Suicide Mortality Following Nursing Home Discharge in the Department of Veterans Affairs Health System

Objectives. We assessed suicide rates up to 6 months following discharge from US Department of Veterans Affairs (VA) nursing homes.Methods. In VA Minimum Data Set (MDS) records, we identified 281 066 live discharges from the 137 VA nursing homes during fiscal years 2002 to 2008. We used MDS and administrative data to assess resident age, gender, behaviors, pain, and indications of psychoses, bipolar disorder, dementia, and depression. We identified vital status and suicide mortality within 6 months of discharge through National Death Index searches.Results. Suicide rates within 6 months of discharge were 88.0 per 100 000 person-years for men and 89.4 overall. Standardized mortality ratios relative to age- and gender-matched individuals in the VA patient population were 2.3 for men (95% confidence interval [CI] = 1.9, 2.8) and 2.4 overall (95% CI = 2.0, 2.9). In multivariable proportional hazards regression analyses, resident characteristics, diagnoses, behaviors, and pain were not significantly associated with suicide risk.Conclusions. Suicide risk was elevated following nursing home discharge. This underscores the importance of ongoing VA efforts to enhance discharge planning and timely postdischarge follow-up.In 2009, 15 700 nursing homes in the United States provided services to 1.4 million individuals.1 In 2008, 36 035 individuals died by suicide in the United States, and suicide was the 10th leading cause of death.2 Men have higher suicide rates than women, and national suicide rates in 2007 were highest among men aged 75 years and older.3 Despite concerns regarding self-destructive behavior among nursing home residents,4,5 few studies have examined suicide mortality related to nursing home stays.6,7 Furthermore, although the literature documents elevated suicide risk following discharge from inpatient psychiatric settings,8,9 we are not aware of any studies that have examined suicide risk following discharge from nursing homes. Assessment of suicide risk following nursing home discharge provides an important opportunity to identify high-risk periods for suicide and to inform discharge planning, outreach, and care coordination activities.Since passage of federal nursing home reform legislation in 1987,10 improving quality of care in US nursing homes has been a national focus. Initiatives target community facilities that are eligible for Medicare and Medicaid reimbursement as well nursing homes in the US Department of Veterans Affairs (VA) health system, which are today called Community Living Centers (CLCs). Central to this effort are quality and performance measures derived from information from the national nursing home resident assessment instrument, the Minimum Data Set (MDS). MDS assessments are mandated for all nursing home residents shortly after admission, at periodic intervals, and when there is a change in health status. The MDS includes indicators specific to quality of life within nursing homes as well as quality of care, focusing on medical, rehabilitative, and mental health issues.The national focus on improving the quality of services provided in nursing homes has not addressed continuity of care after discharge. The VA has begun to evaluate this issue. Previous work has characterized resident risk factors for all-cause mortality following discharge from VA nursing homes.11We evaluated suicide rates following discharge from VA nursing homes. Because previous research suggests that psychopathology and challenging behaviors are associated with increased suicidal ideation and behavior,4,12–15 we evaluated measures of serious mental illness, depression, dementia, behavior problems, and pain as predictors of suicide after discharge.     

Use of VA health care services by women veterans: findings from a national sample

The Department of Veterans Affairs (VA) has a Congressional mandate but few empirical data on which to design and improve national health care services for women. We examined characteristics associated with women's current, former and non-use of the VA health care system. The study included 1,500 female veterans sampled from the Department of Veterans Affairs National Registry of Women Veterans. Women completed a 45-minute telephone survey assessing multiple domains of functional status and health service use. Using multivariate logistic regression, use of VA health care was associated with older age, more education, not being married, lower rates of insurance coverage, and poorer physical and psychological health. Women who were former users of VA health care were more likely to be ethnic minorities, have children, served less time in the military, had higher rates of insurance coverage and better physical and psychological health than current users. Prominent military experiences (e.g., service in a war-zone, exposure to trauma) were associated with former use and never using the VA health care system. Women who use VA health care are at greater economic, social, and health risk than nonusers, factors that have personal implications for the veteran as well as cost and service implications for VA. Additional research is needed to better understand the role of military experiences in women veterans' choice of health care.     

Individual and area-level factors correlated with death by suicide in older adults

ObjectiveTo determine the influence of individual and area-level characteristics associated with suicide in older adults.MethodThis study used two complementary data sources. The first used administrative data from the Quebec Coroner's office and included information on suicide deaths in older adults aged 65 years and over who died by suicide between 2000 and 2005 (n = 903 persons). The second data source, which was used to identify the control group, came from a longitudinal study on seniors' health that was conducted in Quebec between 2004 and 2005 (n = 2493 persons). Logistic regression analyses were used to test for associations between suicide and individual and area-level level characteristics.ResultsSuicide was associated with male gender, age, the presence of a physical and mental disorder and the use of health services. At the area-level level, suicide was associated with a higher population density, concentration of men, lower rates of education and higher rate of unemployment. Gender specific analyses also showed different patterns of associations on suicide risk.ConclusionsSuicide in older adults is associated with area-level and individual characteristics. This suggests that policies targeting only one level of risk factors are less likely to significantly influence suicide among this population.     

深圳市中学生自杀意念及其影响因素的性别差异

目的了解深圳市中学生自杀意念现状及其影响因素的性别差异,为有针对性的干预提供依据。方法分层整群抽取深圳市5所中学3 071名中学生,使用自杀意念量表、社会支持量表以及中学生应对方式量表进行问卷调查。结果男、女中学生的自杀意念报告率分别为29.5%和38.3%,差异有统计学意义(P<0.05);自杀计划和尝试自杀的报告率差异无统计学意义。在控制年龄的条件下,对自杀意念进行多因素Logistic回归分析,感受到的学习压力、主观支持为男、女中学生共同的影响因素;问题解决、忍耐和幻想否认为中学男生特有的影响因素;母亲文化程度、客观支持、对支持的利用度以及发泄情绪为中学女生特有的影响因素。结论中学女生的自杀意念检出率较男生高,男、女中学生自杀意念的影响因素不完全相同,应根据各自的特点进行预防和干预。     

Suicide among male veterans: a prospective population-based study

OBJECTIVES: To assess the risk of mortality from suicide among male veteran participants in a large population-based health survey. DESIGN AND SETTING: A prospective follow-up study in the US. Data were obtained from the US National Health Interview Surveys 1986-94 and linked to the Multiple Cause of Death file (1986-97) through the National Death Index. PARTICIPANTS: The sample comprised 320 890 men, aged >/=18 years at baseline. The participants were followed up with respect to mortality for 12 years. RESULTS: Cox proportional hazards analysis showed that veterans who were white, those with >/=12 years of education and those with activity limitations (after adjusting for medical and psychiatric morbidity) were at a greater risk for completing suicide. Veterans were twice as likely (adjusted hazard ratio 2.13, 95% CI 1.14 to 3.99) [corrected] to die of suicide compared with non-veterans in the general population. The risk of death from "natural" causes (diseases) and the risk of death from "external" causes did not differ between the veterans and the non-veterans. Interestingly, male veterans who were overweight had a significantly lower risk of completing suicide than those who were of normal weight. CONCLUSIONS: Veterans in the general US population, whether or not they are affiliated with the Department of Veterans Affairs (VA), are at an increased risk of suicide. With a projected rise in the incidence of functional impairment and psychiatric morbidity among veterans of the conflicts in Afghanistan and Iraq, clinical and community interventions that are directed towards patients in both VA and non-VA healthcare facilities are needed.     

Designing a Clinical Decision Support Tool That Leverages Machine Learning for Suicide Risk Prediction: Development Study in Partnership With Native American Care Providers

BackgroundMachine learning algorithms for suicide risk prediction have been developed with notable improvements in accuracy. Implementing these algorithms to enhance clinical care and reduce suicide has not been well studied.ObjectiveThis study aims to design a clinical decision support tool and appropriate care pathways for community-based suicide surveillance and case management systems operating on Native American reservations.MethodsParticipants included Native American case managers and supervisors (N=9) who worked on suicide surveillance and case management programs on 2 Native American reservations. We used in-depth interviews to understand how case managers think about and respond to suicide risk. The results from interviews informed a draft clinical decision support tool, which was then reviewed with supervisors and combined with appropriate care pathways.ResultsCase managers reported acceptance of risk flags based on a predictive algorithm in their surveillance system tools, particularly if the information was available in a timely manner and used in conjunction with their clinical judgment. Implementation of risk flags needed to be programmed on a dichotomous basis, so the algorithm could produce output indicating high versus low risk. To dichotomize the continuous predicted probabilities, we developed a cutoff point that favored specificity, with the understanding that case managers’ clinical judgment would help increase sensitivity.ConclusionsSuicide risk prediction algorithms show promise, but implementation to guide clinical care remains relatively elusive. Our study demonstrates the utility of working with partners to develop and guide the operationalization of risk prediction algorithms to enhance clinical care in a community setting.     

Towards a reassessment of the role of divorce in suicide outcomes: evidence from five Pacific Rim populations

The connection between divorce and suicide risk in Asia is unclear. To understand the contribution of cultural transitions to suicide among the divorced, we compare age- and sex-specific suicide rates among divorced men and women from five Pacific Rim populations: Hong Kong, Taiwan, Japan, South Korea and the state of Victoria in Australia. On a cultural spectrum, we consider Hong Kong and Taiwan to lie between the more individualistic Australian culture and the more collectivistic Japanese and Korean cultures. Coefficients of aggravation (COA) are also compared. Suicide rates were found to be higher among the divorced than among other marital status groups in all five populations, but this difference was small in Victoria. The effect of divorce was significantly greater for men than for women only in Japan and South Korea. In the other populations, divorced men and women were at equal risk. Age trends in suicide rates for the divorced groups differed across populations. The COAs for the divorced group aged 40 or younger in the East Asian populations were higher than the COAs for older divorced groups, though this was not the case in the Victorian population. Suicide patterns among the divorced in the East Asian populations can be understood in terms of the legacy of Confucian traditions. Gender differences in Japan and South Korea may reflect either gender inequality (male dominance in formal interactions and emotional dependence in domestic life within a deteriorating Confucian family support system) or unique socio-cultural factors among married women. Divorced East Asian groups aged 40 or younger may be at a higher risk of suicide due to individual-level cultural ambivalence combined with a desire for systemic-level emotional interdependence. Social welfare regimes in the four East Asian populations need to fill the vacancy left by retreating traditional family systems. Research implications are discussed.     

Geographical proximity and health care utilization in veterans with SCI&D in the USA

In the USA, substantial geographic variation in health care utilization exists in the Department of Veterans Affairs (VA) health care system. Utilization of health care services is especially important for veterans with spinal cord injuries and disorders (SCI&D) who are often at high risk for secondary complications related to their SCI&D. Due to impaired mobility, access to health care for veterans with SCI&D may be even more challenging. The goal of this cross-sectional study was to describe health care utilization relative to SCI&D veteran residential geographic proximity to VA health care facilities. A negative binomial regression model was used to examine VA outpatient utilization. Veterans with SCI&D utilized outpatient services less frequently when VA facilities were farther away from their residences (p<0.000). Female (p<0.000), older (p<0.000), and non-white veterans (p<0.000), and veterans with history of respiratory (p<0.000), kidney/urinary tract (p<0.005), circulatory (p<0.000), or digestive system diseases (p<0.003) were more likely to utilize outpatient care during the study period. A Poisson model was used to examine inpatient utilization. Inpatient utilization decreased when travel distance to VA facility increased (p<0.000). Contrary to outpatient, age did not significantly affect veterans' likelihood of using inpatient health care. Marital status, gender, race, and level of injury were not related to inpatient utilization. However, history of prior illnesses including respiratory (p<0.000), kidney/urinary tract (p<0.000), circulatory (p<0.005), digestive system (p<0.015), or skin/subcutaneous tissue/breast-related illnesses (p<0.000) were associated with a greater likelihood of inpatient utilization. Geographic proximity and other factors on health care use must be considered in order to meet the health care demand patterns of veterans with SCI&D.     

Suicide mortality: gender and socioeconomic differences

OBJECTIVE: To describe suicide mortality trend and sociodemographic patterns identifying gender and socioeconomic differences. METHODS: The trend of crude rates of suicide mortality by sex in the city of Campinas, Brazil, for the period 1976-2001 was assessed. Data from the Mortality Registry were used for sociodemographic analyses in the period 1996-2001. An ecological approach was used to examine socioeconomic differences and the 42 city areas of health care units were classified into 4 homogeneous strata. Rates were age-adjusted using direct method. RESULTS: The city has a low suicide rate (less than 5/100,000) in comparison with other countries. Male excess mortality was over 2.7 male suicides for each female suicide. While in 1980-1985 the older group (55 years and older) had the highest suicide rates, in 1997-2001 the middle-aged adult group (35-54 years old) showed the highest ones. As for suicide methods, men used hanging (36.4%) and firearms (31.8%), while women used poisoning (24.2%) and firearms and hanging (21.2% each). Hangings led to death at home, while firearms or poisoning deaths took place more often in hospitals. Suicide is different from homicide in that there is no rate increase with lower socioeconomic level. CONCLUSIONS: Suicide rates are low with successive increments and decrements without consistent growing or lowering trends. The risk of dying by suicide is higher among men and does not increase with lower socioeconomic condition.     

Suicide among nursing home residents: a population-based study

OBJECTIVE: The rate of suicide is highest among the oldest old and is associated with chronic medical illness and functional impairment. These risk factors are prevalent among nursing home (NH) residents, yet little has been published on suicide in this population. METHODS: We performed a population-based, retrospective cohort study to identify clinical features of NH residents attempting or completing suicide. A computerized data-base search was conducted to identify cases of completed suicide in Olmsted County and surrounding communities (846 NH beds) between 1981 and 1997. Subjects' medical records were reviewed to identify clinical details. RESULTS: Five cases of completed suicide and three suicide attempts were identified, including six men and two women. Deaths were the result of drowning, hanging, or medication overdose (the latter following a period of intentional hoarding). Those who died ranged in age from 69 to 87 years. Most had been NH residents for less than 6 months. No deaths occurred in patients with severe cognitive impairment. CONCLUSIONS: Suicide and suicide attempts in the NH seem to be uncommon but are likely underrecognized and underreported. Suicide risk among NH residents seems to be highest among men and those recently admitted to facilities. In addition, suicide methods differ among NH residents compared with community-dwelling older people, likely reflecting environmental restrictions and physical limitations. Suicide and suicide attempts are important resident health issues and risk management concerns for staff in long-term-care facilities.     

成都市2009年自杀死亡分析

目的了解成都市自杀死亡分布特征。方法对成都市死因监测系统中2009年所有自杀死亡病例进行分析。结果成都市自杀死亡率男性高于女性(χ2=18.15,P<0.05),农村高于城市(χ2=74.38,P<0.05),60岁以上人群高于15~59岁人群(χ2=107.87,P<0.05)。离婚人群自杀死亡率最高,丧偶人群次之。自杀死亡率随受教育程度增加而降低。杀虫剂自毒最多,占43.44%,其次是上吊,占22.32%。近60%发生在家中,其次有近32%发生在医疗救治过程中。结论自杀死亡多发生在经济、社会关系存在障碍的人群中。加强自杀医疗救治和农药管理有助于降低成都市自杀死亡率。     

Depression, hopelessness and suicide risk among patients suffering from epilepsy

Suicide risk, as well as psychiatric disorder, has been repeatedly reported in the international literature as an important issue in the care of individuals suffering from epilepsy. In this pilot study a sample comprising 103 patients with a diagnosis of temporal lobe epilepsy, were collected from three clinics. The patients were administered the Beck hopelessness scale (BHS), the Beck depression inventory (BDI) and the Zung self-rating anxiety scale (SAS). Hopelessness has been identified as a construct linked to the prediction and the prevention of suicide. Twenty-six percent of the epileptic patients had scores>or=9 on the BHS, suggesting that they should be evaluated for suicidal inclinations. These patients were significantly older by about 9 years and had higher levels of depression and anxiety, but they did not differ in sex, age of onset of epilepsy or in their responsiveness to medication. In the logistic regression analysis, a hopelessness score>or=9 was predicted by BDI depression scores and SAS anxiety scores taking into account sex, age and response to epileptic medications. Despite a number of limitations, this pilot study adds support for the need for screening for suicide risk in patients with epilepsy. Both clinical and psychometric data should be part of the evaluation of the epileptic patient for psychiatric and suicidality assessment.     

Variations in efficiency and the relationship to quality of care in the veterans health system

There is widespread belief that the US health care system could realize significant improvements in efficiency, savings, and patient outcomes if care were provided in a more integrated and accountable way. We examined efficiency and its relationship to quality of care for medical centers run by the Veterans Health Administration of the Department of Veterans Affairs (VA), a national, vertically integrated health care system that is accountable for a large patient population. After devising a statistical model to indicate efficiency, we found that VA medical centers were highly efficient. We also found only modest variation in the level of efficiency and cost across VA medical centers, and a positive correlation overall between greater efficiency and higher inpatient quality. These findings for VA medical centers suggest that efforts to drive integration and accountability in other parts of the US health care system might have important payoffs in reducing variations in cost without sacrificing quality. Policy makers should focus on what aspects of certain VA medical centers allow them to provide better care at lower costs and consider policies that incentivize other providers, both within and outside the VA, to adopt these practices.     

Women Veterans’ Perspectives on Suicide Prevention in Reproductive Health Care Settings: An Acceptable,Desired, Unmet Opportunity

BackgroundWomen veterans of reproductive age experience a suicide rate more than double their civilian peers. Developing effective suicide prevention strategies for women veterans requires identifying settings frequented by women veterans where acceptable prevention initiatives can be implemented. Reproductive health care (RHC) settings may provide such an opportunity.MethodsWe conducted semi-structured interviews with 21 cisgender women veterans of reproductive age using RHC services provided or paid for by the Department of Veterans Affairs (VA) to understand their beliefs, attitudes, and preferences regarding suicide risk assessment and prevention within these settings. Interview analysis was inductive and used a thematic analysis framework.ResultsFour major themes emerged from the interviews: 1) positive patient-provider relationships in RHC settings are important; 2) some women veterans prefer women providers for RHC and suicide risk screening; 3) women veterans’ experiences with VA suicide risk screening and assessment vary; and 4) suicide risk screening and prevention in RHC settings is a desired and acceptable, yet unmet opportunity.ConclusionsFindings from this novel study suggest that VA RHC settings may present a viable milieu for implementing upstream, gender-sensitive, veteran-centric suicide prevention strategies. Future research is needed with VA RHC providers to determine their needs for successfully implementing such strategies.     

Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics

Objectives. We sought to report clinical and demographic factors associated with suicide among depressed veterans in an attempt to determine what characteristics identified depressed veterans at high risk for suicide.Methods. We used longitudinal, nationally representative data (1999–2004) to determine suicide rates among depressed veterans, estimating time until suicide using Cox proportional hazards regression models.Results. Of 807694 veterans meeting study criteria, 1683 (0.21%) committed suicide during follow-up. Increased suicide risks were observed among male, younger, and non-Hispanic White patients. Veterans without service-connected disabilities, with inpatient psychiatric hospitalizations in the year prior to their qualifying depression diagnosis, with comorbid substance use, and living in the southern or western United States were also at higher risk. Posttraumatic stress disorder (PTSD) with comorbid depression was associated with lower suicide rates, and younger depressed veterans with PTSD had a higher suicide rate than did older depressed veterans with PTSD.Conclusions. Unlike the general population, older and younger veterans are more prone to suicide than are middle-aged veterans. Future research should examine the relationship between depression, PTSD, health service use, and suicide risks among veterans.Suicide is a complex, multidetermined phenomenon.1 There are individual-level biological and psychological contributors, in addition to social, environmental, and economic risk factors.2^–4 Rates of suicide also differ based on demographic and clinical characteristics. In the general population, the incidence of suicide is higher among older than among younger individuals5 and among males than among females.6 Whites are more likely to commit suicide than are African Americans, and older White men have the highest risk of suicide among all age and race groups.6 Suicide rates vary with rates of gun ownership, poverty, employment status, geographical location, and levels of social support,4^,7^,8 as well as other clinical and demographic characteristics. The US Surgeon General,9 the Institute of Medicine,4 and the Department of Veterans Affairs10 (VA) recognize suicide as a key public health problem in need of a national strategy for suicide prevention.Patients with psychiatric disorders, particularly depressive disorders, are at much greater risk for suicide than those in the general population.11^–16 Approximately 5% to 12% of men and 10% to 25% of women will have a major depressive episode during their lifetimes, and higher percentages will experience significant depressive symptoms, which increases their risk for suicide.17^,18 Of patients treated for depression in a variety of settings, approximately 2% to 7% die from suicide,19^,20 with higher rates of suicide occurring among patients who have been hospitalized for depression.3^,14^,19^,21 Patients with co-occurring disorders, such as depression and alcohol abuse or depression and posttraumatic stress disorder (PTSD), have been reported to be at much higher risk for suicide than patients with only 1 of these disorders.11^,12^,22^,23 Patients with prior hospitalizations for psychiatric disorders, such as depression or prior suicide attempts, are also at higher risk of suicide.24^–26The relationship between depression and other risk factors for suicide is likely complex. Qin et al. found that having a psychiatric disorder increased suicide risk more among women than among men.7 Major depression also may increase suicide risk more among older adults than among younger adults.14As a group, veterans may be at particularly high risk for suicide as a result of their high prevalence of depressive disorders and comorbid psychiatric conditions. According to the Veterans Health Study, the prevalence of significant depressive symptoms among veterans is 31%, 2- to 5-times higher than among the general US population.27 In 2002, 12% of veterans treated in VA health care facilities were diagnosed with depressive disorders by a health care provider during an encounter.28 Among veterans, as in the general population, completed suicide is usually associated with a mental disorder, most often depressive disorders and alcohol or substance use disorders; those with comorbid psychiatric disorders are at highest risk.29^,30Because of limited research examining completed suicide, little is known about the relative risks of suicide associated with demographic and clinical factors among depressed veterans. Among depressed patients, the relative risk of suicide among men compared with among women appears to be smaller than that seen for the same comparison among the general population.7^,31 Pokorny reported that, among former VA psychiatric inpatients, older patients did not have a greater suicide risk than did younger patients.32 Thompson et al. reported that the relative risk of suicide deaths in the VA was 2.3 for Whites compared with African Americans,26 which is the same as relative risk of suicide between Whites and African Americans in the general population.6 However, among former VA medical center psychiatric inpatients, Desai et al. reported relative risks for suicide of only 1.5 among men compared with those among women, but relative risks of 3.8 among Whites compared with those among African Americans33—a race disparity that is substantially higher than that observed in the general population.6Several investigators have noted the importance of determining risk profiles for the particular population being targeted.26 Clinicians use this information as “background knowledge” when completing suicide assessments. Administrators also need this information to be able to design, evaluate, and target interventions to decrease suicide risks.In this study, we examined associations between demographic and clinical characteristics and risk of suicide among veterans treated for depression in the VA health system. Based on previous studies of veterans, we hypothesized that the differential risks for suicide associated with being older, male, White, and having medical comorbidities would be smaller within the depressed VA patient population than has been reported for the general population. We also hypothesized that patients with depression and comorbid substance use, PTSD, or a recent psychiatric hospitalization would be at higher risk for suicide than would be patients who have depression without these psychiatric comorbidities.     

Characteristics of veterans using Veterans Affairs community-based outpatient clinics

In the late 1990s, the Department of Veterans Affairs (VA) initiated a system of community-based outpatient clinics to enhance access to care. The purpose of this study was to explore factors that may be related to veterans' desire to transfer care from VA-based to community clinics. Among 1,452 veterans who were currently receiving VA clinic care and were eligible for care in two community-based clinics in rural Minnesota, 85 percent responded to a survey. Fifty-four percent of respondents requested community-based outpatient clinic care. Multivariate analysis revealed that veterans less satisfied with VA care were more likely to request a transfer to a community clinic, whereas Veterans SF-36 scale scores were not strongly associated with request for community-based outpatient clinic care. Veterans who had more VA clinic visits were less likely to request community-based outpatient clinic care. The likelihood of requesting also varied across the VA facilities and by VA eligibility level.     

Suicide rates in psychiatric in-patients: an application of record linkage to mental health research

OBJECTIVE: To study trends in the rate of suicide in psychiatric patients in Western Australia. To examine the associations of suicide with demographic and clinical factors. METHODS: A population-based cohort of 52,010 individuals whose first psychiatric admission occurred in 1980-95 was identified from the Health Services Research Linked Database. There were 471 deaths by suicide by 31 December 1995. Age standardised suicide rates per 1,000 person-years at risk were calculated. Suicide rates in the first year after a patient's first admission were also examined and a proportional hazards regression analysis was performed to examine risk factors for suicide. RESULTS: Male psychiatric patients were 3.4 times more likely to commit suicide than female patients (95% CI 2.76-4.24). Younger patients were at higher risk than older patients, and patients with extended periods of in-patient treatment were at more than double the risk of short-stay patients. Over the 16-year period, the rate of suicide in the first year after first psychiatric admission was found to increase by 3.4% a year (95% CI -0.7-7.6%). CONCLUSIONS: The findings confirm that psychiatric patients are at high risk of suicide. Patient outcomes in terms of risk of suicide after hospital discharge have deteriorated. IMPLICATIONS: Improvements are needed in the provision of community support to high risk psychiatric patients. Further work should be done to identify patients at highest risk of suicide.     

Time Trends and Predictors of Suicide Among Mental Health Outpatients in the Department of Veterans Affairs

Using merged Veterans Affairs (VA) and National Death Index data, this study examined changes in suicide rate among three cohorts of VA mental health outpatients during a time of extensive bed closures and system-wide reorganization (1995, N = 76,105; 1997, N = 81,512; and 2001, N = 102,184). There was a decreasing but nonsignificant trend in suicide rates over time—13.2, 11.4, and 10.3 per 10,000 person-years, respectively. Multivariable predictors of suicide included both younger and older ages (U-shaped association). At the facility level, there was an association between greater per capita outpatient mental health expenditure and reduced suicide risk. The model also showed a protective effect associated with increased mental health spending on inpatient services, and that outpatients at facilities with larger mental health programs, as measured by patient volume, were at greater risk for suicide than were those in smaller programs. Although more chronic patients may have been underrepresented to some extent as a result of the sampling methodology, these findings provide generally reassuring evidence that overall suicide rates have not been adversely affected by VA system changes. Nevertheless, they highlight the importance of funding for mental health services as well as the implications of changing demographics in the VA population.     

Where do elderly veterans obtain care for acute myocardial infarction: Department of Veterans Affairs or Medicare?

OBJECTIVE: To examine Department of Veterans Affairs (VA) and Medicare hospitalizations for elderly veterans with acute myocardial infarction (AMI), their use of cardiac procedures in both systems, and patient mortality. DATA SOURCES: Merging of inpatient discharge abstracts obtained from VA Patient Treatment Files (PTF) and Medicare MedPAR Part A files. STUDY DESIGN: A retrospective cohort study of male veterans 65 years or older who were prior users of the VA medical system (veteran-users) and who were initially admitted to a VA or Medicare hospital with a primary diagnosis of AMI at some time from January 1, 1988 through December 31, 1990 (N = 25,312). We examined the use of cardiac catheterization, coronary bypass surgery, and percutaneous transluminal coronary angioplasty in the 90 days after initial admission for AMI in both VA and Medicare systems, and survival at 30 days, 90 days, and one year. Other key measures included patient age, race, marital status, comorbidities, cardiac complications, prior utilization, and the availability of cardiac technology at the admitting hospital. PRINCIPAL FINDINGS: More than half of veteran-users (54 percent) were initially hospitalized in a Medicare hospital when they suffered an AMI. These Medicare index patients were more likely to receive cardiac catheterization (OR 1.24, 95% C.I. 1.17-1.32), coronary bypass surgery (OR 2.01, 95% C.I. 1.83-2.20), and percutaneous transluminal coronary angioplasty (OR 2.56, 95% C.I. 2.30-2.85) than VA index patients. Small proportions of patients crossed over between systems of care for catheterization procedures (VA to Medicare = 3.3%, and Medicare to VA = 5.1%). Many VA index patients crossed over to Medicare hospitals to obtain bypass surgery (27.6 percent) or coronary angioplasty (12.1 percent). Mortality was not significantly different between veteran-users who were initially admitted to VA versus Medicare hospitals. CONCLUSIONS: Dual-system utilization highlights the need to look at both systems of care when evaluating access, costs, and quality either in VA or in Medicare systems. Policy changes that affect access to and utilization of one system may lead to unpredictable results in the other.     

Why are suicide rates rising in young men but falling in the elderly?-- a time-series analysis of trends in England and Wales 1950-1998

Suicide rates doubled in males aged <45 in England and Wales between 1950 and 1998, in contrast rates declined in older males and females of all ages. Explanations for these divergent trends are largely speculative, but social changes are likely to have played an important role. We undertook a time-series analysis using routinely available age- and sex-specific suicide, social, economic and health data, focussing on the two age groups in which trends have diverged most-25-34 and 60+ year olds. Between 1950 and 1998 there were unfavourable trends in many of the risk factors for suicide: rises in divorce, unemployment and substance misuse and declines in births and marriage. Whilst economic prosperity has increased, so too has income inequality. Trends in suicide risk factors were generally similar in both age-sex groups, although the rises in divorce and markers of substance misuse were most marked in 25-34 year olds and young males experienced the lowest rise in antidepressant prescribing. Statistical modelling indicates that no single factor can be identified as underlying recent trends. The factors most consistently associated with the rises in young male suicide are increases in divorce, declines in marriage and increases in income inequality. These changes have had little effect on suicide in young females. This may be because the drugs commonly used in overdose-their favoured method of suicide-have become less toxic or because they are less affected by the factors underlying the rise in male suicide. In older people declines in suicide were associated with increases in gross domestic product, the size of the female workforce, marriage and the prescribing of antidepressants. Recent population trends in suicide appear to be associated with by a range of social and health related factors. It is possible that some of the patterns observed are due to declining levels of social integration, but such effects do not appear to have adversely influenced patterns in older generations.