Skip to main content

Advertisement

Log in

Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample

  • Original Research
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

BACKGROUND

Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.

OBJECTIVE

Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.

DESIGN

This was a retrospective case–control study.

SUBJECTS

The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.

MAIN MEASURES

Demographic, diagnosis, and utilization data were obtained from VA’s Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.

KEY RESULTS

Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27–0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36–0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79–6.92), functional decline (OR = 2.52; 95 % CI = 1.55–4.10), depression (OR = 1.82; 95 % CI = 1.07–3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07–4.83) were associated with greater odds of suicide.

CONCLUSIONS

Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

REFERENCES

  1. Power AK, McKeon R. Preventing suicide is a national imperative. Am J Public Health. 2012;102(S1):S7.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Blow FC, Bohnert ASB, Ilgen MA, et al. Suicide mortality among patients treated by the veterans health administration from 2000 to 2007. Am J Public Health. 2012;102(S1):S98–S104.

    Article  PubMed Central  PubMed  Google Scholar 

  3. U.S. Surgeon General, National Action Alliance for Suicide Prevention. 2012 national strategy for suicide prevention: Goals and objectives for action: A report of the U.S. surgeon general and of the national action alliance for suicide prevention. Accessed 8/26, 2014: http://www.ncbi.nlm.nih.gov/books/NBK109917/. 2012.

  4. Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: A review of the evidence. Am J Psychiatry. 2002;159(6):909–16.

    Article  PubMed  Google Scholar 

  5. Basham C, Denneson LM, Millet L, Shen X, Duckart J, Dobscha SK. Characteristics and VA health care utilization of U.S. veterans who completed suicide in oregon between 2000 and 2005. Suicide Life Threat Behav. 2011;41(3):287–96.

    Article  PubMed  Google Scholar 

  6. Corson K, Denneson LM, Bair M, Helmer DA, Goulet JL, Dobscha SK. Prevalence and correlates of suicidal ideation among OEF/OIF veterans. J Affect Disord. 2013;149:291–8.

    Article  PubMed  Google Scholar 

  7. Durai UN, Chopra MP, Coakley E, et al. Exposure to trauma and posttraumatic stress disorder symptoms in older veterans attending primary care: comorbid conditions and self-rated health status. J Am Geriatr Soc. 2011;59(6):1087–1092.

    Article  PubMed  Google Scholar 

  8. LeardMann CA, Powell TM, Smith TC, et al. Risk factors associated with suicide in current and former US military personnel. JAMA. 2013;310(5):496–506.

    Article  CAS  PubMed  Google Scholar 

  9. Smith EG, Kim HM, Ganoczy D, Stano C, Pfeiffer PN, Valenstein M. Suicide risk assessment received prior to suicide death by veterans health administration patients with a history of depression. J Clin Psychiatry. 2013;74(3):226–32.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Ilgen MA, Conner KR, Roeder KM, Blow FC, Austin K, Valenstein M. Patterns of treatment utilization before suicide among male veterans with substance use disorders. Am J Public Health. 2012;102(Suppl 1):S88–92.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Mavandadi S, Rook KS, Newsom JT, Oslin DW. Suicidal ideation and social exchanges among at-risk veterans referred for a behavioral health assessment. Soc Psychiatry Psychiatr Epidemiol. 2013;48(2):233–243.

    Article  PubMed  Google Scholar 

  12. Department of Veterans Affairs VA Information Resource Center (VIReC). VIReC corporate data warehouse (CDW). Accessed 8/26, 2014: http://www.hsrd.research.va.gov/for_researchers/vinci/cdw.cfm. 2012.

  13. Rose S, Laan MJ. Why match? investigating matched case–control study designs with causal effect estimation. Int J Biostat. 2009;5(1):Article 1,4679.1127.

  14. Gibbons RD, Brown CH, Hur K. Is the rate of suicide among veterans elevated? Am J Public Health. 2012;102(S1):S17–9.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Haney EM, O'Neil ME, Carson S, et al. Suicide risk factors and risk assessment tools: A systematic review; 2012.

    Google Scholar 

  16. WWAMI Rural Health Research Center. Rural–urban commuting areas (RUCA) data, version 2, 2005 [data file]. Accessed 8/26, 2014 from: http://depts.washington.edu/uwruca/ruca-data.php. 2005.

  17. Morrill R, Cromartie J, Hart G. Metropolitan, urban, and rural commuting areas: Toward a better depiction of the united states settlement system. Urban Geography. 1999;20(8):727–48.

    Article  Google Scholar 

  18. Selim AJ, Fincke G, Ren XS, et al. Comorbidity assessments based on patient report: Results from the veterans health study. J Ambul Care Manage. 2004;27(3):281–95.

    Article  PubMed  Google Scholar 

  19. Copeland LA, Zeber JE, Wang CP, et al. Patterns of primary care and mortality among patients with schizophrenia or diabetes: A cluster analysis approach to the retrospective study of healthcare utilization. BMC Health Serv Res. 2009;9:127.

    Article  PubMed Central  PubMed  Google Scholar 

  20. Martin, J., Ghahramanlou-Holloway, M., Lou, K., Tucciarone, P. A comparative review of U.S. military and civilian suicide behavior: Implications for OEF/OIF suicide prevention efforts. J Ment Health. 2009;31(2):101,118; 101.

  21. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064–74.

    Article  CAS  PubMed  Google Scholar 

  22. Britton PC, Ilgen MA, Rudd MD, Conner KR. Warning signs for suicide within a week of healthcare contact in veteran decedents. Psychiatry Res. 2012;200(2–3):395–9.

    Article  PubMed  Google Scholar 

  23. Smith EG, Craig TJ, Ganoczy D, Walters HM, Valenstein M. Treatment of veterans with depression who died by suicide: Timing and quality of care at last veterans health administration visit. J Clin Psychiatry. 2011;72(5):622–9.

    Article  PubMed Central  PubMed  Google Scholar 

  24. Denneson LM, Basham C, Dickinson KC, et al. Suicide risk assessment and content of VA health care contacts before suicide completion by veterans in oregon. Psychiatr Serv. 2010;61(12):1192–7.

    Article  PubMed  Google Scholar 

  25. Crosby AE, Ortega L, Melanson C. Self-directed violence surveillance: Uniform definitions and recommended data elements, version 1.0. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control: Atlanta, GA; 2011.

    Google Scholar 

  26. Kim HM, Smith EG, Ganoczy D, et al. Predictors of suicide in patient charts among patients with depression in the veterans health administration health system: Importance of prescription drug and alcohol abuse. J Clin Psychiatry. 2012;73(10):e1269–75.

    Article  PubMed  Google Scholar 

  27. Cavanagh JT, Owens DG, Johnstone EC. Life events in suicide and undetermined death in south-east scotland: A case–control study using the method of psychological autopsy. Soc Psychiatry Psychiatr Epidemiol. 1999;34(12):645–50.

    Article  CAS  PubMed  Google Scholar 

  28. Cicchetti DV, Sparrow SA. Developing criteria for establishing interrater reliability of specific items: Applications to assessment of adaptive behavior. Am J Ment Defic. 1981;86(2):127–37.

    CAS  PubMed  Google Scholar 

  29. Centers for Disease Control and Prevention (CDC). Suicide facts at a glance. National Center for Injury Prevention and Control. 2009;Available from http://www.cdc.gov/violenceprevention/pdf/Suicide-DataSheet-a.pdf. Accessed 8/26, 2014.

  30. Callanan VJ, Davis MS. Gender differences in suicide methods. Soc Psychiatry Psychiatr Epidemiol. 2012;47(6):857–69.

    Article  PubMed  Google Scholar 

  31. Conner KR, Bohnert AS, McCarthy JF, et al. Mental disorder comorbidity and suicide among 2.96 million men receiving care in the veterans health administration health system. J Abnorm Psychol. 2013;122(1):256–63.

    Article  PubMed  Google Scholar 

  32. Watson D, Clark LA, Carey G. Positive and negative affectivity and their relation to anxiety and depressive disorders. J Abnorm Psychol. 1988;97(3):346–53.

    Article  CAS  PubMed  Google Scholar 

  33. Clark LA, Watson D. Tripartite model of anxiety and depression: Psychometric evidence and taxonomic implications. J Abnorm Psychol. 1991;100(3):316–36.

    Article  CAS  PubMed  Google Scholar 

  34. Kaplan MS, McFarland BH, Huguet N, Newsom JT. Physical illness, functional limitations, and suicide risk: A population-based study. Am J Orthopsychiatry. 2007;77(1):56–60.

    Article  PubMed  Google Scholar 

  35. Kaplan MS, Huguet N, McFarland BH, Newsom JT. Suicide among male veterans: A prospective population-based study. J Epidemiol Community Health. 2007;61(7):619–24.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Conwell Y, Duberstein PR, Caine ED. Risk factors for suicide in later life. Biol Psychiatry. 2002;52(3):193–204.

    Article  PubMed  Google Scholar 

  37. VetPop2011 table 1L and table 3L. Available at: http://www1.va.gov/vetdata/Veteran_Population.asp. Accessed 8/26, 2014.

  38. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS) fatal injury reports. Atlanta, GA: National Center for Injury Prevention and Control; 2007.

  39. Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatr Serv. 2013;64(12):1195–202.

    Article  PubMed  Google Scholar 

  40. Ganzini L, Denneson L, Press N, et al. Trust is the basis for effective suicide risk assessment in veterans. J Gen Intern Med. 2013;28:1215–21.

    Article  PubMed Central  PubMed  Google Scholar 

  41. Kemp J, Bossarte R. Suicide data report: 2012. Mental Health Services, Suicide Prevention Program: Department of Veterans Affairs; 2013.

    Google Scholar 

  42. Desai RA, Dausey DJ, Rosenheck RA. Mental health service delivery and suicide risk: The role of individual patient and facility factors. Am J Psychiatry. 2005;162(2):311–8.

    Article  PubMed  Google Scholar 

  43. Zivin K, Kim HM, McCarthy JF, et al. Suicide mortality among individuals receiving treatment for depression in the veterans affairs health system: Associations with patient and treatment setting characteristics. Am J Public Health. 2007;97(12):2193–8.

    Article  PubMed Central  PubMed  Google Scholar 

  44. Gradus JL, Suvak MK, Wisco BE, Marx BP, Resick PA. Treatment of posttraumatic stress disorder reduces suicidal ideation. Depress Anxiety. 2013;30(10):1046–53.

    PubMed  Google Scholar 

  45. Jakupcak M, Cook J, Imel Z, Fontana A, Rosenheck R, McFall M. Posttraumatic stress disorder as a risk factor for suicidal ideation in iraq and afghanistan war veterans. J Trauma Stress. 2009;22(4):303–6.

    Article  PubMed  Google Scholar 

  46. Ilgen MA, Kleinberg F, Ignacio RV, et al. Noncancer pain conditions and risk of suicide. JAMA Psychiatry. 2013;70(7):692–7.

    Article  PubMed  Google Scholar 

  47. FY09 end of year: uniques by VERA category – facility. Available at: http://vaww.arc.med.va.gov/reports/annual/not_vera09_toc.htm. Accessed 8/26, 2014.

  48. 2009 VHA facility quality and safety report. Available at: http://www.va.gov/health/docs/HospitalReportCard2009.pdf. Accessed 8/26, 2014.

  49. Suicide risk assessment guide. Available at: http://www.mentalhealth.va.gov/docs/Suicide_Risk_Assessment_Reference_Guide.pdf. Accessed 8/26, 2014.

Download references

Contributors

We wish to acknowledge April Lee MPH, Holly Bratkovich BA, Anna Beane BA, and Joe Warren MA for assistance in developing study procedures and reviewing the medical records.

Funders

This material is based upon work supported by the Department of Veterans Affairs, the Veterans Health Administration, and Health Services Research and Development Service Project IIR 10–331, VA Mental Health Services-Suicide Prevention Program, and VISN 2 Center of Excellence for Suicide Prevention. Dr. Dobscha is the Director of the Center to Improve Veteran Involvement in Care (CIVIC) at the Portland VA Medical Center. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

Prior Presentations

None.

Conflicts of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Steven K. Dobscha MD.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Dobscha, S.K., Denneson, L.M., Kovas, A.E. et al. Correlates of Suicide Among Veterans Treated in Primary Care: Case–Control Study of a Nationally Representative Sample. J GEN INTERN MED 29 (Suppl 4), 853–860 (2014). https://doi.org/10.1007/s11606-014-3028-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-014-3028-1

KEY WORDS

Navigation