Amy S.B. Bohnert

Psychiatric diagnoses and risk of suicide in veterans

CONTEXT Although numerous studies have documented the clear link between psychiatric conditions and suicide, few have allowed for the comparison between the strength of association between different psychiatric diagnoses and suicide. OBJECTIVE To examine the strength of association between different types of psychiatric diagnoses and the risk of suicide in patients receiving health care services from the Department of Veterans Affairs in fiscal year (FY) 1999. DESIGN This project examined National Death Index data and Veterans Health Administration patient treatment records. SETTING Department of Veterans Affairs, Veterans Health Administration. PARTICIPANTS All veterans who used Veterans Health Administration services during FY 1999 (N = 3 291 891) who were alive at the start of FY 2000. MAIN OUTCOME MEASURES Psychiatric diagnoses were obtained from patient treatment records in FY 1998 and 1999 and used to predict subsequent death by suicide during the following 7 years in sex-stratified survival analyses controlling for age. RESULTS In the 7 years after FY 1999, 7684 veterans died by suicide. In diagnosis-specific analyses, patients with bipolar disorder had the greatest estimated risk of suicide among men (hazard ratio, 2.98; 95% confidence interval, 2.73-3.25), and patients with substance use disorders had the greatest risk among women (6.62; 4.72-9.29). CONCLUSIONS Although all the examined psychiatric diagnoses were associated with elevated risk of suicide in veterans, results indicate that men with bipolar disorder and women with substance use disorders are at particularly elevated risk for suicide.

Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study

Objective To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics. Design Case-cohort study. Setting Veterans Health Administration (VHA), 2004-09. Participants US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420 386) who received VHA medical services and opioid analgesics. Main outcome measure Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index. Results During the study period 27% (n=112 069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose. Conclusions Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.

New persistent opioid use after minor and major surgical procedures in us adults

Importance Despite increased focus on reducing opioid prescribing for long-term pain, little is known regarding the incidence and risk factors for persistent opioid use after surgery. Objective To determine the incidence of new persistent opioid use after minor and major surgical procedures. Design, Setting, and Participants Using a nationwide insurance claims data set from 2013 to 2014, we identified US adults aged 18 to 64 years without opioid use in the year prior to surgery (ie, no opioid prescription fulfillments from 12 months to 1 month prior to the procedure). For patients filling a perioperative opioid prescription, we calculated the incidence of persistent opioid use for more than 90 days among opioid-naive patients after both minor surgical procedures (ie, varicose vein removal, laparoscopic cholecystectomy, laparoscopic appendectomy, hemorrhoidectomy, thyroidectomy, transurethral prostate surgery, parathyroidectomy, and carpal tunnel) and major surgical procedures (ie, ventral incisional hernia repair, colectomy, reflux surgery, bariatric surgery, and hysterectomy). We then assessed data for patient-level predictors of persistent opioid use. Main Outcomes and Measures The primary outcome was defined a priori prior to data extraction. The primary outcome was new persistent opioid use, which was defined as an opioid prescription fulfillment between 90 and 180 days after the surgical procedure. Results A total of 36 177 patients met the inclusion criteria, with 29 068 (80.3%) receiving minor surgical procedures and 7109 (19.7%) receiving major procedures. The cohort had a mean (SD) age of 44.6 (11.9) years and was predominately female (23 913 [66.1%]) and white (26 091 [72.1%]). The rates of new persistent opioid use were similar between the 2 groups, ranging from 5.9% to 6.5%. By comparison, the incidence in the nonoperative control cohort was only 0.4%. Risk factors independently associated with new persistent opioid use included preoperative tobacco use (adjusted odds ratio [aOR], 1.35; 95% CI, 1.21-1.49), alcohol and substance abuse disorders (aOR, 1.34; 95% CI, 1.05-1.72), mood disorders (aOR, 1.15; 95% CI, 1.01-1.30), anxiety (aOR, 1.25; 95% CI, 1.10-1.42), and preoperative pain disorders (back pain: aOR, 1.57; 95% CI, 1.42-1.75; neck pain: aOR, 1.22; 95% CI, 1.07-1.39; arthritis: aOR, 1.56; 95% CI, 1.40-1.73; and centralized pain: aOR, 1.39; 95% CI, 1.26-1.54). Conclusions and Relevance New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors. New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness.

Noncancer pain conditions and risk of suicide.

IMPORTANCE There are limited data on the extent to which suicide mortality is associated with specific pain conditions. OBJECTIVE To examine the associations between clinical diagnoses of noncancer pain conditions and suicide among individuals receiving services in the Department of Veterans Affairs Healthcare System. DESIGN Retrospective data analysis. SETTING Data were extracted from National Death Index and treatment records from the Department of Veterans Healthcare System. PARTICIPANTS Individuals receiving services in fiscal year 2005 who remained alive at the start of fiscal year 2006 (N = 4 863 086). MAIN OUTCOMES AND MEASURES Analyses examined the association between baseline clinical diagnoses of pain-related conditions (arthritis, back pain, migraine, neuropathy, headache or tension headache, fibromyalgia, and psychogenic pain) and subsequent suicide death (assessed in fiscal years 2006-2008). RESULTS Controlling for demographic and contextual factors (age, sex, and Charlson score), elevated suicide risks were observed for each pain condition except arthritis and neuropathy (hazard ratios ranging from 1.33 [99% CI, 1.22-1.45] for back pain to 2.61 [1.82-3.74] for psychogenic pain). When analyses controlled for concomitant psychiatric conditions, the associations between pain conditions and suicide death were reduced; however, significant associations remained for back pain (hazard ratio, 1.13 [99% CI, 1.03-1.24]), migraine (1.34 [1.02-1.77]), and psychogenic pain (1.58 [1.11-2.26]). CONCLUSIONS AND RELEVANCE There is a need for increased awareness of suicide risk in individuals with certain noncancer pain diagnoses, in particular back pain, migraine, and psychogenic pain.

Unintentional overdose and suicide among substance users: A review of overlap and risk factors

Substance use is a risk factor for suicide, suicide attempts, and fatal and non-fatal overdose, but to date, little has been done to integrate the research on suicidal behavior and overdose among substance users. This study reviews the literature on suicide and overdose among substance users with the goal of illuminating the similarities and differences between these two events. A structured review resulted in 15 articles (describing 14 unique studies) published between 1990 and 2010 that examined both overdose and suicide in samples of substance users. There is some evidence that substance users who attempt suicide are more likely to report an overdose and vice versa. This relationship may be partially explained by the fact that overdose is a common method of suicide. The results of the literature review also indicate that substance users with a history of both events may represent a group with particularly poor psychological and social functioning and severe drug-related problems. Further research is needed to understand the overlap of, and differences between, suicide and accidental overdose among individuals who misuse substances, particularly individuals who primarily use substances other than heroin. An improved understanding of the interrelationships between suicide and unintentional overdose among individuals who use alcohol or drugs is necessary to guide the development of effective prevention and intervention approaches.

Suicide mortality among patients treated by the Veterans Health Administration from 2000 to 2007.

OBJECTIVES We sought to examine rates of suicide among individuals receiving health care services in Veterans Health Administration (VHA) facilities over an 8-year period. METHODS We included annual cohorts of all individuals who received VHA health care services from fiscal year (FY) 2000 through FY 2007 (October 1, 1999-September 30, 2007; N = 8,855,655). Vital status and cause of death were obtained from the National Death Index. RESULTS Suicide was more common among VHA patients than members of the general US population. The overall rates of suicide among VHA patients decreased slightly but significantly from 2000 to 2007 (P < .001). Male veterans between the ages of 30 and 64 years were at the highest risk of suicide. CONCLUSIONS VHA health care system patients are at elevated risk for suicide and are appropriate for suicide reduction services, although the rate of suicide has decreased in recent years for this group. Comprehensive approaches to suicide prevention in the VHA focus not only on recent returnees from Iraq and Afghanistan but also on middle-aged and older Veterans.

Evaluation of the FDA Warning Against Prescribing Citalopram at Doses Exceeding 40 mg

OBJECTIVE A recent Food and Drug Administration (FDA) warning cautioned that citalopram dosages exceeding 40 mg/day may cause abnormal heart rhythms, including torsade de pointes. The authors assessed relationships between citalopram use and ventricular arrhythmias and mortality. METHOD A cohort study was conducted using Veterans Health Administration data between 2004 and 2009 from depressed patients who received a prescription for citalopram (N=618,450) or for sertraline (N=365,898), a comparison medication with no FDA warning. Cox regression models, adjusted for demographic and clinical characteristics, were used to examine associations of antidepressant dosing with ventricular arrhythmia and cardiac, noncardiac, and all-cause mortality. RESULTS Citalopram daily doses >40 mg were associated with lower risks of ventricular arrhythmia (adjusted hazard ratio=0.68, 95% CI=0.61-0.76), all-cause mortality (adjusted hazard ratio=0.94, 95% CI=0.90-0.99), and noncardiac mortality (adjusted hazard ratio=0.90, 95% CI=0.86-0.96) compared with daily doses of 1-20 mg. No increased risks of cardiac mortality were found. Citalopram daily doses of 21-40 mg were associated with lower risks of ventricular arrhythmia (adjusted hazard ratio=0.80, 95% CI=0.74-0.86) compared with dosages of 1-20 mg/day but did not have significantly different risks of any cause of mortality. The sertraline cohort revealed similar findings, except there were no significant associations between daily dose and either all-cause or noncardiac mortality. CONCLUSIONS This large study found no elevated risks of ventricular arrhythmia or all-cause, cardiac, or noncardiac mortality associated with citalopram dosages >40 mg/day. Higher dosages were associated with fewer adverse outcomes, and similar findings were observed for a comparison medication, sertraline, not subject to the FDA warning. These results raise questions regarding the continued merit of the FDA warning.

Trends and regional variation in opioid overdose mortality among Veterans Health Administration patients, fiscal year 2001 to 2009.

Objectives:Opioid-related mortality has increased in the United States in the past decade. The purpose of this study was to examine trends and regional variation in opioid prescribing and overdose rates in a national health system, the Veterans Health Administration. Materials and Methods:Annual cohorts of Veterans Health Administration patients were identified on the basis of medical records, and overdose mortality was determined from National Death Index records. State-level prescribing and overdose rates were mapped to provide information on regional variability. Results:There were significant increases between 2001 and 2009 in the rate of overdoses associated with nonsynthetic opioids (&bgr;=0.53, 95% confidence interval, 0.35, 0.70) and methadone (&bgr;=0.63, 95% confidence interval, 0.37, 0.90) but not synthetic/semisynthetic opioids. State-level overdose rates had a moderate correlation with the average proportion of patients in that state receiving opioids (r=0.29). Discussion:The present study demonstrates that the increases in prescription opioid overdoses observed in the general population are also found in the patient population of a national health system and provides further evidence of the population-level association between trends in opioid prescribing and opioid overdose deaths. There is substantial regional variation in both opioid prescribing and opioid-related overdose rates, and these data can inform region-specific overdose prevention strategies and opioid policy.

Risk of death from accidental overdose associated with psychiatric and substance use disorders.

OBJECTIVE Despite dramatic increases in the rate of fatal accidental overdose in recent years, risk factors for this outcome remain poorly understood, particularly in clinical populations. The authors examined the association of psychiatric and substance use diagnoses with death from accidental overdose. METHOD The study followed a cohort of patients from 2000 to 2006. The cohort included all patients treated in Veterans Health Administration facilities during fiscal year 1999 who were alive at the start of fiscal year 2000 (N=3,291,891). Death by accidental overdose was determined using National Death Index records and defined as a death with underlying cause of death coded to ICD-10 codes X40-X45 (N=4,485). Diagnoses were determined by patient medical records. RESULTS Adjusting for demographic and clinical characteristics, hazard ratios of death by accidental overdose associated with prior psychiatric and substance use disorder diagnoses ranged from 1.8 to 8.8. Significant associations of non-substance-related psychiatric disorders with risk of death by accidental overdose persisted after additional adjustment for substance use disorders (hazard ratios from 1.2 to 1.8). Depressive disorders and anxiety disorders other than posttraumatic stress disorder had stronger associations with risk of medication-related overdose death (hazard ratios, 3.02 and 3.07, respectively) than with risk of overdose death related to alcohol or illegal drugs (hazard ratios, 1.89 and 1.23, respectively). CONCLUSIONS Among patients receiving care from the Veterans Health Administration, death from accidental overdose was found to be associated with psychiatric and substance use disorders. The study findings suggest the importance of risk assessment and overdose prevention for vulnerable clinical subpopulations.

Characteristics of adults seeking medical marijuana certification

BACKGROUND Very little is known about medical marijuana users. The present study provides descriptive information on adults seeking medical marijuana and compares individuals seeking medical marijuana for the first time with those renewing their medical marijuana card on measures of substance use, pain and functioning. METHODS Research staff approached patients (n=348) in the waiting area of a medical marijuana certification clinic. Chi-square and Wilcoxon signed rank tests were used to compare participants who reported that they were seeking medical marijuana for the first time (n=195) and those who were seeking to renew their access to medical marijuana (n=153). RESULTS Returning medical marijuana patients reported a higher prevalence of lifetime cocaine, amphetamine, inhalant and hallucinogen use than first time patients. Rates of recent alcohol misuse and drug use were relatively similar between first time patients and returning patients with the exception of nonmedical use of prescription sedatives and marijuana use. Nonmedical prescription sedative use was more common among first time visitors compared to those seeking renewal (p<0.05). The frequency of recent marijuana use was higher in returning patients than first time patients (p<0.0001). Compared to first time patients, returning patients reported somewhat lower current pain level and slightly higher mental health and physical functioning. CONCLUSIONS Study results indicate that differences exist between first time and returning medical marijuana patients. Longitudinal data are needed to characterize trajectories of substance use and functioning in these two groups.