Mark S. Kaplan

Suicide among male veterans: a prospective population-based study

Objectives: To assess the risk of mortality from suicide among male veteran participants in a large population-based health survey. Design and setting: A prospective follow-up study in the US. Data were obtained from the US National Health Interview Surveys 1986–94 and linked to the Multiple Cause of Death file (1986–97) through the National Death Index. Participants: The sample comprised 320 890 men, aged ≥18 years at baseline. The participants were followed up with respect to mortality for 12 years. Results: Cox proportional hazards analysis showed that veterans who were white, those with ≥12 years of education and those with activity limitations (after adjusting for medical and psychiatric morbidity) were at a greater risk for completing suicide. Veterans were twice as likely (adjusted hazard ratio 2.04, 95% CI 1.10 to 3.80) to die of suicide compared with non-veterans in the general population. The risk of death from “natural” causes (diseases) and the risk of death from “external” causes did not differ between the veterans and the non-veterans. Interestingly, male veterans who were overweight had a significantly lower risk of completing suicide than those who were of normal weight. Conclusions: Veterans in the general US population, whether or not they are affiliated with the Department of Veterans Affairs (VA), are at an increased risk of suicide. With a projected rise in the incidence of functional impairment and psychiatric morbidity among veterans of the conflicts in Afghanistan and Iraq, clinical and community interventions that are directed towards patients in both VA and non-VA healthcare facilities are needed.

BMI and mortality: results from a National Longitudinal Study of Canadian adults.

Although a clear risk of mortality is associated with obesity, the risk of mortality associated with overweight is equivocal. The objective of this study is to estimate the relationship between BMI and all‐cause mortality in a nationally representative sample of Canadian adults. A sample of 11,326 respondents aged ≥25 in the 1994/1995 National Population Health Survey (Canada) was studied using Cox proportional hazards models. A significant increased risk of mortality over the 12 years of follow‐up was observed for underweight (BMI <18.5; relative risk (RR) = 1.73, P < 0.001) and obesity class II+ (BMI >35; RR = 1.36, P <0.05). Overweight (BMI 25 to <30) was associated with a significantly decreased risk of death (RR = 0.83, P < 0.05). The RR was close to one for obesity class I (BMI 30–35; RR = 0.95, P >0.05). Our results are similar to those from other recent studies, confirming that underweight and obesity class II+ are clear risk factors for mortality, and showing that when compared to the acceptable BMI category, overweight appears to be protective against mortality. Obesity class I was not associated with an increased risk of mortality.

Firearm suicides and homicides in the United States: regional variations and patterns of gun ownership

Among industrialized countries, the United States has the highest rates of firearm suicide and homicide, as well as the highest rate of gun ownership. The present study compares the differential impact of gun availability on firearm suicides and homicides in the U.S. Using data from the NCHS Mortality Detail Files (1989-1991), the 1990 U.S. census population estimates, and the General Social Surveys (1989-1991) for nine geographic divisions, we computed rates of firearm and non-firearm suicides and homicides as well as rates of gun ownership for four gender-race groups. We tested the strength of the associations between gun availability and firearm suicide and homicide rates by computing the Spearman correlation coefficients. To help elucidate the role of method substitution, we conducted similar analyses on non-firearm suicide and homicide. The results show that gun ownership has a stronger impact on firearm suicides than homicides. These findings held up after stratifying by gender and race. The study suggests that reducing the aggregate level of gun availability may decrease the risk of firearm-related deaths.

Health behavior change following chronic illness in middle and later life

OBJECTIVES Understanding lifestyle improvements among individuals with chronic illness is vital for targeting interventions that can increase longevity and improve quality of life. METHODS Data from the U.S. Health and Retirement Study were used to examine changes in smoking, alcohol use, and exercise 2-14 years after a diagnosis of heart disease, diabetes, cancer, stroke, or lung disease. RESULTS Patterns of behavior change following diagnosis indicated that the vast majority of individuals diagnosed with a new chronic condition did not adopt healthier behaviors. Smoking cessation among those with heart disease was the largest observed change, but only 40% of smokers quit. There were no significant increases in exercise for any health condition. Changes in alcohol consumption were small, with significant declines in excessive drinking and increases in abstention for a few health conditions. Over the long term, individuals who made changes appeared to maintain those changes. Latent growth curve analyses up to 14 years after diagnosis showed no average long-term improvement in health behaviors. DISCUSSION Results provide important new information on health behavior changes among those with chronic disease and suggest that intensive efforts are required to help initiate and maintain lifestyle improvements among this population.

Physical Illness, Functional Limitations, and Suicide Risk: A Population‐Based Study

The purpose of this study was to assess the independent association of physical illness and functional limitations with suicide mortality risk. The Cox proportional hazards model was used with data from the 1986-1994 National Health Interview Survey linked to the 1986-1997 National Death Index to analyze the effects of chronic physical illness and functional limitations on suicide deaths (ICD-9 E950-959). After controlling for potential confounders at baseline, functional limitations were shown to be a significant predictor of suicide. Also, psychiatric comorbidity increased the risk of completing suicide. Interestingly, chronic conditions alone were not predictive of suicide completion when functional limitation was added to the model. Implications for the clinical management of suicidal behavior among patients with chronic conditions are discussed.

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.

Acute alcohol intoxication and suicide: a gender-stratified analysis of the National Violent Death Reporting System

Objectives Although it is well known that people with alcohol dependence are at a markedly elevated risk for suicide, much less is known about the role of acute alcohol use in suicidal behaviours. The primary aims of this epidemiological study were to assess the prevalence and factors associated with acute alcohol intoxication among 57 813 suicide decedents in 16 states. Methods Data from the restricted National Violent Death Reporting System 2003–2009 for male and female suicide decedents aged 18 years and older were analysed by multiple logistic regression to compare decedents with and without acute alcohol intoxication (defined as blood alcohol concentration (BAC) ≥0.08 g/dl). Results Among men, those who were younger, American Indian/Alaska Native, Hispanic, veterans, of lower educational attainment, deceased from a self-inflicted firearm injury or hanging/suffocation and residing in rural areas were more likely to have been intoxicated at the time of death. Among women, the factors associated with a BAC ≥0.08 g/dl were younger age, being American Indian/Alaska Native, and using a firearm, hanging/suffocation or falling as method of death. Conclusions In both men and women, alcohol intoxication was associated with violent methods of suicide and declined markedly with age, suggesting that addressing risks associated with acute alcohol use may be of the greatest aid in the prevention of violent suicides among young and middle age adults.

Firearm suicide among veterans in the general population: findings from the national violent death reporting system.

BACKGROUND Military veterans are particularly vulnerable to suicide compared with their civilian peers. Scant attention has been devoted to the problem of firearm suicide among veterans, particularly women. The purpose of this study was to examine the rate, prevalence, and relative odds of firearm use among veteran suicide decedents in the general population. METHODS The analyses are based on data derived from 28,534 suicide decedents from the 2003 to 2006 National Violent Death Reporting System. RESULTS Across the age groups, male and female veterans had higher firearm suicide rates than nonveterans. Among males and females, younger veterans (18-34 years) had the highest firearm and total suicide rates. The male and female veteran suicide decedents were, respectively, 1.3 and 1.6 times more likely to use firearms relative to nonveterans after adjusting for age, marital status, race, and region of residence. CONCLUSIONS Although violent death and the use of firearms are generally associated with men, the results reported here suggest that firearms among female veterans deserve particular attention among health professionals within and outside the veterans affairs system. In addition, the focus should not be exclusively on the Operation Enduring Freedom/Operation Iraqi Freedom military cohort but also on men and women who served in earlier combat theaters, including the Gulf war, Vietnam Era, Korean Conflict, and World War II.

Characteristics of physically inactive older adults with arthritis: Results of a population-based study.

BACKGROUND Arthritis is the most prevalent chronic condition among persons age 65 and older in North America. Physical inactivity in this population is linked to functional limitations, increased risk for cardiovascular disease, diminished quality of life, and disability. The purpose of this study was to identify risk factors for inactivity. METHODS National data for 6256 community-dwelling older adults with arthritis from the 1996-1997 Canadian National Population Health Survey were examined using logistic regression analyses. The independent variables included sociodemographic characteristics, health status, psychosocial factors, health behaviors, and medication use. RESULTS Inactive persons were significantly (P < 0.05) more likely to be women, older (75+), have functional limitations, be underweight (BMI < 20) or overweight (BMI > 25), have severe pain, or not have prescription drug insurance coverage. The same group was less likely to be unmarried, well educated, from western provinces, attend church frequently, consume alcohol infrequently, have higher levels of social support, have better self-rated health, or use pain medication. CONCLUSIONS The profile presented in this study should be fully considered by health care providers when educating patients with arthritis about the adverse health effects of sedentary behavior. Prescription drug insurance coverage may facilitate activity among elders with arthritis.

Self-reported hypertension prevalence and income among older adults in Canada and the United States

Hypertension is one of the most common chronic conditions worldwide. There is strong evidence that low socioeconomic status is associated with elevated rates of blood pressure-related cardiovascular disease. Few studies have examined the association between socioeconomic circumstances and hypertension among people aged 65 years and older. The purpose of this study was to examine the relationship between household income and self-reported hypertension prevalence among persons aged 65 and older in the United States and Canada. Data were obtained from the 2002-2003 Joint Canada/United States Survey of Health for 755 Canadian and 1151 US adults aged 65 and older. Aggregate hypertension prevalence rates in the United States and Canada were generally similar (53.8% versus 48.0%). We found a significant inverse linear relationship between household income and the hypertension prevalence rate in the United States, but no evidence of such a relationship in Canada. In Canada, unlike the United States, the burden of hypertension is approximately equal for socioeconomically advantaged and disadvantaged older adults. It is important to consider these findings in the context of long-term and broader institutional policies. Social disparities and barriers to health care access and primary prevention among non-elderly persons in the United States may play a role in the higher hypertension prevalence rate among low-income older adults.