Article

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

Department of Veterans Affairs, Ann Arbor Center of Excellence (COE), Serious Mental Illness Treatment Research and Evaluation Center (SMITREC), Ann Arbor, Michigan 48113-0170, USA.
Journal of Affective Disorders (Impact Factor: 3.38). 10/2008; 112(1-3):50-8. DOI: 10.1016/j.jad.2008.08.020
Source: PubMed

ABSTRACT

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.
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.
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.
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.

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    • "Some authors have suggested acute factors, such as acute anxiety, agitation, depression, anhedonia, and history of attempts, may be more predictive, however there is general agreement that prediction is difficult (Tischler & Reiss, 2009). Other empirically-based risk factors specific to psychiatric inpatients (in addition to those identified in the systematic reviews ) include: clinical demographic, family, environmental risk factors), and clinician and system failures (Bongar & Sullivan , 2013; Busch, Fawcett, & Jacobs, 2003; Harris & Barraclough , 1994; Janofsky, 2009; Mills et al., 2013; Joint Commission Sentinel Alert, GCAHO, 2004; Silverman, Berman, Bongar, & Litman, 1994; Tischler et al., 2009; Valenstein et al., 2009b; Work Group on Suicidal Behaviors, 2003). Yet, Large and colleagues (2011) conducted a meta-analysis of 29 controlled studies among psychiatric inpatients and concluded that depression and prior suicide attempt were most predictive of a high-risk categorization and subsequent suicide. "
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    ABSTRACT: In total, 75% of suicides reported to the Joint Commission as sentinel events since 1995, have occurred in psychiatric settings. Ensuring patient safety is one of the primary tasks of inpatient psychiatric units. A review of inpatient suicide-specific safety components, inclusive of incidence and risk; guidelines for evidence based care; environmental safety; suicide risk assessment; milieu observation and monitoring; psychotherapeutic interventions; and documentation is provided. The Veterans Health Administration (VA) has been recognized as an exemplar system in suicide prevention. A VA inpatient psychiatric unit is used to illustrate the operationalization of a culture of suicide-specific safety. We conclude by describing preliminary unit outcomes and acknowledging limitations of suicide-specific inpatient care and gaps in the current inpatient practices and research on psychotherapeutic interventions, observation, and monitoring.
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    • "Some authors have suggested acute factors, such as acute anxiety, agitation, depression, anhedonia, and history of attempts, may be more predictive, however there is general agreement that prediction is difficult (Tischler & Reiss, 2009). Other empirically-based risk factors specific to psychiatric inpatients (in addition to those identified in the systematic reviews ) include: clinical demographic, family, environmental risk factors), and clinician and system failures (Bongar & Sullivan , 2013; Busch, Fawcett, & Jacobs, 2003; Harris & Barraclough , 1994; Janofsky, 2009; Mills et al., 2013; Joint Commission Sentinel Alert, GCAHO, 2004; Silverman, Berman, Bongar, & Litman, 1994; Tischler et al., 2009; Valenstein et al., 2009b; Work Group on Suicidal Behaviors, 2003). Yet, Large and colleagues (2011) conducted a meta-analysis of 29 controlled studies among psychiatric inpatients and concluded that depression and prior suicide attempt were most predictive of a high-risk categorization and subsequent suicide. "

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    • "For instance, some antidepressants may be weakly carcinogenic (Cosgrove et al., 2011) or cause osteoporosis (Verdel et al., 2010). Antidepressants have also been associated with an increased acute risk of suicide in younger patients while they may decrease the risk of suicide in older patients or with longer-term use (Ghaemi et al., 2013; Isacsson et al., 2010; Leon et al., 2011; Valenstein et al., 2009). Also, all major classes of antidepressants have been associated with unpleasant (and sometimes dangerous) symptoms when they are discontinued abruptly (Haddad, 2001; Lader, 2007). "
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