Mark A. Ilgen

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

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.

Pain and suicidal thoughts, plans and attempts in the United States ☆

OBJECTIVE This study examined the association between pain and suicidality in the general US population. METHOD Using data from the National Comorbidity Survey-Replication, we assessed relationships between four measures of pain (back and neck, headache, other nonarthritic pain and a summary score of the count of these conditions) and 12-month suicidal thoughts, plans and attempts using chi-square tests and logistic regression models. Multivariate logistic regression models controlled for demographic characteristics, chronic health conditions, mood, anxiety and substance use disorders. RESULTS In multivariate models adjusting for concurrent psychiatric disorders and other chronic medical conditions, suicidal ideation was associated with head pain (OR 1.9, 95% CI: 1.2, 3.0) and the pain summary score (OR 1.2, 95% CI: 1.0, 1.4). Suicide attempt was also associated with head pain (OR 2.3, 95% CI: 1.2, 4.4) and pain summary score (OR 1.7, 95% CI: 1.1, 2.6). Other nonarthritic pain was associated with suicide attempts (OR4.0, 95% CI: 1.8, 9.1). CONCLUSIONS These findings highlight the importance of pain as a potentially independent risk factor for suicide, particularly among those with head pain or multiple forms of co-occurring pain. Individuals suffering from chronic pain may be particularly appropriate for suicide screening and intervention efforts.

Excess heart-disease-related mortality in a national study of patients with mental disorders: identifying modifiable risk factors.

OBJECTIVE People with mental disorders are estimated to die 25 years younger than the general population, and heart disease (HD) is a major contributor to their mortality. We assessed whether Veterans Affairs (VA) health system patients with mental disorders were more likely to die from HD than patients without these disorders, and whether modifiable factors may explain differential mortality risks. METHODS Subjects included VA patients who completed the 1999 Large Health Survey of Veteran Enrollees (LHSV) and were either diagnosed with schizophrenia, bipolar disorder, other psychotic disorders, major depressive disorder or other depression diagnosis or diagnosed with none of these disorders. LHSV data on patient sociodemographic, clinical and behavioral factors (e.g., physical activity, smoking) were linked to mortality data from the National Death Index of the Centers for Disease Control and Prevention. Hierarchical multivariable Cox proportional hazards models were used to assess 8-year HD-related mortality risk by diagnosis, adding patient sociodemographic, clinical and behavioral factors. RESULTS Of 147,193 respondents, 11,809 (8%) died from HD. After controlling for sociodemographic and clinical factors, we found that those with schizophrenia [hazard ratio (HR)=1.25; 95% confidence interval (95% CI): 1.15-1.36; P<.001] or other psychotic disorders (HR=1.41; 95% CI: 1.27-1.55; P<.001) were more likely to die from HD than those without mental disorders. Controlling for behavioral factors diminished, but did not eliminate, the impact of psychosis on mortality. Smoking (HR=1.32; 95% CI: 1.26-1.39; P<.001) and inadequate physical activity (HR=1.66; 95% CI: 1.59-1.74; P<.001) were also associated with HD-related mortality. CONCLUSIONS Patients with psychosis were more likely to die from HD. For reduction of HD-related mortality, early interventions that promote smoking cessation and physical activity among veterans with psychotic disorders are warranted.

Sleep problems and suicidality in the National Comorbidity Survey Replication

OBJECTIVE Links between sleep problems and suicidality have been frequently described in clinical samples; however, this issue has not been well-studied in the general population. Using data from a nationally representative survey, we examined the association between self-reported sleep difficulties and suicidality in the United States. METHODS The WHO Composite International Diagnostic Interview was used to assess sleep problems and suicidality in the National Comorbidity Survey Replication (NCS-R). Relationships between three measures of sleep (difficulty initiating sleep, maintaining sleep, early morning awaking), and suicidal thoughts, plans, and attempts were assessed in logistic regression analyses, while controlling for demographic characteristics, 12-month diagnoses of mood, anxiety and substance use disorders, and chronic health conditions. RESULTS In multivariate models, the presence of any of these sleep problems was significantly related to each measure of suicidality, including suicidal ideation (OR=2.1), planning (OR=2.6), and suicide attempt (OR=2.5). Early morning awakening was associated with suicidal ideation (OR=2.0), suicide planning (OR=2.1), and suicide attempt (OR=2.7). Difficulty initiating sleep was a significant predictor of suicidal ideation and planning (ORs: 1.9 for ideation; 2.2 for planning), while difficulty maintaining sleep during the night was a significant predictor of suicidal ideation and suicide attempts (ORs: 2.0 for ideation; 3.0 for attempt). CONCLUSIONS Among community residents, chronic sleep problems are consistently associated with greater risk for suicidality. Efforts to develop comprehensive models of suicidality should consider sleep problems as potentially independent indicators of risk.

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.

Association Between Val66Met Brain-Derived Neurotrophic Factor (BDNF) Gene Polymorphism and Post-Treatment Relapse in Alcohol Dependence

BACKGROUND The purpose of this study was to examine relationships between genetic markers of central serotonin (5-HT) and dopamine function, and risk for post-treatment relapse, in a sample of alcohol-dependent patients. METHODS The study included 154 patients from addiction treatment programs in Poland, who met DSM-IV criteria for alcohol dependence. After assessing demographics, severity of alcohol use, suicidality, impulsivity, depression, hopelessness, and severity of alcohol use at baseline, patients were followed for approximately 1 year to evaluate treatment outcomes. Genetic polymorphisms in several genes (TPH2, SLC6A4, HTR1A, HTR2A, COMT, and BDNF) were tested as predictors of relapse (defined as any drinking during follow-up) while controlling for baseline measures. RESULTS Of 154 eligible patients, 123 (80%) completed follow-up and 48% (n = 59) of these individuals relapsed. Patients with the Val allele in the Val66Met BDNF polymorphism and the Met allele in the Val158Met COMT polymorphism were more likely to relapse. Only the BDNF Val/Val genotype predicted post-treatment relapse [odds ratio (OR) = 2.62; p = 0.019], and time to relapse (OR = 2.57; p = 0.002), after adjusting for baseline measures and other significant genetic markers. When the analysis was restricted to patients with a family history of alcohol dependence (n = 73), the associations between the BDNF Val/Val genotype and relapse (OR = 5.76, p = 0.0045) and time to relapse (hazard ratio = 4.93, p = 0.001) were even stronger. CONCLUSIONS The Val66Met BDNF gene polymorphism was associated with a higher risk and earlier occurrence of relapse among patients treated for alcohol dependence. The study suggests a relationship between genetic markers and treatment outcomes in alcohol dependence. Because a large number of statistical tests were conducted for this study and the literature on genetics and relapse is so novel, the results should be considered as hypothesis generating and need to be replicated in independent studies.

Comorbid anxiety as a suicide risk factor among depressed veterans

Background: Depressive disorders greatly increase suicide risk; however, little is known about the contribution of comorbid anxiety disorders or anxiety symptoms to the risk of suicide death among depressed patients. We examined whether depressed veterans with comorbid anxiety had higher risks of suicide death. Methods: Using VA administrative databases we identified 887,859 patients with depression. We then used univariate and multivariate logistic regression, controlling for demographics and substance use disorders, to determine the odds ratios of completed suicide associated with individual comorbid anxiety disorders, the presence of any comorbid anxiety disorder, the prescription of an antianxiety medication, or the prescription of a high dose of an antianxiety medication. Results: In multivariate analyses, the odds of completed suicide were significantly increased for patients with panic disorder (OR 1.26, 95% CI: 1.04–1.53), generalized anxiety disorder (OR 1.27, 95% CI: 1.09–1.47), and anxiety disorder, not otherwise specified (OR 1.25, 95% CI: 1.12–1.38). The odds of completed suicide were also greater among patients who received any antianxiety medication (OR 1.71, 95% CI: 1.55–1.88), and were further increased among those who received high dose treatment (OR 2.26, 95% CI: 1.98–2.57). Odds of completed suicide were decreased among patients with comorbid posttraumatic stress disorder (OR 0.87, 95% CI: 0.77–0.97), and there was no statistically significant relationship between social phobia, obsessive–compulsive disorder, and all other anxiety disorders and suicide. Conclusions: These findings emphasize the importance of comorbid anxiety disorders and symptoms in increasing suicide risk among depressed patients and may inform suicide prevention efforts among these patients. Depression and Anxiety, 2009.

Prevalence and Health Correlates of Prostitution Among Patients Entering Treatment for Substance Use Disorders

CONTEXT Studies of prostitution have focused largely on individuals involved in the commercial sex trade, with an emphasis on understanding the public health effect of this behavior. However, a broader understanding of how prostitution affects mental and physical health is needed. In particular, the study of prostitution among individuals in substance use treatment would improve efforts to provide comprehensive treatment. OBJECTIVES To document the prevalence of prostitution among women and men entering substance use treatment, and to test the association between prostitution, physical and mental health, and health care utilization while adjusting for reported history of childhood sexual abuse, a known correlate of prostitution and poor health outcomes. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional, secondary data analysis of 1606 women and 3001 men entering substance use treatment in the United States who completed a semistructured intake interview as part of a larger study. MAIN OUTCOME MEASURES Self-reported physical health (respiratory, circulatory, neurological, and internal organ conditions, bloodborne infections) and mental health (depression, anxiety, psychotic symptoms, and suicidal behavior), and use of emergency department, clinic, hospital, or inpatient mental health services within the past year. RESULTS Many participants reported prostitution in their lifetime (50.8% of women and 18.5% of men) and in the past year (41.4% of women and 11.2% of men). Prostitution was associated with increased risk for bloodborne viral infections, sexually transmitted diseases, and mental health symptoms. Prostitution was associated with use of emergency care in women and use of inpatient mental health services for men. CONCLUSIONS Prostitution was common among a sample of individuals entering substance use treatment in the United States and was associated with higher risk of physical and mental health problems. Increased efforts toward understanding prostitution among patients in substance use treatment are warranted. Screening for prostitution in substance use treatment could allow for more comprehensive care to this population.