Psychiatry and Primary CarePrimary care clinician responses to positive suicidal ideation risk assessments in veterans of Iraq and Afghanistan
Introduction
Veterans utilizing Veterans Health Administration (VHA) services die by suicide at a higher rate than the general population [1], and while specific rates of suicide among veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are unknown, OEF/OIF veterans have high rates of previously documented risk factors for suicide including depression, substance use disorder (SUD), posttraumatic stress disorder (PTSD), chronic pain and traumatic brain injury [2], [3], [4], [5], [6], [7], [8]. Furthermore, the rate of suicide among active duty OEF/OIF soldiers has increased in recent years, a trend which could follow this group into postdeployment [9].
The Department of Veterans Affairs (VA) has implemented a multimodal strategy to improve detection and response to suicide risk [10]. As one part of this strategy, the VA designated assessment for possible suicidal ideation (SI) among veterans at higher risk for suicide as a national performance goal. Specifically, since 2007, brief templated, structured suicide risk assessment tools are administered across the VA as part of routine care following positive depression and PTSD screens. These tools, typically consisting of less than five items, are designed to be used in conjunction with clinical judgment to assess suicide risk. Depression and PTSD screening, and the use of templated suicide risk assessments to assess for SI, frequently occur in primary care settings [11].
Prior research indicates that up to half of individuals have contact with primary care clinicians in the month prior to suicide, while a smaller proportion has contact with mental health care clinicians during that month [12], [13]. As such, primary care clinicians may play a critical role in addressing suicide risk of veterans by detecting and treating important mental and general medical conditions, and being prepared to identify and intervene when veterans are at high risk. However, despite these high contact rates, there are substantial gaps in our knowledge of how primary care clinicians address suicide risk. A recent study by Smith et al. [14] showed that a minority (34%) of VA patients with a history of depression had a mental health diagnosis coded during final nonmental health visits within 30 days prior to suicide, and only 41% were receiving recommended dosages of antidepressants. Vannoy et al. [15], [16] found that while primary care clinicians may use language and communication approaches that support patient disclosures of SI, primary care clinicians are frequently challenged to go beyond assessment to develop well-defined and structured treatment plans when they encounter SI. Aside from this small group of studies, little is known about the specific actions primary care clinicians take when they encounter SI in their patients.
Two risk factors of particular importance for clinicians to address with veterans who disclose SI are firearms access and alcohol and drug use. Nearly three quarters of veteran suicides in Oregon between 2000 and 2005 were firearms deaths [13]. Other studies suggest that veterans are significantly more likely to use firearms as a means for suicide than nonveterans [17]. National survey data have shown that individuals with an SUD have a sixfold greater likelihood of a lifetime suicide attempt than those without SUDs [18]. Among veteran suicide decedents in Oregon who received care in the VA healthcare system during the year prior to death, 20% were given an SUD diagnosis during that year, the second most common mental health disorder diagnosed after mood disorders [13], [19]. In addition, it is well-documented that intoxication frequently precedes suicide attempts and death by suicide [20], [21], especially among those who die by gunshot wound [21].
The main objective of the current study was to describe primary care clinician discussions and clinical actions following depression screening and positive suicide risk assessments (indicating SI) administered to OEF/OIF veterans. A secondary objective was to identify correlates of documented clinician–patient discussions and actions related to two key suicide risk factors: discussions of firearms access and counseling to reduce alcohol or drug use.
Section snippets
Methods
This study was approved by the institutional review boards of the participating medical centers. Methods for the overall research project have been described in prior publications [11], [22].
Results
Across the three study sites, 1017 veterans had positive depression screens administered in primary care over the study period. Seven hundred twenty-two (71%) were subsequently administered suicide risk assessments in primary care; 97% of these were conducted within 1 day of depression screens. Among these 722 veterans, 199 (28%) had positive suicide risk assessments. For 157 (79%) of the patients with positive assessments, either their primary care clinicians conducted the assessment
Discussion
This is the first study to examine primary care clinician actions taken in response to routinely administered brief, templated assessments for SI. There were a number of encouraging findings. Primary care clinicians usually documented awareness of positive suicide risk assessment results and almost always assessed for mental health conditions, including SUDs. Mental health referrals or acknowledgement of upcoming appointments were almost universal. Clinicians usually discussed some psychosocial
Conclusion
Our results suggest that barriers remain to clinicians querying and counseling veterans at risk for suicide, including discussion of firearms access and psychosocial stressors relevant to suicide risk. Women with SI may be less likely to receive counseling to reduce use of alcohol and drugs. Our findings call upon investigators and other stakeholders to further study clinician, patient and system barriers to exploring and documenting key risk factors for patients at risk for suicide and to
Acknowledgements
We gratefully acknowledge Kathryn Dickinson, MPH; Megan Crutchfield, MPH; Anna Beane, BA; Joseph Warren, MA; and April Wilson, MPH, for assistance with reviewing medical records and coding and organizing data. The research reported here was supported by the Department of VA, VHA, Health Services Research and Development Service projects DHI-08-096 and IIR 10–331. Dr. Dobscha is Director of the Center to Improve Veteran Involvement in Care at the Portland VAMC. The views expressed in this
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