to overall uncertainty in the optimal treatment. Limitation: Long-term trials comparing CBT and SGA are lacking. Conclusion: Neither SGAs nor CBT provides consistently superior cost-effectiveness relative to the other. Given many patients' preference for psychotherapy over pharmacotherapy, increasing patient access to CBT may be warranted. Primary Funding Source: Department of Veterans Affairs, National Institute of Mental Health.

Differences in Mental Health Service Use Among Unemployed Veterans of Different Eras.

Mental disorders have been linked to unemployment among veterans. Improving mental health conditions, such as depression, can improve veteran employment outcomes. This study compared mental health treatment among unemployed Operation Enduring Freedom (OEF; in Afghanistan) and Operation Iraqi Freedom (OIF; in Iraq) veterans and veterans from other service eras. The study included 3165 unemployed veterans from six Veterans Affairs medical centers with a positive screen that indicates a possible mental disorder. Chi-squared tests and logistic regression analyses assessed whether veteran era was associated with mental health treatment. Unemployed OEF/OIF veterans were less likely to receive psychotropic medication and four or more psychotherapy sessions compared to veterans from other eras. Multivariable analyses controlling for age found associations based on younger age rather than era. Younger unemployed veterans received fewer mental health services, which is concerning because reducing mental health symptoms may increase employment and employment may reduce symptoms, which are key factors in reintegration into civilian life.

Longitudinal patterns of PTSD symptom classes among US National Guard service members during reintegration.

PURPOSE: The purpose of this study was to identify posttraumatic stress disorder (PTSD) symptom groups and assess their longitudinal progression during their first year of reintegration among United States (US) National Guard (NG) service members. METHODS: A cohort of NG service members (n = 886) completed surveys at 6 and 12 months following their return from deployment to Iraq or Afghanistan. Latent class analysis (LCA) and latent transition analysis (LTA) were used to empirically derive groups based on their PTSD symptoms and examine their longitudinal course, respectively. RESULTS: The best fitting model at both assessments was the four-class model, comprising an asymptomatic class (6 months = 54%; 12 months = 55%), a mild symptom class with elevated hyperarousal symptoms (6 months = 22%; 12 months = 17%), a moderate symptom class (6 months = 15%; 12 months = 15%), and a severe symptom class (6 months = 10%; 12 months = 13%). Based on LTA, stability of class membership at the two assessments was 0.797 for the asymptomatic class, 0.453 for the mild class, 0.560 for the moderate class, and 0.580 for the severe class. Estimated transition probabilities were greater with respect to transitioning to less severe, rather than more severe, classes over time. CONCLUSIONS: The four latent PTSD classes were distinguished primarily by severity; however, the mild symptom class was characterized by higher levels of hyperarousal than other symptoms. Although the absolute number of individuals within classes remained fairly constant between 6 and 12 months, there was movement between severity classes. Most NG service members without symptoms continued to do well during the first year, with only an estimated 7% moving to the moderate or severe class.

Pilot study of enhanced social support with automated telephone monitoring after psychiatric hospitalization for depression.

BACKGROUND: Following discharge, patients hospitalized for depression are at high risk for poor retention in outpatient care and adverse outcomes. AIMS: Pilot tests a post-hospital monitoring and enhanced support program for depression. METHOD: 48 patients at a Veterans Affairs Medical Center discharged following a depression-related inpatient stay received weekly visits or phone calls for 6 months from their choice of either a family member/friend (n = 19) or a certified peer support specialist (n = 29). Participants also completed weekly automated telephone monitoring calls assessing depressive symptoms and antidepressant medication adherence. RESULTS: Over 90% of participants were more satisfied with their care due to the service. The mean change from baseline to 6 months in depression symptoms was -7.9 (p < 0.05) according to the Patient Health Questionnaire and -11.2 (p < 0.05) according to the Beck Depression Inventory-II for those supported by a family member/friend, whereas those supported by a peer specialist had mean changes of -3.5 (p < 0.05) and -1.7 (p > 0.10), respectively. CONCLUSIONS: Increased contact with a chosen support person coupled with automated telephone monitoring after psychiatric hospitalization is an acceptable service for patients with depression. Those who received the service, and particularly those supported by a family member/friend, experienced reductions in symptoms of depression.

Antidepressant Medication Treatment and Risk of Death.

OBJECTIVE: Although previous studies have assessed whether depression is a mortality risk factor, few have examined whether antidepressant medications (ADMs) influence mortality risk. METHODS: We estimated hazards of 1-year all-cause mortality associated with ADMs, with use occurring within 90 days of depression diagnosis among 720 821 patients who received treatment in a Veterans Health Administration facility during fiscal year 2006. We addressed treatment selection biases using conventional Cox regression, propensity-stratified Cox regression (propensity score), and 2 forms of marginal structural models. Models accounted for multiple potential clinical and demographic confounders, and sensitivity analyses compared findings by antidepressant class. RESULTS: Antidepressant medication use compared with no use was associated with significantly lower hazards of 1-year mortality risk in Cox (hazard ratio [HR], 0.93; 95% confidence interval [CI], 0.90-0.97) and propensity score estimates (HR, 0.94; 95% CI, 0.91-0.98), whereas marginal structural model-based estimates showed no difference in mortality risk when the exposure was specified as "as-treated" in every 90-day intervals of the 1-year follow-up (HR, 0.91; 95% CI, 0.66-1.26) but showed increased risk when specified as "intent-to-treat" (HR, 1.07; 95% CI, 1.02-1.13). CONCLUSIONS: Among patients treated with ADMs belonging to a single class in the first 90 days, there were no significant differences in 1-year all-cause mortality risks. When accounting for clinical and demographic characteristics and treatment selection bias, ADM use was associated with no excess harm.

Self-Determination Theory and Outpatient Follow-Up After Psychiatric Hospitalization.

The objective of this study was to assess whether the constructs of self-determination theory-autonomy, competence, and relatedness-are associated with adherence to outpatient follow-up appointments after psychiatric hospitalization. 242 individuals discharged from inpatient psychiatric treatment within the Veterans Health Administration completed surveys assessing self-determination theory constructs as well as measures of depression and barriers to treatment. Medical records were used to count the number of mental health visits and no-shows in the 14 weeks following discharge. Logistic regression models assessed the association between survey items assessing theory constructs and attendance at mental healthcare visits. In multivariate models, none of the self-determination theory factors predicted outpatient follow-up attendance. The constructs of self-determination theory as measured by a single self-report survey may not reliably predict adherence to post-hospital care. Need factors such as depression may be more strongly predictive of treatment adherence.

Mortality associated with lithium and valproate treatment of US Veterans Health Administration patients with mental disorders.

BackgroundThe mood stabilisers lithium and valproate might plausibly have differing associations with mortality because of differing effects on mental health and various physiological indicators.AimsTo assess associations between lithium, valproate and non-suicide mortality.MethodIntention-to-treat, propensity score-matched cohort study.ResultsLithium was associated with significantly reduced non-suicide mortality in the intent-to-treat cohort over 0-90 days (hazard ratio (HR) = 0.67, 95% CI 0.51-0.87) but not longer. In secondary analyses, a sizeable reduction in mortality was observed during active treatment with lithium across all time periods studied (for example 365-day HR = 0.62, 95% CI 0.45-0.84), but significantly increased risks were observed among patients discontinuing lithium by 180 days (HR = 1.54, 95% CI 1.01-2.37).ConclusionsPatients initiating lithium had lower non-suicide mortality over 0-90 days than patients initiating valproate and consistently lower non-suicide mortality among patients maintaining treatment, but elevated risk among patients discontinuing treatment by 180 days. Although residual confounding or selection effects cannot be excluded, this study suggests potential benefits to enhancing lithium treatment persistence and the monitoring of patients discontinuing lithium. There is a need for further research.

Social networks, mental health problems, and mental health service utilization in OEF/OIF National Guard veterans.

PURPOSE: Low social support and small social network size have been associated with a variety of negative mental health outcomes, while their impact on mental health services use is less clear. To date, few studies have examined these associations in National Guard service members, where frequency of mental health problems is high, social support may come from military as well as other sources, and services use may be suboptimal. METHODS: Surveys were administered to 1448 recently returned National Guard members. Multivariable regression models assessed the associations between social support characteristics, probable mental health conditions, and service utilization. RESULTS: In bivariate analyses, large social network size, high social network diversity, high perceived social support, and high military unit support were each associated with lower likelihood of having a probable mental health condition (p < .001). In adjusted analyses, high perceived social support (OR .90, CI .88-.92) and high unit support (OR .96, CI .94-.97) continued to be significantly associated with lower likelihood of mental health conditions. Two social support measures were associated with lower likelihood of receiving mental health services in bivariate analyses, but were not significant in adjusted models. CONCLUSIONS: General social support and military-specific support were robustly associated with reduced mental health symptoms in National Guard members. Policy makers, military leaders, and clinicians should attend to service members' level of support from both the community and their units and continue efforts to bolster these supports. Other strategies, such as focused outreach, may be needed to bring National Guard members with need into mental health care.

Association between chronic illness complexity and receipt of evidence-based depression care.

BACKGROUND: The rate of guideline concordance with antidepressant treatment for persons with depression is low. The problem may be even more pronounced for patients with depression and other multiple chronic conditions (MCC). OBJECTIVES: To study, for persons with new depressive episodes, the association between MCC and the likelihood of receiving guideline-concordant depression treatment. RESEARCH DESIGN: Retrospective cohort study using Veterans Affairs administrative data. SUBJECTS: A total of 43,189 Veterans Affairs patients who had a new depressive episode during 2007 were included. MEASURES: We assessed whether patients had an adequate supply of antidepressants during acute and continuation phases of depression treatment, which indicates guideline-concordant care. We determined the association between comorbid conditions and receipt of adequate antidepressant supplies after adjusting for potential confounders. RESULTS: Compared with patients with depression alone, those with comorbid cardiovascular/cerebrovascular disease, peptic ulcer/gastroesophageal reflux disease (GERD), or arthritis were 8%-13% more likely to receive adequate antidepressant supplies during the acute phase. Patients with depression and substance/alcohol abuse were 15% less likely to receive adequate supplies in the acute treatment phase. Those with cardiovascular/cerebrovascular disease or peptic ulcer/GERD were 9%-10% more likely to receive continuation phase guideline-concordant depression treatment. Patients with comorbid substance/alcohol abuse were 19% less likely to receive continuation phase guideline-concordant depression treatment. Relatively few of the most prevalent MCC clusters were significantly associated with receipt of guideline-concordant depression treatment. CONCLUSIONS: There was no consistent association between specific clusters of chronic conditions and adequate antidepressant supplies. There continues to be need for practice-level and system-level interventions to increase quality of depression treatment, particularly among persons with certain comorbid conditions such as cardiovascular/cerebrovascular disease, peptic ulcer/GERD, and arthritis.

A global logrank test for adaptive treatment strategies based on observational studies.

In studying adaptive treatment strategies, a natural question that is of paramount interest is whether there is any significant difference among all possible treatment strategies. When the outcome variable of interest is time-to-event, we propose an inverse probability weighted logrank test for testing the equivalence of a fixed set of pre-specified adaptive treatment strategies based on data from an observational study. The weights take into account both the possible selection bias in an observational study and the fact that the same subject may be consistent with more than one treatment strategy. The asymptotic distribution of the weighted logrank statistic under the null hypothesis is obtained. We show that, in an observational study where the treatment selection probabilities need to be estimated, the estimation of these probabilities does not have an effect on the asymptotic distribution of the weighted logrank statistic, as long as the estimation of the parameters in the models for these probabilities is n-consistent. Finite sample performance of the test is assessed via a simulation study. We also show in the simulation that the test can be pretty robust to misspecification of the models for the probabilities of treatment selection. The method is applied to analyze data on antidepressant adherence time from an observational database maintained at the Department of Veterans Affairs' Serious Mental Illness Treatment Research and Evaluation Center.

Suicide risk in Veterans Health Administration patients with mental health diagnoses initiating lithium or valproate: a historical prospective cohort study.

BACKGROUND: Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate. METHODS: A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008. RESULTS: Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015). CONCLUSIONS: In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.

Reported barriers to mental health care in three samples of U.S. Army National Guard soldiers at three time points.

The military community and its partners have made vigorous efforts to address treatment barriers and increase appropriate mental health services use among returning National Guard soldiers. We assessed whether there were differences in reports of treatment barriers in 3 categories (stigma, logistics, or negative beliefs about treatment) in sequential cross-sectional samples of U.S. soldiers from a Midwestern Army National Guard Organization who were returning from overseas deployments. Data were collected during 3 time periods: September 2007-August 2008 (n = 333), March 2009-March 2010 (n = 884), and August 2011-August 2012 (n = 737). In analyses using discretized time periods and in trend analyses, the percentages of soldiers endorsing negative beliefs about treatment declined significantly across the 3 sequential samples (19.1%, 13.9%, and 11.1%). The percentages endorsing stigma barriers (37.8%, 35.2%, 31.8%) decreased significantly only in trend analyses. Within the stigma category, endorsement of individual barriers regarding negative reactions to a soldier seeking treatment declined, but barriers related to concerns about career advancement did not. Negative treatment beliefs were associated with reduced services use (OR = 0.57; 95% CI [0.33, 0.97]).

Depression, healthcare utilization, and comorbid psychiatric disorders after spinal cord injury.

BACKGROUND: Depression is often comorbid with other psychiatric conditions in the general population, with resultant impact on severity of conditions and healthcare utilization. It is unclear to what degree this is also true among persons with spinal cord injury (SCI). OBJECTIVE: This study examined rates at which psychiatric conditions were comorbid with depression after SCI, and the association between a depression diagnosis and healthcare and pharmaceutical drug use. METHODS: Retrospective analysis of data (N = 41 213) abstracted from Veterans Health Administration administrative databases between fiscal years (FYs) 1997 and 2007 to examine overall rates of depression. Administrative data from FY 2007 was used to examine rates of psychiatric disorders comorbid with depression, and to compare veterans with SCI and depression to veterans with SCI but no depression on healthcare and pharmaceutical use. RESULTS: Twenty-eight percent (n = 11 506) of 41 213 veterans who received SCI care between FY 1997 and FY 2007 were diagnosed with depressive disorders. Among the veterans with SCI and depression diagnoses in 2007 (n = 2615), 70% were also diagnosed with another psychiatric illness, with posttraumatic stress disorder and other anxiety disorders being the most common. Veterans with SCI and depression had more healthcare visits and received more pharmaceutical prescriptions than their counterparts without depression. CONCLUSIONS: Persons with SCI and depression are likely to experience comorbid psychiatric illnesses, with associated increased healthcare visits and medication use. Research and theory on depression after SCI should develop toward describing and addressing psychiatric and medical co-morbidities that are normative in this population.

Racial differences in adherence to antidepressant treatment in later life.

OBJECTIVE: Although antidepressants are an effective treatment for later-life depression, older patients often choose not to initiate or to discontinue medication treatment prematurely. Although racial differences in depression treatment preferences have been reported, little is known about racial differences in antidepressant medication adherence among older patients. DESIGN: Prospective, observational study comparing antidepressant adherence for older African American and white primary care patients. PARTICIPANTS: A total of 188 subjects age 60 and older, diagnosed with clinically significant depression with a new recommendation for antidepressant treatment by their primary care physician. MEASUREMENT: Study participants were assessed at study entry and at the 4-month follow-up (encompassing the acute treatment phase). Depression medication adherence was based on a well-validated self-report measure. RESULTS: At the 4-month follow-up, 61.2% of subjects reported that they were adherent to their antidepressant medication. In unadjusted and two of the three adjusted analyses, African American subjects (n = 82) had significantly lower rates of 4-month antidepressant adherence than white subjects (n = 106). African American women had the lowest adherence rates (44.4%) followed by African American men (56.8%), white men (65.3%), and white women (73.7%). In logistic regression models controlling for demographic, illness, and functional status variables, significant differences persisted between African American women and white women in reported 4-month antidepressant adherence (OR: 3.58, 95% CI: 1.27-10.07, Wald χ(2) = 2.42, df = 1, p <0.02). CONCLUSIONS: The results demonstrate racial and gender differences in antidepressant adherence in older adults. Depression treatment interventions for older adults should take into account the potential impact of race and gender on adherence to prescribed medications.

Trends in antidepressant prescribing for new episodes of depression and implications for health system quality measures.

BACKGROUND: The nationally reported Healthcare Effectiveness Data and Information Set (HEDIS) antidepressant medication management measure assesses whether patients with new episodes of depression receive antidepressant coverage for 84 of the first 114 days of treatment. Although initial prescriptions for a 90-day supply satisfy measure requirements, they may circumvent its purpose of ensuring adequate medication management. OBJECTIVES: To assess the extent to which 90-day initial prescriptions have contributed to health system performance on the HEDIS antidepressant measure from fiscal years 2001 to 2008. RESEARCH DESIGN: Retrospective cohort analysis of Veterans Health Administration administrative data. SUBJECTS: Patients with a new diagnosis of depression and a new antidepressant prescription (N=383,634). MEASURES: HEDIS antidepressant measures, days supply of initial antidepressant prescriptions, antidepressant refills, and clinical encounters. RESULTS: Health system performance on the HEDIS acute phase antidepressant measure increased from 63.1% in 2001 to 71.0% in 2008. Receipt of an initial 90-day antidepressant supply increased from 10.5% to 29.1% during this same period; when these are excluded, HEDIS performance was 58.8% in 2001 and 59.4% in 2008. Receiving an initial 90-day prescription was associated with prior antidepressant treatment, fewer clinical encounters, and similar rates of antidepressant refills compared with patients prescribed less than 90-day supplies. CONCLUSION: Although increases in initial 90-day supplies contribute to improved performance on the HEDIS measure, actual adherence during the acute treatment phase may not be changed by this practice. Quality measures based on pharmacy fills may need modification in the setting of large initial prescriptions.

Antidepressant agents and suicide death among US Department of Veterans Affairs patients in depression treatment.

BACKGROUND: Studies report mixed findings regarding antidepressant agents and suicide risks, and few examine suicide deaths. Studies using observational data can accrue the large sample sizes needed to examine suicide death, but selection biases must be addressed. We assessed associations between suicide death and treatment with the 7 most commonly used antidepressants in a national sample of Department of Veterans Affairs patients in depression treatment. Multiple analytic strategies were used to address potential selection biases. METHODS: We identified Department of Veterans Affairs patients with depression diagnoses and new antidepressant starts between April 1, 1999, and September 30, 2004 (N = 502,179). Conventional Cox regression models, Cox models with inverse probability of treatment weighting, propensity-stratified Cox models, marginal structural models (MSM), and instrumental variable analyses were used to examine relationships between suicide and exposure to bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine. RESULTS: Crude suicide rates varied from 88 to 247 per 100,000 person-years across antidepressant agents. In multiple Cox models and MSMs, sertraline and fluoxetine had lower risks for suicide death than paroxetine. Bupropion had lower risks than several antidepressants in Cox models but not MSMs. Instrumental variable analyses did not find significant differences across antidepressants. DISCUSSION: Most antidepressants did not differ in their risk for suicide death. However, across several analytic approaches, although not instrumental variable analyses, fluoxetine and sertraline had lower risks of suicide death than paroxetine. These findings are congruent with the Food and Drug Administration meta-analysis of randomized controlled trials reporting lower risks for "suicidality" for sertraline and a trend toward lower risks with fluoxetine than for other antidepressants. Nevertheless, divergence in findings by analytic approach suggests caution when interpreting results.

Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans.

OBJECTIVES: The purpose of this study was to evaluate the risk of suicide among veteran men relative to nonveteran men by age and to examine the prevalence of suicide circumstances among male veterans in different age groups (18-34, 35-44, 45-64, and ≥ 65 years). METHODS: Data from the National Violent Death Reporting System (2003-2008) were used to calculate age-specific suicide rates for veterans (n = 8440) and nonveterans (n = 21,668) and to calculate the age-stratified mortality ratio for veterans. Multiple logistic regression was used to compare health status, stressful life events preceding suicide, and means of death among young, middle-aged, and older veterans. RESULTS: Veterans were at higher risk for suicide compared with nonveterans in all age groups except the oldest. Mental health, substance abuse, and financial and relationship problems were more common in younger than in older veteran suicide decedents, whereas health problems were more prevalent in the older veterans. Most male veterans used firearms for suicide, and nearly all elderly veterans did so. CONCLUSIONS: Our study highlighted heightened risk of suicide in male veterans compared with nonveterans. Within the veteran population, suicide might be influenced by different precipitating factors at various stages of life.

Differences between veteran suicides with and without psychiatric symptoms.

OBJECTIVES: Our objective was to examine all suicides (n = 423) in 2 geographic areas of the Veterans Health Administration (VHA) over a 7-year period and to perform detailed chart reviews on the subsample that had a VHA visit in the last year of life (n = 381). METHODS: Within this sample, we compared a group with 1 or more documented psychiatric symptoms (68.5%) to a group with no such symptoms (31.5%). The groups were compared on suicidal thoughts and behaviors, somatic symptoms, and stressors using the χ(2) test and on time to death after the last visit using survival analyses. RESULTS: Veterans with documented psychiatric symptoms were more likely to receive a suicide risk assessment, and have suicidal ideation and a suicide plan, sleep problems, pain, and several stressors. These veterans were also more likely to die in the 60 days after their last visit. CONCLUSIONS: Findings indicated presence of 2 large and distinct groups of veterans at risk for suicide in the VHA, underscoring the value of tailored prevention strategies, including approaches suitable for those without identified psychiatric symptoms.