H. Myra Kim

Suicide mortality among patients receiving care in the veterans health administration health system.

Understanding and reducing mortality from suicide among veterans is a national priority, particularly for individuals receiving care from the US Veterans Health Administration (VHA). This report examines suicide rates among VHA patients and compares them with rates in the general population. Suicide mortality was assessed in fiscal year 2001 for patients alive at the start of that fiscal year and with VHA use in fiscal years 2000-2001 (n = 4,692,034). Deaths from suicide were identified by using National Death Index data. General population rates were identified by use of the Web-based Injury Statistics Query and Reporting System. VHA rates were 43.13/100,000 person-years for men and 10.41/100,000 person-years for women. For male patients, the age-adjusted standardized mortality ratio was 1.66; for females, it was 1.87. Male patients aged 30-79 years had increased risks relative to men in the general population; standardized mortality ratios ranged from 2.56 (ages 30-39 years) to 1.33 (ages 70-79 years). Female patients aged 40-59 years had greater risks than did women in the general population, with standardized mortality ratios of 2.15 (ages 40-49 years) and 2.36 (ages 50-59 years). Findings offer heretofore unavailable comparison points for health systems. Prior to the conflicts in Afghanistan and Iraq and before recent VHA initiatives, rates were higher among VHA patients than in the general population. Female patients had particularly high relative risks.

Psychiatric diagnoses and risk of suicide in veterans

CONTEXTnAlthough 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.nnnOBJECTIVEnTo 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.nnnDESIGNnThis project examined National Death Index data and Veterans Health Administration patient treatment records.nnnSETTINGnDepartment of Veterans Affairs, Veterans Health Administration.nnnPARTICIPANTSnAll veterans who used Veterans Health Administration services during FY 1999 (N = 3 291 891) who were alive at the start of FY 2000.nnnMAIN OUTCOME MEASURESnPsychiatric 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.nnnRESULTSnIn 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).nnnCONCLUSIONSnAlthough 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.

Predictors of suicidal ideation among depressed veterans and the interpersonal theory of suicide

BACKGROUNDnWe assessed whether key constructs of the interpersonal theory of suicide were associated with suicidal ideation in depressed US Veterans.nnnMETHODSn443 patients of the Veterans Health Administration diagnosed with a depressive disorder completed the Beck Depression Inventory, Interpersonal Support Evaluation List, and Beck Hopelessness Scale, from which we derived measures of burdensomeness, belongingness, and hopelessness consistent with the interpersonal theory of suicide. Measures of active and passive suicidal ideation were constructed from the Beck Suicide Scale and Beck Depression Inventory obtained at baseline and 3-months follow-up. Multivariable logistic regression was used to identify predictors of passive and active suicidal ideation while adjusting for demographic characteristics and somatic-affective symptoms of depression (e.g., anhedonia, insomnia).nnnRESULTSnBurdensomeness and hopelessness were significantly associated with passive suicidal ideation at baseline and 3 months follow-up, but belongingness and the interaction between belongingness and burdensomeness were not significant predictors as proposed by the interpersonal theory of suicide. Somatic-affective depressive symptoms, but not any of the main effects predicted by the interpersonal theory of suicide or their interactions, were associated with active suicidal ideation at baseline. No factors were consistently associated with active suicidal ideation at 3 months follow-up.nnnLIMITATIONSnThe measure of burdensomeness used in this study only partially represents the construct described by the interpersonal theory of suicide.nnnCONCLUSIONnWe found little support for the predictions of the interpersonal theory of suicide. Hopelessness appears to be an important determinant of passive suicidal ideation, while somatic-affective depression symptoms may be a key contributor to active suicidal ideation.

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]).

Associations between depression and all-cause and cause-specific risk of death: a retrospective cohort study in the Veterans Health Administration

OBJECTIVEnDepression may be associated with increased mortality risk, but there are substantial limitations to existing studies assessing this relationship. We sought to overcome limitations of existing studies by conducting a large, national, longitudinal study to assess the impact of depression on all-cause and cause-specific risk of death.nnnMETHODSnWe used Cox regression models to estimate hazard ratios associated with baseline depression diagnosis (N=849,474) and three-year mortality among 5,078,082 patients treated in Veterans Health Administration (VHA) settings in fiscal year (FY) 2006. Cause of death was obtained from the National Death Index (NDI).nnnRESULTSnBaseline depression was associated with 17% greater hazard of all-cause three-year mortality (95% CI hazard ratio [HR]: 1.15, 1.18) after adjusting for baseline patient demographic and clinical characteristics and VHA facility characteristics. Depression was associated with a higher hazard of three-year mortality from heart disease, respiratory illness, cerebrovascular disease, accidents, diabetes, nephritis, influenza, Alzheimers disease, septicemia, suicide, Parkinsons disease, and hypertension. Depression was associated with a lower hazard of death from malignant neoplasm and liver disease. Depression was not associated with mortality due to assault.nnnCONCLUSIONSnIn addition to being associated with suicide and injury-related causes of death, depression is associated with increased risk of death from nearly all major medical causes, independent of multiple major risk factors. Findings highlight the need to better understand and prevent mortality seen with multiple medical disorders associated with depression.

Exploratory data mining analysis identifying subgroups of patients with depression who are at high risk for suicide

OBJECTIVEnAlthough prior research has identified a number of separate risk factors for suicide among patients with depression, little is known about how these factors may interact to modify suicide risk. Using an empirically based decision tree analysis for a large national sample of Veterans Affairs (VA) health system patients treated for depression, we identified subgroups with particularly high or low rates of suicide.nnnMETHODnWe identified 887,859 VA patients treated for depression between April 1, 1999, and September 30, 2004. Randomly splitting the data into 2 samples (primary and replication samples), we developed a decision tree for the primary sample using recursive partitioning. We then tested whether the groups developed within the primary sample were associated with increased suicide risk in the replication sample.nnnRESULTSnThe exploratory data analysis produced a decision tree with subgroups of patients at differing levels of risk for suicide. These were identified by a combination of factors including a co-occurring substance use disorder diagnosis, male sex, African American race, and psychiatric hospitalization in the past year. The groups developed as part of the decision tree accurately discriminated between those with and without suicide in the replication sample. The patients at highest risk for suicide were those with a substance use disorder who were non-African American and had an inpatient psychiatric stay within the past 12 months.nnnCONCLUSIONSnStudy findings suggest that the identification of depressed patients at increased risk for suicide is improved through the examination of higher order interactions between potential risk factors.

The association between race and gender, treatment attitudes, and antidepressant treatment adherence

We examined the associations between treatment attitudes and beliefs with race–gender differences in antidepressant adherence.

Who Receives Outpatient Monitoring During High-Risk Depression Treatment Periods?

OBJECTIVES: To examine the intensity of monitoring received by important patient subgroups during high‐risk periods (the 12 weeks after psychiatric hospitalization and after new antidepressant starts).

Predictors of Antidepressant Nonadherence Among Older Veterans With Depression

OBJECTIVEnMost depression among older adults is treated in primary care, and many patients do not adhere to medication treatment. The U.S. Department of Veterans Affairs (VA) has recently introduced initiatives to address such treatment gaps. This study examined patient-reported antidepressant nonadherence during the acute treatment period (first four months after a prescription) and identified predictors of nonadherence in a sample of older veterans.nnnMETHODSnThis was a prospective, observational study of 311 participants ages 60 and older who received care at three VA medical centers and who had a diagnosis of clinically significant depression and were given a new outpatient antidepressant prescription. Participants completed an initial interview and a follow-up interview at four months after treatment recommendation. Antidepressant adherence was measured with a well-validated self-report measure.nnnRESULTSnAt four months, 29% of participants reported nonadherence to their antidepressant medication. In unadjusted analyses, nonadherence was significantly associated with being African American, having no spouse or significant other, having greater general medical comorbidity, and receiving the prescription in a primary care setting (versus a specialty mental health setting). In logistic regression models controlling for several variables (demographic, illness, and functional status variables; type of antidepressant; contact with a therapist; medical setting; and site of recruitment), two predictors remained significantly associated with nonadherence: African-American race (odds ratio [OR]=4.23, p<.001) and general medical comorbidity (OR=1.33, p=.002).nnnCONCLUSIONSnThe two main predictors of nonadherence among older adults with depression were African-American race and general medical comorbidity. Results suggest that significant needs remain for important patient subgroups to improve antidepressant adherence.

Association of the Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care With the Use of Antipsychotics and Other Psychotropics in Long-term Care in the United States From 2009 to 2014

Importance The Centers for Medicare & Medicaid Services’ National Partnership to Improve Dementia Care in Nursing Homes (hereafter referred to as the partnership) was established to improve the quality of care for patients with dementia, measured by the rate of antipsychotic prescribing. Objective To determine the association of the partnership with trends in prescribing of antipsychotic and other psychotropic medication among older adults in long-term care. Design, Setting, and Participants This interrupted time-series analysis of a 20% Medicare sample from January 1, 2009, to December 31, 2014, was conducted among 637 426 fee-for-service Medicare beneficiaries in long-term care with Part D coverage. Data analysis was conducted from May 1, 2017, to January 9, 2018. Main Outcomes and Measures Quarterly prevalence of use of antipsychotic and nonantipsychotic psychotropic medications (antidepressants, mood stabilizers [eg, valproic acid and carbamazepine], benzodiazepines, and other anxiolytics or sedative-hypnotics). Results Among the 637 426 individuals in the study (446 538 women and 190 888 men; mean [SD] age at entering nursing home, 79.3 [12.1] years), psychotropic use was declining before initiation of the partnership with the exception of mood stabilizers. In the first quarter of 2009, a total of 31 056 of 145 841 patients (21.3%) were prescribed antipsychotics, which declined at a quarterly rate of –0.53% (95% CI, –0.63% to –0.44%; Pu2009<u2009.001) until the start of the partnership. At that point, the quarterly rate of decline decreased to –0.29% (95% CI, –0.39% to –0.20%; Pu2009<u2009.001), a postpartnership slowing of 0.24% per quarter (95% CI, 0.09%-0.39%; Pu2009=u2009.003). The use of mood stabilizers was growing before initiation of the partnership and then accelerated after initiation of the partnership (rate, 0.22%; 95% CI, 0.18%-0.25%; Pu2009<u2009.001; rate change, 0.14%; 95% CI, 0.10%-0.18%; Pu2009<u2009.001), reaching 71 492 of 355 716 patients (20.1%) by the final quarter of 2014. Antidepressants were the most commonly prescribed medication overall: in the beginning of 2009, a total of 75 841 of 145 841 patients (52.0%) were prescribed antidepressants. As with antipsychotics, antidepressant use declined both before and after initiation of the partnership, but the decrease slowed (rate change, 0.34%; 95% CI, 0.18%-0.50%; Pu2009<u2009.001). Findings were similar when limited to patients with dementia. Conclusions and Relevance Prescribing of psychotropic medications to patients in long-term care has declined, although the partnership did not accelerate this decrease. However, the use of mood stabilizers, possibly as a substitute for antipsychotics, increased and accelerated after initiation of the partnership in both long-term care residents overall and in those with dementia. Measuring use of antipsychotics alone may be an inadequate proxy for quality of care and may have contributed to a shift in prescribing to alternative medications with a poorer risk-benefit balance.