Higher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts

doi:10.1016/j.jad.2008.08.020

Journal of Affective Disorders

Volume 112, Issues 1–3, January 2009, Pages 50-58

https://doi.org/10.1016/j.jad.2008.08.020 Get rights and content

Abstract

Background

Health systems with limited resources may have the greatest impact on suicide if their prevention efforts target the highest-risk treatment groups during the highest-risk periods. To date, few health systems have carefully segmented their depression treatment populations by level of risk and prioritized prevention efforts on this basis.

Methods

We conducted a retrospective cohort study of 887,859 VA patients receiving depression treatment between 4/1/1999 and 9/30/2004. We calculated suicide rates for five sequential 12-week periods following treatment events that health systems could readily identify: psychiatric hospitalizations, new antidepressant starts (> 6 months without fills), “other” antidepressant starts, and dose changes. Using piecewise exponential models, we examined whether rates differed across time-periods. We also examined whether suicide rates differed by age-group in these periods.

Results

Over all time-periods, the suicide rate was 114/100,000 person-years (95% CI; 108, 120). In the first 12-week periods, suicide rates were: 568/100,000 p-y (95% CI; 493, 651) following psychiatric hospitalizations; 210/100,000 p-y (95% CI; 187, 236) following new antidepressant starts; 193/100,000 p-y (95% CI; 167, 222) following other starts; and 154/100,000 p-y (95% CI; 133, 177) following dose changes. Suicide rates remained above the base rate for 48 weeks following hospital discharge and 12 weeks following antidepressant events. Adults aged 61–80 years were at highest risk in the first 12-week periods.

Conclusions

To have the greatest impact on suicide, health systems should prioritize prevention efforts following psychiatric hospitalizations. If resources allow, closer monitoring may also be warranted in the first 12 weeks following antidepressant starts, across all age-groups.

Section snippets

Methods

Study data were obtained from the VA's National Registry for Depression (NARDEP) which was developed by the VA's Serious Mental Illness Treatment Research and Evaluation Center (SMITREC) in Ann Arbor, Michigan. The study was approved by the Institutional Review Board of the Veterans Affairs Ann Arbor Health System.

Patient sample and observation-days

The characteristics of the patient cohort (N = 887,859) are outlined in Table 1. The population had a mean age of 58.6 years and was predominantly male (92%).

There were 433,086,931 observation-days (1,185,727 patient-years) during the study period.

Psychiatric hospitalizations, antidepressant starts and dose changes

A total of 182,518 psychiatric hospitalizations occurred during the observation period. Approximately 10% of the patients had one or more and 4% had two or more hospitalizations during the study period.

Across the entire observation period, there were

Discussion

Health systems should consider segmenting their depression treatment populations by levels of suicide risk to most usefully deploy limited resources for suicide prevention. Our data suggest that health systems might have the most impact on suicide if they first allocated resources for prevention efforts for depressed patients recently discharged from inpatient psychiatric settings.

In the first 12 weeks following inpatient discharge, suicide rates were 568/100,000 person-years, or approximately

Role of funding source

Department of Veterans Affairs, Health Services Research and Development Service, IIR 04-211-1 and MRP 03-320 and by the National Institute of Mental Health, R01-MH078698-01. Resources were also contributed by the Serious Mental Illness Treatment, Research, and Evaluation Center, Ann Arbor, MI.

Conflict of interest

There are no additional contributors to this article.

There are no potential conflicts of interest on the part of authors or the sponsors.

The funding sources for this work were the Department of Veterans Affairs, Health Services Research and Development Service, IIR 04-211-1 and MRP 03-320 and the National Institute of Mental Health, R01-MH078698-01. Resources were also contributed by the Serious Mental Illness Treatment, Research, and Evaluation Center, Ann Arbor, MI. The sponsors provided

Acknowledgements

This research was supported by grants from the Department of Veterans Affairs, Health Services Research and Development Service, IIR 04-211-1 and MRP 03-320 and by the National Institute of Mental Health, R01-MH078698-01. Resources were also contributed by the Serious Mental Illness Treatment Research and Evaluation Center, Ann Arbor, MI. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

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Research reportHigher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Patient sample and observation-days

Psychiatric hospitalizations, antidepressant starts and dose changes

Discussion

Role of funding source

Conflict of interest

Acknowledgements

Ann. Epidemiol.

Ann. Epidemiol.

Lancet

Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association

Am. J. Psychiatry

Practice guideline for the assessment and treatment of patients with suicidal behaviors

Am. J. Psychiatry

The impact of managed care on cross-system use of mental health services by veterans in Colorado

Psychiatr. Serv.

Cross-system service use among VA mental health patients living in Philadelphia

Adm. Policy Ment. Health

Mental health service delivery and suicide risk: the role of individual patient and facility factors

Am. J. Psychiatry

Time trends and predictors of suicide among mental health outpatients in the Department of Veterans Affairs

J. Behav. Health Serv. Res.

Piecewise exponential models for survival data with covariates

Ann. Stat.

Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets

Am. J. Psychiatry

Research report
Higher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts