VA strategy may effectively identify veterans at risk for suicide
A suicide risk identification strategy appeared effective at identifying veterans who were not receiving mental health treatment, according to results of a cross-sectional study published in JAMA Network Open.
“During the last decade, the Veterans Health Administration (VHA) has made significant strides in suicide prevention,” Nazanin Bahraini, PhD, of the Rocky Mountain Regional Veterans Affairs (VA) Medical Center in Colorado, and colleagues wrote. “However, most of these efforts have focused on downstream interventions to reduce suicidal behavior among those already identified to be at high risk. Recognizing the need to implement more upstream efforts that are consistent with the National Strategy for Preventing Veteran Suicide 2018-2028, the VHA Office of Mental Health and Suicide Prevention established an interdisciplinary workgroup of experts to identify an evidence-informed approach to detect suicide risk among patients across VHA settings.”
The workgroup developed the VA Suicide Risk Identification Strategy (Risk ID), a suicide risk screening and evaluation process in three stages: a primary screen via the Patient Health Questionnaire 9; a secondary screen via the Columbia Suicide Severity Rating Scale Screener; and the VHA’s Comprehensive Suicide Risk Evaluation (CSRE).
In the current study, Bahraini and colleagues aimed to evaluate the prevalence of positive suicide screening results among veterans in ambulatory care and EDs or urgent care clinics (UCCs), as well as to compare suicide risk acuity among patients screened in these settings. They analyzed data of 4,101,685 veterans with one or more ambulatory care visit and 1,044,056 veterans with one or more ED or UUC visit across 140 VHA medical centers. Main measures included 1-year rate of suicide risk screening and evaluation, prevalence of positive results on primary and secondary suicide risk screenings and levels of chronic and acute risk according to the VHA’s CSRE.
Results showed positive suicide screening result prevalence of 3.5% for primary screening and 0.4% for secondary screening in ambulatory care, as well as 3.6% for primary screening 2.1% in secondary screening for EDs and UCCs. Veterans screened in the ED or UCC were at greater risk for endorsing suicidal ideation with intent (OR = 4.55; 95% CI, 4.37-4.74), specific plan (OR = 3.16; 95% CI, 3.04-3.29) and recent suicidal behavior (OR = 1.95; 95% CI, 1.87-2.03) during secondary screening vs. those screened in ambulatory care. Veterans who received a CSRE in EDs or UCCs were at greater risk vs. those in ambulatory care settings to exhibit high acute risk.
“The higher acuity of risk among veterans presenting to ED or UCC compared with [ambulatory care] settings highlights the importance of scaling up implementation of brief evidence-based interventions designed for ED or UCC settings to promote treatment engagement and reduce suicidal behavior,” Bahraini and colleagues wrote. “Improving implementation of Risk ID across health care settings and identifying effective interventions for mitigating suicide risk that can be feasibly administered in primary care are important areas for further investigation.”
In a related editorial, Roy H. Perlis, MD, MSc, of the department of psychiatry at Massachusetts General Hospital and Harvard Medical School, and Stephan D. Fihn, MD, MPH, of the department of medicine at University of Seattle, Washington, underscored the implications of these findings.
“Although the VA is not representative of general clinical practice, these numbers provide a useful reference for estimating the yield of routine screening in these settings,” they wrote. “Even so, nearly two-thirds of veterans who die by suicide have not sought any type of health care from the VA. Thus, even in a perfect world of optimal screening and intervention by the VA, two-thirds of suicide deaths among veterans would not be prevented.”