Suicide is a leading cause of death. A substantial proportion of the people who die by suicide come into contact with the health care system in the year before their death. This observation has ...resulted in the development of numerous suicide prediction tools to help target patients for preventive interventions. However, low sensitivity and low positive predictive value have led critics to argue that these tools have no clinical value. We review these tools and critiques here. We conclude that existing tools are suboptimal and that improvements, if they can be made, will require developers to work with more comprehensive predictor sets, staged screening designs, and advanced statistical analysis methods. We also conclude that although existing suicide prediction tools currently have little clinical value, and in some cases might do more harm than good, an even-handed assessment of the potential value of refined tools of this sort cannot currently be made because such an assessment would depend on evidence that currently does not exist about the effectiveness of preventive interventions. We argue that the only way to resolve this uncertainty is to link future efforts to develop or evaluate suicide prediction tools with concrete questions about specific clinical decisions aimed at reducing suicides and to evaluate the clinical value of these tools in terms of net benefit rather than sensitivity or positive predictive value. We also argue for a focus on the development of individualized treatment rules to help select the right suicide-focused treatments for the right patients at the right times. Challenges will exist in doing this because of the rarity of suicide even among patients considered high-risk, but we offer practical suggestions for how these challenges can be addressed.
Background Unintentional poisoning deaths have been increasing dramatically over the past decade, and the majority of this increase has resulted from overdoses of specific prescription drugs. Despite ...this trend, there are limited existing data examining hospitalizations for poisonings, both unintentional and intentional, associated with prescription drugs. A better understanding of these hospitalizations may help identify high-risk populations in need of intervention to prevent subsequent mortality. Purpose This article aims to describe the incidence and characteristics of hospitalizations resulting from poisoning by prescription opioids, sedatives, and tranquilizers in the U.S. from 1999 to 2006 and make comparisons to hospitalizations for all other poisonings during this time period. Methods Hospitalizations for poisonings were selected from the Nationwide Inpatient Sample (NIS), a stratified, representative sample of approximately 8 million hospitalizations each year, according to the principal discharge diagnosis. Intentionality of the poisoning was determined by external cause of injury codes. SAS callable SUDAAN software was used to calculate weighted estimates of poisoning hospitalizations by type and intentionality. Demographic and clinical characteristics of poisoning cohorts were compared. Data were analyzed in 2009. Results From 1999 to 2006, U.S. hospitalizations for poisoning by prescription opioids, sedatives, and tranquilizers increased a total of 65%. This increase was double the increase observed in hospitalizations for poisoning by other drugs and substances. The largest increase in the number of hospitalized cases over the 7-year period was seen for poisonings by benzodiazepines, whereas the largest percentage increase was observed for methadone (400%). In comparison to patients hospitalized for poisoning from other substances, those hospitalized for prescription opioids, sedatives, and tranquilizers were more likely to be women, aged >34 years, and to present to a rural or urban nonteaching hospital. Conclusions Prescription opioids, sedatives, and tranquilizers are an increasing cause of hospitalization. The hospital admission provides an opportunity to better understand the contextual factors contributing to these cases, which may aid in the development of targeted prevention strategies.
Adverse childhood experiences (ACEs) are associated with several adulthood health problems, such as self-directed violence. For some individuals, enlistment in the military may be an instrumental act ...to escape adverse household environments; however, to our knowledge prevalence of ACEs among persons with a history of military service has not been documented in the United States using population-based data.
To compare the prevalence of ACEs among individuals with and without a history of military service.
Data are from the 2010 Behavioral Risk Factor Surveillance System. Computer-assisted telephone interviews were conducted with population-based samples of noninstitutionalized US adults from January 1 through December 31, 2010. Analyses were limited to respondents who received the ACE module (n = 60,598). Participants were categorized by history of military service and whether a respondent was 18 years of age in 1973.
History of military service was defined by active duty service, veteran status, or training for the Reserves or National Guard. The ACE inventory assessed 11 negative experiences before the age of 18 years. Weighted χ2 tests and multiple logistic regression analyses were used to examine differences in ACEs by history of military service, era of service, and sex.
Those with military experience had greater odds of any difference in prevalence of ACEs. In the all-volunteer era, men with military service had a higher prevalence of ACEs in all 11 categories than men without military service. Notably, in the all-volunteer era, men with military service had twice the odds of reporting forced sex before the age of 18 years (odds ratio, 2.19; 95% CI, 1.34-3.57) compared with men without military service. In the draft era, the only difference among men was household drug use, in which men with a history of military service had a significantly lower prevalence than men without a history of military service (2.1% vs. 3.3%; P = .003). Fewer differences were observed among women in the all-volunteer and draft eras.
Differences in ACEs by era and sex lend preliminary support that enlistment may serve as an escape from adversity for some individuals, at least among men. Further research is needed to understand how best to support service members and veterans who may have experienced ACEs.
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.
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.
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%.
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.
VA Suicide Prevention Applications Network Hoffmire, Claire; Stephens, Brady; Morley, Sybil ...
Public health reports (1974),
11/2016, Volume:
131, Issue:
6
Journal Article
Peer reviewed
Open access
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.
Background
Health care systems struggle to identify risk factors for suicide. Adverse social determinants of health (SDH) are strong predictors of suicide risk, but most electronic health records ...(EHR) do not include SDH data.
Objective
To determine the prevalence of SDH documentation in the EHR and how SDH are associated with suicide ideation and attempt.
Design
This cross-sectional analysis included EHR data spanning October 1, 2015–September 30, 2016, from the Veterans Integrated Service Network Region 4.
Participants
The study included all patients with at least one inpatient or outpatient visit (
n
= 293,872).
Main Measurements
Adverse SDH, operationalized using Veterans Health Administration (VHA) coding for services and International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes, encompassed seven types (violence, housing instability, financial/employment problems, legal problems, familial/social problems, lack of access to care/transportation, and nonspecific psychosocial needs). We defined suicide morbidity by ICD-10 codes and data from the VHA’s Suicide Prevention Applications Network. Logistic regression assessed associations of SDH with suicide morbidity, adjusting for socio-demographics and mental health diagnoses (e.g., major depression). Statistical significance was assessed with
p
< .01.
Key Results
Overall, 16.4% of patients had at least one adverse SDH indicator. Adverse SDH exhibited dose-response-like associations with suicidal ideation and suicide attempt: each additional adverse SDH increased odds of suicidal ideation by 67% (AOR = 1.67, 99%CI = 1.60–1.75;
p
< .01) and suicide attempt by 49% (AOR = 1.49, 99%CI = 1.33–1.68;
p
< .01). Independently, each adverse SDH had strong effect sizes, ranging from 1.86 (99%CI = 1.58–2.19;
p
< .01) for legal issues to 3.10 (99%CI = 2.74–3.50;
p
< .01) for non-specific psychosocial needs in models assessing suicidal ideation and from 1.58 (99%CI = 1.10–2.27;
p
< .01) for employment/financial problems to 2.90 (99%CI = 2.30–4.16;
p
< .01) for violence in models assessing suicide attempt.
Conclusions
SDH were strongly associated with suicidal ideation and suicide attempt even after adjusting for mental health diagnoses. Integration of SDH data in EHR could improve suicide prevention.
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.
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.
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.
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.
Heterogeneity of major depressive disorder (MDD) illness course complicates clinical decision-making. Although efforts to use symptom profiles or biomarkers to develop clinically useful prognostic ...subtypes have had limited success, a recent report showed that machine-learning (ML) models developed from self-reports about incident episode characteristics and comorbidities among respondents with lifetime MDD in the World Health Organization World Mental Health (WMH) Surveys predicted MDD persistence, chronicity and severity with good accuracy. We report results of model validation in an independent prospective national household sample of 1056 respondents with lifetime MDD at baseline. The WMH ML models were applied to these baseline data to generate predicted outcome scores that were compared with observed scores assessed 10-12 years after baseline. ML model prediction accuracy was also compared with that of conventional logistic regression models. Area under the receiver operating characteristic curve based on ML (0.63 for high chronicity and 0.71-0.76 for the other prospective outcomes) was consistently higher than for the logistic models (0.62-0.70) despite the latter models including more predictors. A total of 34.6-38.1% of respondents with subsequent high persistence chronicity and 40.8-55.8% with the severity indicators were in the top 20% of the baseline ML-predicted risk distribution, while only 0.9% of respondents with subsequent hospitalizations and 1.5% with suicide attempts were in the lowest 20% of the ML-predicted risk distribution. These results confirm that clinically useful MDD risk-stratification models can be generated from baseline patient self-reports and that ML methods improve on conventional methods in developing such models.
We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among ...veterans with a GID diagnosis.
We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk.
GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population.
The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.
Abstract Purpose To examine the cross-sectional associations between preteen alcohol use initiation and subsequent suicide ideation and attempts for boys and girls in a nationally representative ...sample of high school students. Methods Analyses are computed using data from the 2005 national Youth Risk Behavior Survey, which includes a representative sample (n = 13,639) of high-school students in grades 9–12 in the United States. Cross-sectional logistic regression analyses were conducted to determine the associations between early alcohol use and reports of suicide ideation and suicide attempts for boys and girls while controlling for demographic characteristics, substance use, involvement in physical fights, weapon carrying, physical abuse by dating partner, sexual assault, and sadness. Results Among study participants, 25.4% reported drinking before age 13 years. Preteen alcohol use initiation was statistically significantly associated with suicidal ideation (adjusted OR = 1.89, 95% CI =1.46–2.44) and suicide attempts (adjusted OR = 2.71, 95% CI =1.82–4.02) relative to nondrinkers. Preteen alcohol use initiation was statistically significantly associated with suicidal ideation and attempts relative to nondrinkers for both boys and girls. Conclusions Alcohol use among adolescents, particularly preteen alcohol use initiation, is an important risk factor for both suicide ideation and suicide attempts among boys and girls. Increased efforts to delay and reduce early alcohol use are needed, and may reduce suicide attempts.
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