Research reportPrevalence and correlates of suicidal ideation and suicide attempts among veterans in primary care referred for a mental health evaluation
Introduction
Suicide is the tenth most common cause of death in the United States, with nearly 40,000 in 2012 (Xu et al., 2014). It has been estimated that approximately one-fifth of suicide decedents are veterans of the United States military (Sundararaman et al., 2008), and about one-quarter of these veterans are in contact with the Veterans Health Administration (VHA) in the year prior to their death (Basham et al., 2011, Kemp and Bossarte, 2012). Suicide rates among veterans seeking care in the VHA are estimated to be more than 50% higher compared to civilians (Blow et al., 2012; McCarthy et al., 2009), which is likely attributable to the high prevalence of risk factors for suicide among veterans seeking VHA care (Blow et al., 2012).
A key aspect in suicide prevention research is to assess factors associated with past suicide attempt given that it has been identified as the strongest risk factor of suicide (e.g., Harris and Barraclough, 1997). Despite this relationship, most individuals who die by suicide have no previous attempts (Isometsa and Lonnqvist, 1998) suggesting that the evaluation of other factors is warranted. Suicidal ideation is another potential target for risk recognition and intervention as it confers potent and prospective risk of suicide. For example, a reassessment of the National Comorbidity Survey revealed that the association of suicidal ideation at the initial survey with suicide-related outcomes (suicidal ideation, plans, gestures, and attempts) 10 years later is overwhelmed by the influence of suicidal ideation measured more proximally (Borges et al., 2008). It has been argued that stressful life events and mental disorders are key determinants of suicidal ideation but other factors (e.g., availability of method of suicide) are more determinant of whether an individual with suicide ideation engages in suicidal behavior (Mann et al., 2005). Although previous studies have noted that some variables associated with suicidal ideation are different than those that are associated with suicide attempts (Brezo et al., 2007, Kessler et al., 1999) or suicide (Mann et al., 2005), use of ideation in risk recognition is particularly germane to veterans who tend to use lethal means of suicide and, as a result, are vulnerable to die in their first (and only) attempt.
Research has identified mental health problems as significant risk factors for suicidal ideation. For example, previous research has found that depression is associated with greater suicidal ideation (Corson et al., 2013, Guerra et al., 2011, Kramer et al., 1994, Lemaire and Graham, 2011, Lish et al., 1996, Pietrzak et al., 2010). This is also consistent with veterans who have been diagnosed with bipolar disorder (Chakravorty et al., 2014, Corson et al., 2013) and psychotic disorders (Corson et al., 2013, Lemaire and Graham, 2011). Furthermore, numerous studies have also found that substance use is associated with greater risk of suicidal ideation among veterans (Chakravorty et al., 2014, Corson et al., 2013, Lish et al., 1996, Pietrzak et al., 2010). While research supports the relationship between post-traumatic stress disorder (PTSD) and suicidal ideation (Guerra et al., 2011, Hendin and Haas, 1991, Jakupcak et al., 2009, Kramer et al., 1994, Lemaire and Graham, 2011, Pietrzak et al., 2010), the evidence on the relationship with other anxiety disorders is more mixed (Chakravorty et al., 2014, Corson et al., 2013, Lemaire and Graham, 2011, Lish et al., 1996). These studies provide overwhelming evidence that suicidal ideation is associated with mental health conditions across numerous settings; however, there has been considerably less research assessing the prevalence and correlates of suicidal ideation and suicide attempts among veterans being recently seen in VHA primary care.
Primary care is an important setting for suicide prevention, in part, because it is upstream from specialty mental health care and caries less stigma. In addition, in a systematic review, researchers found that nearly half of the people who died by suicide were seen by a primary care physician in the month before their death and over three-fourths were seen in the year before their death (Luoma et al., 2002). Furthermore, suicidal ideation in primary care in particular is important given a greater proportion of suicide decedents who were seen in primary care primary care in the 6 months prior to their death endorse suicidal ideation compared to controls who were also seen in primary care during this time, but did not die by suicide (Dobscha et al., 2014).
VHA has been at the forefront of providing care management and clinical services to identify and treat mental health conditions and to reduce the risk of suicide (Zeiss and Karlin, 2008). VHA's primary care Patient Aligned Care Teams (PACTs) have been identified as frontline providers responsible for identifying and treating depressive symptoms and screening for suicidal ideation. VHA also rolled out the Primary Care-Mental Health Initiative (PCMHI; Department of Veteran Affairs, 2008) to integrate mental health services within all PACTs. Each VAMC primary care setting must integrate one or more mental health providers (MHPs; Oslin, 2009) and have a care management program, which comprises protocol-driven and diagnosis-specific interventions serving to support the PACT's interventions (Department of Veterans Affairs, 2013). The integrated MHPs and care management programs result in a blended model of integrative collaborative care. Veterans referred to PCMHI are likely at higher risk of suicide compared to veterans in primary care not referred to PCMHI because screening positive for a mental health problem, alcohol misuse, and/or suicidal ideation triggers a referral from primary care. Research has also indicated that those utilizing PCMHI clinics are different from those who utilize specialty mental health clinics and that those using PCMHI clinics are less likely to also use specialty mental health clinics (Johnson-Lawrence et al., 2012).
Therefore, assessing correlates of suicidal ideation and suicide attempts among a sample of veterans referred to PCMHI represents a novel opportunity to study a broader sample than those in specialty mental healthcare, but also a more targeted, potentially at-risk sample of primary care patients. The primary study aim was to identify demographic and clinical correlates of suicidal ideation as a dependent variable among individuals referred to the Behavioral Health Laboratory (BHL), a PCMHI service offered at the Philadelphia VA. A second aim of this study was to explore correlates of past-year suicide attempts as a dependent variable among those referred to the BHL. Identifying similarities or differences between correlates of suicidal ideation and correlates of attempts may help refine and target prevention and treatment efforts. The current study includes a large sample of veterans from various eras whose positive screen for a mental health problem in primary care was more rigorously assessed using comprehensive measures.
Section snippets
Participants and procedure
Potential participants were those veterans who were contacted by the Behavioral Health Laboratory (BHL), a PCMHI service at the Philadelphia VA Medical Center and affiliated community-based outpatient clinics, during the 2012 fiscal year. Primary care clinicians administered screeners for depression, PTSD, and substance use. If patients screened positive for at least one of the measures and the veteran was interested, a consultation was placed for a supervised mental health technician or
Results
Overall, the majority of participants were male (89%) and half were white (50%) with a mean age of 51.0 (SD=15.9). Nearly half of the sample was married (44%) and a little more than a quarter were financially stable (29%). Depression was the most common psychiatric disorder (65%) and over one-third of the sample was positive for generalized anxiety disorder (39%) and PTSD (45%). Alcohol dependence (12%) was the only other measured psychiatric disorder for which more than one-tenth of the
Discussion
The purpose of this study was to assess demographic and mental health factors that are associated with increased severity of suicidal ideation and past-year suicide attempts using a sample of veterans referred from primary care for mental health symptoms. Overall, more severe suicidal ideation was relatively common in this sample with over one-quarter reporting at least thoughts of taking his or her own life. Conversely, suicide attempts were reported for less than 2% of the sample; however,
Conflicts of interest
The authors have no conflicts of interest to report.
References (50)
- et al.
Psychometric properties of the PTSD Checklist (PCL)
Behav. Res. Ther.
(1996) - et al.
Risk factors for the incidence and persistence of suicide-related outcomes: a 10-year follow-up study using the National Comorbidity Surveys
J. Affect. Disord.
(2008) - et al.
Suicidal ideation in veterans misusing alcohol: relationship with insomnia symptoms and sleep duration.
Addict. Behav.
(2014) - et al.
Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the Veterans Health Administration health system
J. Affect. Disord.
(2014) - et al.
Prevalence and correlates of suicidal ideation among Operation Enduring Freedom and Operation Iraqi Freedom veterans
J. Affect. Disord.
(2013) - et al.
Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample
J. Anxiety Disord.
(2011) - et al.
Factors associated with suicidal ideation in OEF/OIF veterans
J. Affect. Disord.
(2011) - et al.
Suicide screening in a primary care setting at a Veterans Affairs medical center
Psychosomatics
(1996) - et al.
Injection drug use is associated with suicide attempts but not ideation or plans in a sample of adolescents with depressive symptoms
J. Psychiatr. Res.
(2014) - et al.
A meta-analysis of the association between posttraumatic stress disorder and suicidality: the role of comorbid depression
Compr. Psychiatry
(2012)