Improving Understanding of Veteran Suicide Relative to VHA Service Use

BRIEF COMMUNICATION

[[{"type":"media","view_mode":"media_crop","fid":"29389","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2680231362948","media_crop_h":"163","media_crop_image_style":"-1","media_crop_instance":"4154","media_crop_rotate":"0","media_crop_scale_h":"118","media_crop_scale_w":"100","media_crop_w":"138","media_crop_x":"96","media_crop_y":"21","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Recently, the first study that compared suicide risk for veterans who do and those who do not use Veterans Health Administration (VHA) services was published online.¹ The US Department of Veterans Affairs (VA) developed and implemented a comprehensive Suicide Prevention Program that closely monitors veterans identified as being at risk for suicide. Despite this effort, the majority of veterans are not enrolled in or accessing VHA services. Up to now, available data were insufficient to answer questions about characteristics of suicide among those with and without use of VHA services. Our study offers information on 3 fronts:

• A comparison of suicide risk for the broad veteran population and civilian adults

• A comparison of suicide risk for veterans who access VHA services and those who do not

• Insight into important sex differences in these relationships

VA-archived suicide data collected in partnership with data from US states made the analysis possible. The VA state suicide database compiles death certificate records obtained directly from participating states for all adult suicide decedents, regardless of their military history; veteran status is carefully validated.²

There is an immediate need to better understand suicide risk and trends over time in female veterans as well as in younger veterans. Woman veterans are the fastest-growing veteran subgroup, and recent data suggest that rates of suicide among women who used VHA services have not declined in a manner consistent with declines in men.³

The goal of our study was to analyze data from 173,969 suicide decedents from the states participating in the VA’s archive of suicide data. One-quarter of the suicide decedents were veterans; 20% did not use VHA services and 5% did use VHA services in the year before their death. Participating states were geographically diverse and the range in state suicide rates was comparable to that of all US states and territories. The study methods included the computation of crude suicide rates, direct age-adjusted suicide rates, and standardized mortality ratios by year (2000 to 2010) for the 4 groups studied: US civilians, all veterans, VHA-accessing veterans, and non–VHA-accessing veterans (overall and stratified by sex).

Some key findings from the study indicate that overall suicide rates are increasing for both male and female veterans as are rates for non-veterans. Moreover, suicide rates in female veterans are increasing more rapidly than in male veterans. The observed percent increase in crude suicide rates from 2000 to 2010 was 25% among male veterans and 40% among female veterans. However, when considering VHA utilization history, VHA-utilizing veterans were the only study group for which crude suicide rates decreased (by 20%) over the study period.

When VHA utilization and sex were considered simultaneously, it became clear that the greatest excess suicide risk was found among female veterans who did not use VHA services, when compared with their non-veteran peers. Conversely, female veterans who accessed VHA services had consistently and significantly fewer suicide attempts/completions than female veterans who had not accessed care during the study period. In 2000, the suicide rate was higher among male veterans who accessed VHA services than among veterans outside the VHA, but this relative rate declined from 2000 to 2003; since 2003, male veterans accessing VHA services have fared better than their peers who did not use VHA services.

Taken together, one plausible explanation for these findings is that the VA’s Mental Health Enhancement Initiative beginning in 2004 and the VA Suicide Prevention Program launched in 2007 have helped curb rising veteran suicide rates. A recently published study in JAMA Psychiatry found similar results for users of specialty mental health care services offered through the Henry Ford Health System, a large HMO.⁴ The VHA study does not, however, allow inferences to be drawn on what components of the VA Suicide Prevention Program are most effective, nor can we be certain that differences observed are not due, at least in part, to differences in underlying characteristics between veterans who do and those who do not use VHA services, which may be related to suicide risk. Veterans are a diverse group, and further research is needed to understand suicide risk in this majority subgroup of veterans.

Disclosures:

Dr Hoffmire is with the VISN 19 Rocky Mountain MIRECC for Suicide Prevention, US Department of Veterans Affairs, Denver. Dr Bossarte is with the Office of Public Health, US Department of Veterans Affairs, Washington, DC. Dr Hoffmire and Dr Bossarte are also with the department of psychiatry at the University of Rochester in Rochester, NY. The authors report no conflicts of interest concerning the subject matter of this article.

References:

1. Hoffmire CA, Kemp JE, Bossarte RM. Changes in suicide mortality for veterans and nonveterans by gender and history of VHA service use, 2000-2010. Psychiatr Serv. 2015 May 1; [Epub ahead of print].

2. Hoffmire CA, Bossarte RM. A reconsideration of the correlation between veteran status and firearm suicide in the general population. Inj Prev. 2014;20:317-321.

3. Kemp J. Suicide data report update, 2014. Department of Veterans Affairs, Mental Health Services, Suicide Prevention Program; January 2014. http://www.blogs.va.gov/VAntage/11973/january-2014-va-suicide-data-update. Accessed June 30, 2015.

4. Coffey MJ, Coffey CE, Ahmedani BK. Suicide in a health maintenance organization population. JAMA Psychiatry. 2015;72:294-296.