Janet Kemp

Changes in Suicide Mortality for Veterans and Nonveterans by Gender and History of VHA Service Use, 2000–2010

OBJECTIVE Veterans are believed to be at high risk of suicide. However, research comparing suicide rates between veterans and nonveterans is limited, and even less is known regarding differences by history of Veterans Health Administration (VHA) service use. This study directly compared veteran and nonveteran suicide risk while for the first time differentiating veterans by VHA service use. METHODS The cross-sectional study analyzed data from 173,969 adult suicide decedents from 23 states (2000-2010) included in the U.S. Department of Veterans Affairs suicide data archive. Annual standardized mortality ratios (SMRs) were computed for veterans compared with nonveterans and for veterans who used VHA services compared with veterans who did not, overall and separately for males and females. RESULTS After the analysis controlled for age and gender differences, the number of observed veteran suicides was approximately 20% higher than expected in 2000 (SMR=1.19, 95% confidence interval [CI]=1.10-1.28), and this increased to 60% higher by 2010 (SMR=1.63, CI=1.58-1.68). The elevated risk for female veterans (2010 SMR=5.89) was higher than that observed for male veterans (2010 SMR=1.54). Trends for non-VHA-utilizing veterans mirrored those of the veteran population as a whole, and the SMR for VHA-utilizing veterans declined. Since 2003, the number of suicides among VHA-utilizing veterans was less than expected when compared directly with the suicide rate among non-VHA-utilizing veterans. CONCLUSIONS Veterans are members of the community and, as such, are an important part of observed increases in U.S. suicide rates. Not all veterans are at equal or increasing risk of suicide, however. VHA-utilizing veterans appear to have declining absolute and relative suicide rates.

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs

OBJECTIVES The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. METHODS Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. RESULTS Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. CONCLUSIONS Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Prevalence and Characteristics of Suicide Ideation and Attempts Among Active Military and Veteran Participants in a National Health Survey

The relationships between military service and suicide are not clear, and comparatively little is known about the characteristics and correlates of suicide ideation and attempts among those with history of military service. We used data from a national health survey to estimate the prevalence and correlates of suicidal behaviors among veterans and service members in 2 states. The prevalence of suicidal behaviors among Veterans was similar to previous estimates of ideation and attempts among adults in the US general population.

Surveillance of Suicide and Suicide Attempts Among Veterans: Addressing a National Imperative

In 2008, the Department of Veterans Affairs (VA) implemented a suicide event reporting system designed to collect standardized information on all suicide attempts reported to VA clinicians and suicide prevention coordinators in VA medical centers and outpatient facilities. Since that time, the VA has collected information on nearly 46 000 suicide attempts, and the suicide event reporting system has transitioned from an aggregate spreadsheet submitted monthly to an electronic reporting system capable of achieving near “real time” surveillance of suicide events among veterans. The VAs suicide event reporting system, known collectively as the Suicide Prevention Applications Network (SPAN), and complimentary programs such as the Department of Defenses (DoDs) Suicide Event Reporting system (DoDSER), represent vertical advances in the surveillance of suicide and provide a foundation for the development of similar efforts among broader segments of the US general population. However, these systems alone are not sufficient to fill existing gaps in the availability of timely and comprehensive data on suicide-related events among members of the broader US general population. The need for improved and expanded surveillance of suicide and suicide attempts is well recognized. The 2001 National Strategy for Suicide Prevention (NSSP)1 called for improved systems for collecting data on suicide and suicide attempts and included objectives to implement a national violent death reporting system, increase the utility of hospital data, and increase the number of states that produce annual reports on suicide and suicide attempts using information from multiple linked data systems. The Institute of Medicines (IOMs) 2002 report on reducing suicide similarly called for the “sustained and systematic collection, analysis, and dissemination of accurate information on the incidence, prevalence, and characteristics of suicide and suicide attempts” and noted “serious inadequacies in the availability and quality” of information on suicide and similar limitations associated with of data on suicide attempts.2 The 2010 document “Charting the Future of Suicide Prevention” reviewed progress toward achieving the goals set forth in the 2001 National Strategy for Suicide Prevention. In a 2010 review of progress data and surveillance, the Charting the Future report supported the 2002 IOM report conclusion that there exists significant deficiencies in the availability of data on nonfatal suicidal behavior and concluded that the NSSP goal of achieving regular systematic reporting of suicide and suicide attempts is still occurring on a “very limited” basis.3 Models for comprehensive data systems that provide a foundation for surveillance of suicide exist internationally in the population registries of Denmark4 and more locally in population-specific efforts such as mandatory reporting of suicide attempts among youth in Oregon.5 However, US public health agencies have been slow to respond to calls for standardization of data elements and integrated systems for surveillance of suicide. Limitations associated with the availability of population registries or event reporting are compounded by differences in terminology that complicate comparisons across systems or populations. The suicide event reporting systems established by the Department of Veterans Affairs (SPAN) and Department of Defense (DoDSER) provide templates for the continued expansion of suicide event reporting that is consistent with existing calls for action. As reported by Gahm et al.,6 DoDSER is an event-based reporting system collecting systematic information on a standardized set of variables for all suicide events known to the Department of Defense. Similarly, SPAN collects information on a standardized set of variables for all suicide events (fatal and nonfatal) known by VA providers. Importantly, officials for both systems have agreed to collect information on suicide events using a single standardized suicide event nomenclature that was developed as a result of an integrated effort including partners from the VA, DoD, Centers for Disease Control and Prevention, and National Institutes of Health.7 The adoption of a standardized nomenclature increases the utility of suicide event data by providing a mechanism for comparability across systems and time. Together these distinct but interrelated systems represent the most comprehensive information available for the surveillance of suicide among any single US population. The efforts of the VA and DoD are necessary but not sufficient components of adequate suicide surveillance. In 2010, the Action Alliance for Suicide Prevention was formed as a public–private partnership with the primary mission of revisiting the goals of the 2001 National Strategy and advancing suicide prevention in the United States.8 Once again, addressing gaps in the availability of data for the surveillance of suicide and suicide attempts has been identified as a priority for prevention programs. The surveillance systems implemented in the VA and DoD provide a foundation for the development of comparable systems among broader segments of the US general population. Together, these systems will provide the information necessary for the identification of emerging risk populations, changes in characteristics or context associated with increased risk, and the evaluation of suicide prevention needed for the development of effective and evidence-based programs. Since October 1, 2008, the Department of Veterans Affairs has recorded information on nearly 46 000 suicide events among more than 38 000 individuals. Information from the SPAN system has been used to inform clinical management of high risk Veterans, identify periods of increased risk, measure the impact of prevention programs on suicide and suicide attempts, and identify changes in the distribution of risk across populations and time. Additional efforts include the assessment of risk for suicide and suicide attempt, including an emphasis on the impact of prevention programs on repeat suicide attempts. Over time, information obtained from SPAN, linked with data from DoDSER and comparable surveillance systems, is expected to provide the single-most comprehensive source of information on the identification and management of suicide risk available to clinicians and public health professionals. In 2008, suicide was once again a top ten leading cause of death in the US general population. The time for action is now. The development of comparable surveillance systems for veterans and others who do not receive care from the VA is needed for the adequate and timely assessment of suicide and improved clinical management for those with established risk. The systems implemented by the VA and DoD provide a foundation for integrated and active suicide surveillance, but should not stand alone. Addressing the challenge of suicide prevention will require interagency synergism to enhance and extend existing VA and DoD efforts.9 Comparable systems, utilizing a common nomenclature, are needed to supplement these systems and support our national effort to reduce the burden of suicide.

Changes in Suicide Rates and in Mental Health Staffing in the Veterans Health Administration, 2005–2009

OBJECTIVE Between 2005 and 2009, the Veterans Health Administration (VHA) enhanced its mental health programs and increased outpatient mental health staffing by 52.8%. However, suicide rates among VHA patients remained the same. This study evaluated this finding by examining variability in staffing increases between VHAs 21 regional networks (Veterans Integrated Service Networks) (VISNs) and associations with suicide rates. METHODS Suicide rates among VHA patients were derived from the National Death Index and VHA clinical and administrative records for 2005 and 2009. Comparisons across VISNs used measures of proportional change in mental health staffing (overall and in inpatient, residential, intensive case management, and outpatient programs) and comparable measures of mental health staffing per 1,000 mental health patients. RESULTS Significant correlations were found between proportional changes from 2005 to 2009 in suicide rates and outpatient mental health staffing (r=-.453, p=.039) and outpatient mental health staffing per 1,000 patients (r=-.533, p=.013). The ten VISNs above the median in proportional changes in mental health staffing had average decreases in suicide rates of 12.6% while those below had increases of 11.6% (p=.005). For proportional changes in mental health staffing per 1,000 patients, those above the median had decreases of 11.2% and those below had increases of 13.8% (p=.014). For the average VISN, it would have required a 27.5%-36.8% increase in outpatient staff over 2005 levels to decrease suicide rates by 10%. CONCLUSIONS Mental health enhancements in VHA were associated with decreases in suicide rates in VISNs where the increases in mental health outpatient staffing were greatest.

Evaluation of a suicide prevention training curriculum for substance abuse treatment providers based on Treatment Improvement Protocol Number 50.

Substance use disorders (SUDs) confer risk for suicide yet there are no empirically supported suicide prevention training curricula tailored to SUD treatment providers. We assessed the efficacy of a 2-hour training that featured a suicide prevention training video produced by the Department of Veterans Affairs. The video was based on Treatment Improvement Protocol Number 50 (TIP 50) a practical manual to manage suicide risk produced by the Substance Abuse and Mental Health Services Administration. The training was provided in small groups to 273 SUD treatment providers in 18 states. Results were evaluated using self-report assessments obtained at pre-test, post-test, and 2-month follow-up. Statistically significant changes (p < .001) within subjects were obtained on self-efficacy, knowledge, and frequency of suicide prevention practice behaviors. The positive results together with the brevity of the training and its ease of implementation indicate high potential for widespread adoption and the importance of further study.

Using media to promote suicide prevention hotlines to Veteran households

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

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

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

Age-Related Concerns of Male Veteran Callers to a Suicide Crisis Line

In July 2007, the United States Department of Veterans Affairs (VA) partnered with the Department of Health and Human Services’ Substance Abuse and Mental Health Service Administration (SAMHSA) to create the Veterans Crisis Line (VCL) in order to meet the unique needs of Veterans in distress. The current study utilized a mixed methods design to examine characteristics of male callers to the VCL. Results from qualitative analyses demonstrated that the majority of callers between April 1 and August 31, 2008 contacted the VCL with concerns related to mental health issues, suicide ideation, and substance abuse issues. Quantitative analyses demonstrated age differences associated with concerns presented by callers such that middle-aged and older callers were more likely to present with loneliness and younger callers were more likely to present with mental health concerns. The results of this study will help to inform future research designed to optimize the effectiveness of the VCL for suicide prevention in Veterans.

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

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