Posttraumatic Stress Disorder and Incident Heart Failure Among a Community-Based Sample of US Veterans

Objectives. We investigated the association between posttraumatic stress disorder (PTSD) and incident heart failure in a community-based sample of veterans.Methods. We examined Veterans Affairs Pacific Islands Health Care System outpatient medical records for 8248 veterans between 2005 and 2012. We used multivariable Cox regression to estimate hazard ratios and 95% confidence intervals for the development of heart failure by PTSD status.Results. Over a mean follow-up of 7.2 years, veterans with PTSD were at increased risk for developing heart failure (hazard ratio [HR] = 1.47; 95% confidence interval [CI] = 1.13, 1.92) compared with veterans without PTSD after adjustment for age, gender, diabetes, hyperlipidemia, hypertension, body mass index, combat service, and military service period. Additional predictors for heart failure included age (HR = 1.05; 95% CI = 1.03, 1.07), diabetes (HR = 2.54; 95% CI = 2.02, 3.20), hypertension (HR = 1.87; 95% CI = 1.42, 2.46), overweight (HR = 1.72; 95% CI = 1.25, 2.36), obesity (HR = 3.43; 95% CI = 2.50, 4.70), and combat service (HR = 4.99; 95% CI = 1.29, 19.38).Conclusions. Ours is the first large-scale longitudinal study to report an association between PTSD and incident heart failure in an outpatient sample of US veterans. Prevention and treatment efforts for heart failure and its associated risk factors should be expanded among US veterans with PTSD.Posttraumatic stress disorder (PTSD) is a psychiatric illness that affects approximately 7.7 million Americans aged older than 18 years.1 PTSD typically results after the experience of severe trauma, and veterans are at elevated risk for the disorder. The National Vietnam Veterans Readjustment Study reported the prevalence of PTSD among veterans who served in Vietnam as 15.2% among men and 8.1% among women.2 In fiscal year 2009, nearly 446 045 Veterans Administration (VA) patients had a primary diagnosis of PTSD, a threefold increase since 1999.3 PTSD is of growing clinical concern as evidence continues to link psychiatric illnesses to conditions such as arthritis,4 liver disease,5 digestive disease,6 and cancer.6 When the postwar health status of Vietnam veterans was examined, those with PTSD had higher rates of diseases of the circulatory, nervous, digestive, musculoskeletal, and respiratory systems.7The evidence linking PTSD to coronary heart disease (CHD) is substantial.8–10 Veterans with PTSD are significantly more likely to have abnormal electrocardiograph results, myocardial infarctions, and atrioventricular conduction deficits than are veterans without PTSD.11 In a study of 605 male veterans of World War II and the Korean War, CHD was more common among veterans with PTSD than among those without PTSD.12 Worldwide, adults exposed to the disaster at Chernobyl experienced increased rates of CHD up to 10 years after the event,13 and studies of stressors resulting from the civil war in Lebanon found elevated CHD mortality.14,15Although the exact biological mechanism by which PTSD contributes to CHD remains unclear, several hypotheses have been suggested, including autonomic nervous system dysfunction,16 inflammation,17 hypercoagulability,18 cardiac hyperreactivity,19 altered neurochemistry,20 and co-occurring metabolic syndrome.16 One of the hallmark symptoms of PTSD is hyperarousal,21 and the neurobiological changes brought on from sustained sympathetic nervous system activation affect the release of neurotransmitters and endocrine function.22 These changes have negative effects on the cardiovascular system, including increased blood pressure, heart rate, and cardiac output.22,23Most extant literature to date examining cardiovascular sequelae has shown a positive association between PTSD and coronary artery disease.8–10 Coronary artery disease is well documented as one of the most significant risk factors for future development of heart failure.24 Despite burgeoning evidence for the role of PTSD in the development of coronary artery disease, there are few studies specifically exploring the relationship between PTSD and heart failure. Limited data suggest that PTSD imparts roughly a threefold increase in the odds of developing heart failure in both the general population5 and in a sample of the elderly.25 These investigations, however, have been limited by cross-sectional study design, a small proportion of participants with PTSD, and reliance on self-reported measures for both PTSD and heart failure.5,25 Heart failure is a uniquely large public health issue, as nearly 5 million patients in the United States are affected and there are approximately 500 000 new cases each year.26 Identifying predictors of heart failure can aid in early detection efforts while simultaneously increasing understanding of the mechanism behind development of heart failure.To mitigate the limitations of previous investigations, we undertook a large-scale prospective study to further elucidate the role of prevalent PTSD and development of incident heart failure among veterans, while controlling for service-related and clinical covariates. Many studies investigating heart failure have relied on inpatient records; we leveraged outpatient records to more accurately reflect the community burden of disease.     

The Effects of Misclassification Biases on Veteran Suicide Rate Estimates

Objectives. We assessed the impact that possible veteran suicide misclassification biases (i.e., inaccuracy in ascertainment of veteran status on the death certificate and misclassification of suicide as other manner of death) have on veteran suicide rate estimates.Methods. We obtained suicide mortality data from the 2003–2010 National Violent Death Reporting System and the 2003–2010 Department of Defense Casualty Analysis System. We derived population estimates from the 2003–2010 American Community Survey and 2003–2010 Department of Veterans Affairs data. We computed veteran and nonveteran suicide rates.Results. The results showed that suicide rates were minimally affected by the adjustment for the misclassification of current military personnel suicides as veterans. Moreover, combining suicides and deaths by injury of undetermined intent did not alter the conclusions.Conclusions. The National Violent Death Reporting System is a valid surveillance system for veteran suicide. However, more than half of younger (< 25 years) male and female suicides, labeled as veterans, were likely to have been current military personnel at the time of their death and misclassified on the death certificate.Rapidly rising suicide rates among current and former US military personnel have generated nationwide concern. There is increasing evidence that veterans of both genders are at greater risk for suicide than their nonveteran counterparts.1–5 Moreover, veterans who receive care through the Veterans Health Administration (VHA) have higher rates of suicide than non–VHA users6–8 and nonveterans.9 Furthermore, younger veterans (< 35 years) have the highest risk of suicide.1,4,10,11 But some studies have found no connection between military service and suicide.12–14These conflicting findings have been attributed in part to misclassification biases. Previous research15,16 and the Blue Ribbon Work Group’s report17 have noted that suicide mortality estimates are often compromised by 2 main sources of misclassification: (1) inaccuracy in ascertainment of veteran status on the death certificate and (2) misclassification of suicides as other manners of death. The first bias refers to the designation of veteran status on the death certificate: “ever served in the armed forces.” The argument is that the item does not distinguish between military personnel currently serving on active duty, in the National Guard, or in the Reserves, and veterans who have separated from the service. However, recent evidence shows high correlation between death certificate and self-reported veteran status (agreement rate = 95%18), proxy-derived information (κ = 0.914), and VHA records (sensitivity = 95%; specificity = 91%19). Nonetheless, the validity of the designation of veteran status on the death certificate may differ by age.20 It is likely that the death certificate item would be accurate for older veterans but not necessarily for younger decedents. As a consequence, suicide rate estimates derived for younger veterans are likely to be more affected by this bias resulting in overestimation. This concern is particularly important because the relative risk for suicide is highest among younger veterans.The second bias refers to self-inflicted death misclassified as other manners of death such as injuries of undetermined intent. Previous studies have shown evidence that veterans’ deaths relative to nonveterans’ are less likely to be classified as injuries of undetermined intent.5,17 Deceased veterans may be more likely than nonveterans to be classified as suicides for several reasons, including higher use of firearms (more likely to be classified as suicide than another method), greater availability of accurate information for death certificates among VHA users, and implicit societal beliefs that veterans are at elevated risk for suicide. In this case, misclassification bias (chiefly for nonveterans) may account for the apparently higher suicide rates found in the veteran population.Few, if any, studies have attempted to test for the effect of these misclassification biases on suicide rate estimation in the veteran and nonveteran populations. Yet this information is essential for surveillance efforts and suicide prevention among veterans. Therefore, the aims of this study were (1) to assess the effect of excluding current military personnel (listed as veterans on the death certificate) from veteran suicide rate estimates by age and gender and (2) to test the effect of including deaths by injury of undetermined intent as suicides on suicide rate estimates.     

Socioeconomic Disparities in Sleep Duration Among Veterans of the US Wars in Iraq and Afghanistan

We characterized socioeconomic disparities in short sleep duration, which is linked to multiple adverse health outcomes, in a population-based sample of veterans of the US wars in Iraq and Afghanistan who had interacted with the Minneapolis VA Health Care System. Lower reported household assets, lower food security, greater reported discrimination, and lower subjective social status were significantly (P < .05) related to less sleep, even after adjusting for demographics, health behaviors, and posttraumatic stress disorder diagnosis. Assisting veterans to navigate social and socioeconomic stressors could promote healthful sleep and overall health.Inadequate sleep is common, with just more than 1 in 4 adults in the United States reporting that they average 6 or less hours of sleep per night.1 Short sleep duration (commonly defined as < 6–8 hr per day) has been linked to serious health problems, including injury,2–4 cardiovascular disease and associated risk factors,5–14 poor mental health,15–19 and all-cause mortality.20–27 Disparities exist in which Blacks28–32 and those who are of lower socioeconomic status (SES)33 are at increased risk for sleep deficiency. Military members and veterans, especially those who have been deployed, appear to be at greater risk for short sleep duration.34–37 This risk may relate to aspects of the deployment cycle such as irregular schedule and shift work, stress, mental health issues such as posttraumatic stress disorder (PTSD), and injury. Of further concern is that short sleep duration and its risk factors may be part of a mutually reinforcing cycle. Indeed, research has indicated that predeployment short sleep duration may contribute to the development of PTSD.38,39In this study, we sought to characterize socioeconomic disparities in short sleep duration among veterans who served in the US wars in Iraq or Afghanistan and to test whether, independent of other known risk factors, socioeconomic obstacles, such as having low income or experiencing discrimination, are linked to short sleep duration.     

Brief Intervention and Follow-Up for Suicidal Patients With Repeat Emergency Department Visits Enhances Treatment Engagement

We implemented an innovative, brief, easy-to-administer 2-part intervention to enhance coping and treatment engagement. The intervention consisted of safety planning and structured telephone follow-up postdischarge with 95 veterans who had 2 or more emergency department (ED) visits within 6 months for suicide-related concerns (i.e., suicide ideation or behavior). The intervention significantly increased behavioral health treatment attendance 3 months after intervention, compared with treatment attendance in the 3 months after a previous ED visit without intervention. The trend was for a decreasing hospitalization rate.Approximately 400 000 to 500 000 US emergency department (ED) visits occur annually for suicide attempts.1,2 The ED is a primary site for the treatment of suicide attempts, and for many patients, ED interventions are the only treatment they receive.3 As many as 60% of suicidal ED patients are stabilized and discharged directly to outpatient care.1,2 Unfortunately, only 50% of these patients follow up on their referrals and attend 1 or more outpatient behavioral health sessions.3 Consequently, costly repeat ED visits and additional suicidal behavior are frequent. As many as 30% of patients presenting to the ED for a suicide-related concern return to the ED for another suicide-related concern within 1 year,4 and 2-year follow-up suicide mortality rates among suicide attempters are estimated at 2%.5 Recurrent suicidal behavior and limited outpatient treatment engagement are similarly significant problems among veterans,6–8 who may be at greater risk for suicide than civilians despite more recent reductions.9,10 Given that the ED is the only place where many suicidal individuals receive care, it could be an important intervention site to increase outpatient treatment engagement and reduce repeat suicidal behavior, ED visits, and hospitalizations.11     

Effects of Repeated Deployment to Iraq and Afghanistan on the Health of New Jersey Army National Guard Troops: Implications for Military Readiness

Objectives. We assessed the effects of prior military service in Iraq or Afghanistan on the health of New Jersey Army National Guard members preparing for deployment to Iraq.Methods. We analyzed anonymous, self-administered predeployment surveys from 2543 National Guard members deployed to Iraq in 2008. We used bivariate and multivariate analyses to measure the effects of prior service in Afghanistan (Operation Enduring Freedom [OEF]) or Iraq (Operation Iraqi Freedom [OIF]) on mental and physical health.Results. Nearly 25% of respondents reported at least 1 previous OEF or OIF deployment. Previously deployed soldiers were more than 3 times as likely as soldiers with no previous deployments to screen positive for posttraumatic stress disorder (adjusted odds ratio [AOR] = 3.69; 95% confidence interval [CI] = 2.59, 5.24) and major depression (AOR = 3.07; 95% CI = 1.81, 5.19), more than twice as likely to report chronic pain (AOR = 2.20; 95% CI = 1.78, 2.72) and more than 90% more likely to score below the general population norm on physical functioning (AOR = 1.94; 95% CI = 1.51, 2.48).Conclusions. Repeated OEF and OIF deployments may adversely affect the military readiness of New Jersey National Guard combat soldiers.The mental and physical health consequences of service in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) have been well documented. Studies report rates of posttraumatic stress disorder (PTSD) among returning soldiers ranging from 4%¹ to 31%² and rates of depression ranging from 3%³ to 25%,⁴ with rates varying by diagnostic criteria, military population, deployment location, and time since deployment. Traumatic brain injury has been identified in 19% of returning troops.⁵ Those experiencing multiple deployments are most at risk, with the Office of the US Army Surgeon General⁶ reporting mental health problems in 11.9% of those with 1 deployment, 18.5% with 2 deployments, and 27.2% with 3 or 4 deployments. National Guard and Reserve troops are more vulnerable than active-duty troops, with 35.5% of Guard and Reserve troops at mental health risk 6 months after deployment compared with 27.1% of active-duty soldiers.⁷ With respect to physical health, the OEF and OIF conflicts have produced the highest ratio of wounded to killed of any previous military operation (approximately 7:1), with over 33 170 wounded in action as of October 2008.⁸ Orthopedic injuries are the most common class of injury⁹ and pain one of the most frequently reported symptoms.^10,11Although the adverse health consequences of service in OEF and OIF have focused public attention on the medical needs of returning veterans, concern has also centered on the military readiness of our fighting force, given the unprecedented pattern of repeat deployments unique to this particular conflict. Of all soldiers deployed to Iraq since 2003, approximately 38% have been deployed more than once and 10% have been deployed 3 times or more.¹² The Department of Defense and state National Guard authorities conduct extensive pre- and postdeployment screenings to ensure that only “healthy and medically prepared”¹³ soldiers are deployed to combat. However, because most studies of veterans of OEF and OIF to date have focused on postdeployment populations, we have little information about the effectiveness of military programs in screening seriously impaired soldiers out of the eligibility pool for future deployment. Postdeployment studies, moreover, are likely to include many medically compromised soldiers who were subsequently disqualified from, or voluntarily left, active military service before being recalled to duty. In the absence of large-scale predeployment health studies, we have no information on the effect of multiple deployments on the fitness of soldiers returning to combat. The 1 published study identified by the authors to date that examined predeployment health status⁷ included a small sample of combat veterans (n = 173) with mixed histories of previous service: some had served in Afghanistan, some in conflicts other than OEF and OIF, but none in Iraq, even though, until recently, Iraq war veterans experienced substantially greater combat stress than veterans from Afghanistan.¹⁴We explored the effects of multiple deployments on the mental and physical health of New Jersey Army National Guard troops preparing for deployment to Iraq. Specifically, we (1) compared the health status of soldiers with previous OEF and OIF deployments with that of soldiers experiencing their first deployment, (2) examined associations between deployment status and health after controlling for possible confounding factors, and (3) compared the present survey with New Jersey''s predeployment health assessment on identification rates of key mental health problems.     

Elevated Risk of Posttraumatic Stress in Sexual Minority Youths: Mediation by Childhood Abuse and Gender Nonconformity

Objectives. We examined whether lifetime risk of posttraumatic stress disorder (PTSD) was elevated in sexual minority versus heterosexual youths, whether childhood abuse accounted for disparities in PTSD, and whether childhood gender nonconformity explained sexual-orientation disparities in abuse and subsequent PTSD.Methods. We used data from a population-based study (n = 9369, mean age = 22.7 years) to estimate risk ratios for PTSD. We calculated the percentage of PTSD disparities by sexual orientation accounted for by childhood abuse and gender nonconformity, and the percentage of abuse disparities by sexual orientation accounted for by gender nonconformity.Results. Sexual minorities had between 1.6 and 3.9 times greater risk of probable PTSD than heterosexuals. Child abuse victimization disparities accounted for one third to one half of PTSD disparities by sexual orientation. Higher prevalence of gender nonconformity before age 11 years partly accounted for higher prevalence of abuse exposure before age 11 years and PTSD by early adulthood in sexual minorities (range = 5.2%–33.2%).Conclusions. Clinicians, teachers, and others who work with youths should consider abuse prevention and treatment measures for gender-nonconforming children and sexual minority youths.Posttraumatic stress disorder (PTSD) has severe sequelae that can particularly affect youths by disrupting the achievement of adulthood milestones. PTSD negatively affects career prospects through elevated risk of substance abuse1 and unemployment,2 reduces educational attainment by increasing the risk of school dropout,2 and affects family formation by increasing the risk of relationship instability and adolescent pregnancy.2 Studies have also indicated that the course of PTSD is chronic in one third of cases2; identifying risk factors in children and early adulthood is therefore particularly important for public health because PTSD in adolescence or early adulthood may affect health and well-being throughout adulthood. Research indicates that lesbian, gay, and bisexual youths have higher prevalence of mental health problems than heterosexuals, including anxiety, depression, and suicidality3–6; to our knowledge, however, no studies of youths have examined the association between sexual orientation and probable PTSD in samples including both sexual minorities and heterosexuals.Childhood abuse greatly increases risk of developing PTSD.7–9 Child abuse can directly trigger PTSD,10 increase the risk of exposure to subsequent stressful events,8 and increase the conditional risk of developing PTSD following exposure to subsequent stressful events.11,12 Sexual minorities—lesbians, gay men, bisexuals, and “mostly heterosexuals”—experience higher rates of childhood abuse than do heterosexuals.13–18 Thus, disparities in childhood abuse may be a cause of higher prevalence of PTSD among sexual minority youths compared with heterosexuals.Additionally, gender-nonconforming appearance and behavior in childhood is more common among persons who will later have a minority sexual orientation.19–21 Differences in gender nonconformity may contribute to sexual-orientation disparities in maltreatment in early and middle childhood, before sexual identity has developed, as childhood gender nonconformity has been associated with parental rejection, harassment, and physical and verbal victimization related to sexual orientation.22–26We examine whether there are disparities in lifetime probable PTSD in youths by sexual orientation and whether greater exposure to child abuse may account for differences in PTSD. Additionally, we examine whether gender nonconformity accounts for higher prevalence of abuse before age 11 years and possible increased risk of PTSD among sexual minorities compared with heterosexuals. Because gender nonconformity has been associated with psychosocial stressors other than childhood abuse—namely, harassment and bullying—nonconformity may increase the risk of PTSD above and beyond its possible effects on childhood abuse. Given the high population prevalence of PTSD, its chronicity, and its associated impairment,2 identifying factors that put children and youths at risk for PTSD is vital.Although several studies have separately noted elevated prevalence of both child maltreatment and adulthood PTSD in sexual minorities,17,22 to date, only 1 study in adults has shown that higher rates of childhood abuse may partially account for higher prevalence of PTSD in sexual minorities.15 Very few studies have examined whether childhood gender nonconformity might explain elevated exposure to child abuse before adolescence24,27 or probable PTSD among sexual minorities. We examine possible sexual-orientation disparities in childhood abuse and PTSD separately by gender because studies have found gender differences in PTSD and childhood abuse.28,29 We further examine possible gender-by-sexual-orientation interactions in risk of PTSD and abuse.     

Longitudinal Associations Between Types of Childhood Trauma and Suicidal Behavior Among Substance Users: A Cohort Study

Objectives. We examined the longitudinal associations between different types and severities of childhood trauma and suicide attempts among illicit drug users.Methods. Data came from 2 prospective cohort studies of illicit drug users in Vancouver, Canada, in 2005 to 2010. We used recurrent event proportional means models to estimate adjusted and weighted associations between types and severities of childhood maltreatment and suicide attempts.Results. Of 1634 participants, 411 (25.2%) reported a history of suicidal behavior at baseline. Over 5 years, 80 (4.9%) participants reported 97 suicide attempts, a rate of 2.6 per 100 person-years. Severe to extreme levels of sexual abuse (adjusted hazard ratio [AHR] = 2.5; 95% confidence interval [CI] = 1.4, 4.4), physical abuse (AHR = 2.0; 95% CI = 1.1, 3.8), and emotional abuse (AHR = 3.5; 95% CI = 1.4, 8.7) predicted suicide attempts. Severe forms of physical and emotional neglect were not significantly associated with an increased risk of suicidal behavior.Conclusions. Severe sexual, physical, and emotional childhood abuse confer substantial risk of repeated suicidal behavior in adulthood. Illicit drug users require intensive secondary suicide prevention efforts, particularly among those with a history of childhood trauma.The global burden of suicide is considerable and is the tenth leading cause of death worldwide, with annual mortality estimated at 14.5 deaths per 100 000.1 Suicide is a major and preventable public health problem among young people aged 15 to 24 years in Canada (second leading cause of death2) and the United States (third leading cause of death3). Each year, approximately 1 million adults in the United States attempt suicide, resulting in 35 000 deaths and more than 320 000 emergency department visits.4 The societal, financial, and public health burdens associated with suicide are therefore substantial.The epidemiology of suicide is multifactorial and complex.1 The 2012 National Strategy for Suicide Prevention identifies several groups at particularly high risk of suicide in the United States, including individuals with a past history of suicidal behavior, members of the armed forces and veterans, American Indians/Alaska Natives, men in midlife, and individuals in justice and child welfare settings.5 Of public health concern in Canada, suicide rates among Aboriginal Peoples are 2 to 3 times that observed in the nonaboriginal population.6,7 A large body of literature has also demonstrated high rates of suicidal behavior among lesbian, gay, bisexual, and transgender populations.8–10People who use illicit drugs are particularly vulnerable to suicidal ideation and behavior, and suicide is a leading cause of death in drug-using populations.11,12 Furthermore, the relationship between substance abuse and increased suicide risk has been well established.13,14 A growing body of research has examined various correlates of suicide attempts among drug users. In treatment-seeking samples of drug and alcohol abusers, major depressive disorder and other psychiatric conditions (e.g., borderline personality disorder, anxiety, agoraphobia) have been associated with a history of suicide attempts.15–20 Furthermore, markers of social disadvantage and marginalization, such as unemployment and homelessness, are associated with a heightened risk of suicide and are common among drug users.11 Specific typologies of drug use have also been linked to a greater likelihood of attempting suicide, including longer durations of substance use,18,21 polysubstance use,20,22 and injection methamphetamine use.23In recent years, childhood maltreatment has emerged as a consistent correlate of suicidal ideation and behavior among drug users.19,24,25 These studies provide preliminary evidence that childhood abuse and neglect are important determinants of suicide in drug-using populations. However, it is unclear whether certain types of childhood maltreatment are more strongly associated with suicidal behavior than others. The majority of studies to date have examined suicide and early traumatic experiences among clinical samples, which may be subject to selection bias if being in treatment is a common effect of both exposure (i.e., childhood maltreatment) and other, unmeasured factors that may cause suicidal behavior (e.g., genetic or familial susceptibility to psychiatric disorders such as depression). To our knowledge no studies have prospectively examined suicidal behavior in a community-recruited cohort of drug users. Drug-using cohorts are particularly well suited to examining the relationship between childhood maltreatment and recurrent suicidal behavior because of their high rates of suicide. We used recurrent event survival models to determine the longitudinal associations between exposure to different types and severities of childhood trauma and suicide attempts, measured prospectively in a cohort of drug users in Vancouver, British Columbia.     

Suicide Risk in Nursing Homes and Assisted Living Facilities: 2003–2011

Objectives. We investigated the epidemiology of suicide among adults aged 50 years and older in nursing homes and assisted living facilities and whether anticipating transitioning into long-term care (LTC) is a risk factor for suicide.Methods. Data come from the Virginia Violent Death Reporting System (2003–2011). We matched locations of suicides (n = 3453) against publicly available resource registries of nursing homes (n = 285) and assisted living facilities (n = 548). We examined individual and organizational correlates of suicide by logistic regression. We identified decedents anticipating entry into LTC through qualitative text analysis.Results. Incidence of suicide was 14.16 per 100 000 in nursing homes and 15.66 in the community. Better performance on Nursing Home Compare quality metrics was associated with higher odds of suicide in nursing homes (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.21, 3.14). Larger facility size was associated with higher suicide risk in assisted living facilities (OR = 1.01; 95% CI = 1.00, 1.01). Text narratives identified 38 decedents anticipating transitioning into LTC and 16 whose loved one recently transitioned or resided in LTC.Conclusions. LTC may be an important point of engagement in suicide prevention.Approximately 40% of adults aged 65 years and older will need skilled residential nursing care at some point in their lifetime.1 Older adults have among the highest suicide risks in the United States2; the rate of suicide among men aged 65 years and older is 30 per 100 000; by contrast, it is 7 per 100 000 for men younger than 25 years.3 A key element of suicide prevention is the identification of points of engagement to interact with potential victims.4 Risk factors for suicide, such as social isolation, depression, and functional impairment, are common among long-term care (LTC) residents,5–7 and these facilities may therefore be important locations for preventing suicide among older adults. Indeed, the 1987 Nursing Home Reform Act mandated screening of LTC admissions to facilitate appropriate placement and increased psychiatric services,8 and the Minimum Data Set 3.0 includes a mandatory screener for depressive symptoms and suicidal ideation.9 Nearly 1.5 million adults reside in nursing homes,10,11 and another 1 million reside in assisted living facilities.12Little is known regarding risk and protective factors for suicide in LTC.13 In 2011 the Substance Abuse and Mental Health Services Administration released a tool kit on preventing suicide in senior-living communities, which notes,

We do not know how many residents of senior living communities attempt suicide or die by suicide. But, we do know that a suicide in a facility . . . profoundly impacts the lives of everyone concerned—residents, families, and staff.^14(p4)

Suicidal ideation is common among LTC residents, with between 5% and 33% reporting ideation (active or passive) within the past month.15 As a result, suicide risk may be substantial in these facilities despite countervailing factors such as regular monitoring by staff and limited access to lethal means. The handful of studies that have compared incidence of completed suicide in LTC to the general community are mixed, with 1 reporting higher16 and another reporting lower17 risk in these settings.Suicidal behavior in LTC likely reflects a combination of factors shared with community cases (e.g., presence of a psychiatric disorder), as well as factors that are unique to LTC (e.g., facility characteristics). For example, bed size (number of beds) and high staff turnover have been associated with higher risk of suicidal behaviors among residents.18,19 However, these studies were conducted in the 1980s, prior to the growth of assisted living,20 which reduces their applicability to modern facilities. Finally, it is unknown whether the transition to LTC, or the process of having a loved one transition, is a risk factor for suicide.21 These transitions often involve a complex interplay of social and psychological factors, including feelings of autonomy, social connectedness, and identity,22,23 and can produce feelings of anxiety, loneliness, and hopelessness because they affect a people’s sense of being at home, which is not simply their physical residence.24 Such transitions have potential implications for the psychological well-being of caregivers of the person moving into LTC as well.25To identify whether LTC settings are important points of engagement for reducing suicide risk among older adults,4,26 we analyzed data from the 2003 to 2011 Virginia Violent Death Reporting System (VVDRS). We aimed to (1) describe the epidemiology of completed suicide in nursing homes and assisted living facilities, (2) examine whether facility characteristics were related to suicide risk, and (3) assess whether the process of transitioning into an LTC facility was associated with suicide.     

Use of a Learning Collaborative to Support Implementation of Integrated Care for Smoking Cessation for Veterans With Posttraumatic Stress Disorder

Objectives. We evaluated the feasibility of incorporating integrated care (IC) for smoking cessation into routine treatment for posttraumatic stress disorder (PTSD) at Department of Veterans Affairs (VA) Medical Centers and the utility of the Learning Collaborative (LC) model in facilitating implementation.Methods. We conducted 2 LCs aimed at implementing IC for smoking cessation using multidisciplinary teams comprising 70 staff members from 12 VA PTSD clinics. Using questionnaires, we evaluated providers’ perceptions of the LC methodology and the effectiveness and feasibility of routine IC delivery. We assessed number of providers delivering and patients receiving IC using medical record data.Results. More than 85% of participating VA staff considered the LC to be an effective training and implementation platform. The majority thought IC effectively addressed an important need and could be delivered in routine PTSD care. All LC participants who planned to deliver IC did so (n = 52). Within 12 months of initial training, an additional 46 locally trained providers delivered IC and 395 veterans received IC.Conclusions. The LC model effectively facilitated rapid and broad implementation of IC. Facilitators and barriers to sustained use of IC are unknown and should be identified to understand how best to promote ongoing access to evidence-based treatment for smoking cessation in mental health populations.Despite gains in reducing tobacco use among the general public, nicotine dependence continues to disproportionately affect individuals with mental illness, including those with posttraumatic stress disorder (PTSD), a prevalent mental health disorder1 associated with heavy cigarette consumption and low cessation rates.2 One in 10 current US smokers have had PTSD at some point in their lives.2 Tobacco dependence likely contributes to the high mortality,3 morbidity,4 and health care costs5 of persons with PTSD. Recent epidemiological studies, although unable to elucidate causal pathways unequivocally, strongly suggest that smoking cessation reduces risk for suicidal ideation,6 depression,7,8 and anxiety,9 emphasizing the critical importance for cessation among those with PTSD and other mental health conditions. Thus, effective cessation treatment interventions and delivery systems are needed to reach this population.To address this need within the Veterans Health Administration, McFall et al.10 developed integrated care (IC) for smoking cessation, which incorporates guideline-based cessation treatment into mental health care for veterans with PTSD. IC is delivered by veterans’ PTSD providers, capitalizing on the existing therapeutic relationship between provider and patient. A randomized trial at 10 Department of Veterans Affairs (VA) Medical Centers, VA Cooperative Study No. 519 (CSP 519), found that, compared with referral to specialized smoking cessation clinics, IC improved cessation outcomes among veterans with PTSD without detracting from mental health treatment.10Although providers who participated in CSP 519 held positive views of IC and supported delivering cessation treatment in mental health care,11 most did not continue delivering IC at the study’s conclusion (C. Wallace, PhD, unpublished data, August 2011). Such a finding is unsurprising given that the use of evidence-based treatments in mental health remains sparse and inconsistent outside of academic settings.12,13 The challenge of making best practice usual practice has been identified as a major public health priority.12,14 Information dissemination and training remain 2 of the most widely used strategies for attempting to spread new practices13,15 but are insufficient for ensuring broad and sustained use of evidence-based treatments; longer-term multilevel implementation strategies are necessary to overcome numerous and complex barriers to adoption.15–17Quality collaboratives are one methodology used to support health care system change and improve quality of care.18–21 The Breakthrough Series is a quality collaborative model that brings together multidisciplinary teams from different organizations with recognized experts to work in a structured way to accelerate spread of best practices.22 The National Center for Child Traumatic Stress’s Learning Collaborative (LC) Model, an adaptation of the Breakthrough Series, supports rapid delivery and sustained use of effective treatments in community settings23 by melding best practices in training and consultation with quality improvement methods.In 2010, the VA partnered with the Duke Evidence-Based Practice Implementation Center to conduct an LC to implement IC in 6 Veterans Affairs PTSD clinics, followed by a second LC with 6 additional Veterans Affairs PTSD clinics in 2012. The objective of this project evaluation was to assess the feasibility of delivering IC as part of routine PTSD care and the utility of the LC model in facilitating IC implementation. Specifically, we examined whether (1) VA staff actively participated in the collaborative and considered LC methodology useful in supporting IC implementation; (2) collaborative participation resulted in rapid delivery of IC (i.e., delivery within 3 months of training) and continued use of the intervention after LC completion; and (3) VA providers viewed IC as compatible with current clinical practices and feasible to deliver as part of routine mental health care for veterans with PTSD. Because troops newly returning from deployment have higher rates of smoking than the general population24,25 and high rates of PTSD,26 it is imperative than an evidence-based treatment such as IC be widely implemented to preserve the physical and mental health of our returning service members.     

Posttraumatic stress disorder and HIV risk among poor, inner-city women receiving care in an emergency department

Objectives. We examined the associations between posttraumatic stress disorder (PTSD) and HIV risk behaviors among a random sample of 241 low-income women receiving care in an urban emergency department.Methods. We recruited participants from the emergency department waiting room during randomly selected 6-hour blocks of time. Multivariate analyses and propensity score weighting were used to examine the associations between PTSD and HIV risk after adjustment for potentially confounding sociodemographic variables, substance use, childhood sexual abuse, and intimate partner violence.Results. A large majority of the sample self-identified as Latina (49%) or African American (44%). Almost one third (29%) of the participants met PTSD criteria. Women who exhibited symptoms in 1 or more PTSD symptom clusters were more likely than women who did not to report having had sex with multiple sexual partners, having had sex with a risky partner, and having experienced partner violence related to condom use in the preceding 6 months.Conclusions. The high rate of PTSD found in this sample and the significant associations between PTSD symptom clusters and partner-related risk behaviors highlight the need to take PTSD into account when designing HIV prevention interventions for low-income, urban women.The relationship between posttraumatic stress disorder (PTSD) and HIV risk behaviors remains relatively underresearched. However, several studies have shown that PTSD is associated with sexual HIV risk behaviors and HIV seropositive status.^1–3 Emergency departments have been identified as the first and primary source of medical treatment of many women infected with or at high risk for HIV^4–6 and for those with high rates of interpersonal violence and trauma, including those suffering from PSTD.^7–11Hutton et al. found that, after adjustment for potentially confounding factors, a PTSD diagnosis was associated with engaging in anal intercourse and exchanging sex for money or drugs in a sample of 177 female inmates.¹² High rates of PTSD have also been found among HIV-positive women,^3,13,14 many of whom have experienced repeated traumas associated with PTSD, such as childhood sexual abuse and intimate partner violence (IPV).^3,13,14 In a study of HIV-positive women, 35% of those with a trauma history met the criteria for PTSD,¹⁵ a rate far exceeding both the lifetime PTSD rate (10.4%) among women in the general population¹⁶ and the PTSD rate (4.6%) in a nationally representative sample of female crime victims.¹⁷The relationship between PTSD and HIV risk behaviors has been found to vary according to the presence of different PTSD symptoms (avoidance, hyperarousal, and reexperiencing trauma). In their study of 64 HIV-positive women and men, Gore-Felton and Koopman found that moderate to severe reexperiencing symptoms were associated with multiple sexual partners and unprotected sex during the preceding 3 months.¹⁸ Individuals with avoidant symptoms were less likely to have engaged in unprotected sex, possibly as a result of deficits in establishing and maintaining intimate partnerships.¹⁸ The presence of hyperarousal symptoms may trigger individuals to seek sexual stimulation and engage in riskier sex, and they may experience difficulty in problem solving and negotiating safe sex.¹⁹The research just described highlights mechanisms of how different PTSD symptom clusters may increase the likelihood of engaging in HIV risks. However, it should also be acknowledged that the relationship may be bidirectional: a traumatic experience (e.g., forced unprotected sex) associated with a risk of HIV may lead to PTSD.Furthermore, research suggests that the relationship between PTSD and HIV risk may be mediated by several factors, including childhood sexual abuse, IPV, and substance abuse. Those who have experienced childhood sexual abuse are at increased risk of developing PTSD,^20–22 engaging in subsequent sexual HIV risk behaviors, and HIV transmission.^3,23 Similarly, IPV has been found to increase the risk of both developing PTSD and engaging in a range of HIV risk behaviors, including unprotected sex,^24–38 sexual practices leading to a high risk of sexually transmitted infections,^6,32,39–42 sex with multiple partners,^31,32,43 trading of sex for money or drugs,^40,44 sex with risky partners,^38,45 and sex with HIV-positive partners.³⁸ Finally, substantial research indicates that drug and alcohol dependencies are associated with both PTSD^46,47 and engaging in a range of HIV risk behaviors.^48–51We examined the relationship between PTSD (and the symptom clusters of avoidance, reexperiencing trauma, and hyperarousal) and sexual HIV risk behaviors in a random sample of 241 women attending an emergency department in a low-income neighborhood of the Bronx, New York. We hypothesized that women who met the criteria for PTSD and the symptom clusters of hyperarousal, reexperiencing trauma, or avoidance would be more likely than women who did not meet these criteria to engage in sexual HIV risk behaviors after adjustment and matching for potentially confounding factors such as sociodemographic characteristics, childhood sexual abuse, substance abuse, and IPV.     

Suicide,Guns, and Public Policy

Suicide is a serious public health concern that is responsible for almost 1 million deaths each year worldwide. It is commonly an impulsive act by a vulnerable individual. The impulsivity of suicide provides opportunities to reduce the risk of suicide by restricting access to lethal means.In the United States, firearms, particularly handguns, are the most common means of suicide. Despite strong empirical evidence that restriction of access to firearms reduces suicides, access to firearms in the United States is generally subject to few restrictions.Implementation and evaluation of measures such as waiting periods and permit requirements that restrict access to handguns should be a top priority for reducing deaths from impulsive suicide in the United States.

“Knowing is not enough; we must apply. Willing is not enough; we must do.”1a

—Johann Wolfgang von Goethe

Suicide is a complex behavior involving the intentional termination of one’s own life. The prevalence, causes, means, and prevention of suicide have been extensively studied and widely reported.1b–4 The World Health Organization (WHO) has identified suicide as a serious public health concern that is responsible for more deaths worldwide each year than homicide and war combined,5 with almost 1 million suicides now occurring annually. In 2007, the Centers for Disease Control and Prevention (CDC) reported that 34 598 Americans died by suicide, far more than the 18 361 murders during the same period.6 Among Americans younger than 40 years, suicide claimed more lives (n = 13 315) than any other single cause except motor vehicle accidents (n = 23 471).6Psychiatric disorders are present in at least 90% of suicide victims, but untreated in more than 80% of these at the time of death.7 Treatment of depression and other mood disorders is therefore a central component of suicide prevention. Other factors associated with suicidal behavior include physical illness, alcohol and drug abuse, access to lethal means, and impulsivity. All of these are potentially amenable to modification or treatment if recognized and addressed. It is important to distinguish between impulsivity as a personality trait and the impulsivity of the act of suicide itself. It is not generally appreciated that suicide is often an impulsive final act by a vulnerable individual8 who may or may not exhibit the features of an impulsive personality.9The impulsivity of suicide provides opportunities to reduce suicide risk by restriction of access to lethal means of suicide (“means restriction”). Numerous medical organizations and governmental agencies, including the WHO,5 the European Union,10 the Department of Health in England,11 the American College of Physicians,12 the CDC,4,13 and the Institute of Medicine,14 have recommended that means restriction be included in suicide prevention strategies. In the United States, firearms are the most common means of suicide,15 with a suicide attempt with a firearm more likely to be fatal than most other means.16 In a study of case fatality rates in the northeastern United States, it was found that 91% of suicide attempts by firearms resulted in death.17 By comparison, the mortality rate was 84% by drowning and 82% by hanging; poisoning with drugs accounted for 74% of acts but only 14% of fatalities. Many studies have shown that the vast majority of those who survive a suicide attempt do not go on to die by suicide. A systematic review of 90 studies following patients after an event of self-harm found that only two pecent went on to die by suicide in the following year and that seven percent had died by suicide after more than nine years.18The availability of guns in the community is an important determinate of suicide attempts by gun.19 Given the public health importance of suicide and what is known about the role of guns in suicide, strategies that keep guns out of the hands of individuals who intend self-harm are worthy of careful scrutiny. Since a handgun (revolver or pistol) is far more likely to be used for suicide than a long gun (shotgun or rifle),20 it may be particularly beneficial to focus suicide prevention efforts on this type of weapon. Only a small minority of states restrict access to handguns by methods such a waiting period, a permit requiring gun safety training, or safe storage of guns in the home. In 2010, US Department of Justice reported that only 15 states had a waiting period for purchasing a handgun.21 Although federal law prohibits the sale of handguns to persons younger than 21 years, in the absence of federal preemption (i.e., the removal of legislative authority from a lower level of government), some states and municipalities allow the sale of handguns to younger individuals.21     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Lesbian,Gay, Bisexual,and Transgender Hate Crimes and Suicidality Among a Population-Based Sample of Sexual-Minority Adolescents in Boston

Objectives. We examined whether past-year suicidality among sexual-minority adolescents was more common in neighborhoods with a higher prevalence of hate crimes targeting lesbian, gay, bisexual, and transgender (LGBT) individuals.Methods. Participants’ data came from a racially/ethnically diverse population-based sample of 9th- through 12th-grade public school students in Boston, Massachusetts (n = 1292). Of these, 108 (8.36%) reported a minority sexual orientation. We obtained data on LGBT hate crimes involving assaults or assaults with battery between 2005 and 2008 from the Boston Police Department and linked the data to the adolescent’s residential address.Results. Sexual-minority youths residing in neighborhoods with higher rates of LGBT assault hate crimes were significantly more likely to report suicidal ideation (P = .013) and suicide attempts (P = .006), than were those residing in neighborhoods with lower LGBT assault hate crime rates. We observed no relationships between overall neighborhood-level violent and property crimes and suicidality among sexual-minority adolescents (P > .05), providing evidence for specificity of the results to LGBT assault hate crimes.Conclusions. Neighborhood context (i.e., LGBT hate crimes) may contribute to sexual-orientation disparities in adolescent suicidality, highlighting potential targets for community-level suicide-prevention programs.Suicide is the second-leading cause of death among all youths worldwide and is the third-leading cause of death among all youths in the United States,1 making the topic of adolescent suicidality a global public health and medical priority.2 One of the most consistent findings in psychiatric epidemiology is the existence of marked sexual orientation disparities in adolescent suicidality (e.g., suicidal ideation and suicide attempts).3 Lesbian, gay, bisexual, and transgender (LGBT, or sexual minority) adolescents are more likely to contemplate,4–6 plan,7 and attempt4,5,8 suicide than their heterosexual peers, and these disparities have been documented across multiple countries.4,5,8Despite the increased attention devoted to eliminating sexual orientation disparities in adolescent suicide, a 2011 report from the Institute of Medicine on LGBT health disparities noted the dearth of research into determinants of adverse health outcomes, including suicidality, within this population.9 To date, research has focused predominantly on individual (e.g., hopelessness, depressed mood),5,8,10–13 peer (e.g., recent suicide attempts by a peer, peer victimization),5,8,14,15 family (e.g., family rejection, family abuse),5,8,13,16–18 and school (e.g., presence of gay–straight alliances in schools, school safety)14,18,19 factors that are associated with suicidality among sexual-minority adolescents, which mirrors research on adolescent suicidality more broadly.20 This research has offered key insights into determinants of suicide risk, but sexual orientation–related disparities in suicidality remain after control for these established risk factors.4,5,8 The persistence of these disparities indicates the importance of considering additional risk factors, including at the social-ecological level, which we define as influences that occur above individuals, peers, families, and schools, including neighborhoods as well as institutional practices and policies (e.g., state policies that ban same-sex marriage).21,22Decades of research in medical sociology and social epidemiology have provided substantial evidence for the role that broad social-ecological factors play in shaping population health,23,24 and Healthy People 2020 recognizes that such factors may be implicated in LGBT health.25 Yet there is a paucity of research into the social-ecological risk factors for suicide among sexual-minority adolescents. In one of the few studies to address this topic, Hatzenbuehler26 created an ecological measure of the social environment surrounding lesbian, gay, and bisexual youths living in counties across the state of Oregon. Compared with lesbian, gay, and bisexual youths living in counties with supportive environments, the risk of attempting suicide was 20% higher among sexual-minority youths in less-supportive environments,26 suggesting that ecological measures can reveal previously unrecognized social determinants of suicide risk among sexual-minority adolescents. However, additional research on other social-ecological factors that may influence suicide risk within this population is warranted.Therefore, in the current study, we used a novel measure of the social environment: neighborhood-level hate crimes targeting LGBT persons. Hate crimes refer to “unlawful, violent, destructive or threatening conduct in which the perpetrator is motivated by prejudice toward the victim’s putative social group.”27^(p480) Evidence demonstrates that many sexual minorities experience hate crimes28; data from the Federal Bureau of Investigation demonstrated that 17.4% of the 88 463 hate crimes between the years of 1995 and 2008 targeted sexual minorities,29 a rate that was more than 8 times what would be expected when one considers the relatively low percentage of sexual minorities in the general population.30The objective of the present study was to examine whether suicidal ideation and suicide attempts among sexual-minority adolescents are more common in neighborhoods with a higher prevalence of hate crimes targeting LGBT individuals. Although there is limited research on the relationship between neighborhood-level LGBT hate crimes and suicidality among sexual-minority populations, existing research suggests strong associations between neighborhood-level exposure to violence and suicide in general (i.e., non-LGBT) populations.31,32 On the basis of this literature, we hypothesized higher rates of suicidal ideation and attempts among sexual minority adolescents residing in neighborhoods with more LGBT hate crimes. To test this hypothesis, we obtained LGBT hate crimes data from the Boston Police Department Community Disorders Unit and linked this information to individual-level data on suicidality (i.e., ideation and attempts) and sexual orientation from a population-based sample of Boston, Massachusetts, adolescents. This study therefore capitalizes on a rare opportunity to examine a potentially salient social-ecological risk factor for suicidality among sexual-minority adolescents.     

All-Cause and External Mortality in Released Prisoners: Systematic Review and Meta-Analysis

Objectives. We systematically reviewed studies of mortality following release from prison and examined possible demographic and methodological factors associated with variation in mortality rates.Methods. We searched 5 computer-based literature indexes to conduct a systematic review of studies that reported all-cause, drug-related, suicide, and homicide deaths of released prisoners. We extracted and meta-analyzed crude death rates and standardized mortality ratios by age, gender, and race/ethnicity, where reported.Results. Eighteen cohorts met review criteria reporting 26 163 deaths with substantial heterogeneity in rates. The all-cause crude death rates ranged from 720 to 2054 per 100 000 person-years. Male all-cause standardized mortality ratios ranged from 1.0 to 9.4 and female standardized mortality ratios from 2.6 to 41.3. There were higher standardized mortality ratios in White, female, and younger prisoners.Conclusions. Released prisoners are at increased risk for death following release from prison, particularly in the early period. Aftercare planning for released prisoners could potentially have a large public health impact, and further work is needed to determine whether certain groups should be targeted as part of strategies to reduce mortality.The global prison population in 2008 was estimated at 9.8 million with a median rate of imprisonment of 145 prisoners per 100 000 persons, most of whom are aged between 18 and 44 years.1 More than 2.3 million of these prisoners reside in the United States, which has the highest rate of imprisonment of 756 per 100 000 population. Natural cause mortality inside prison has been reported to be lower than that of the general population in France,2 Russia,3 England and Wales,4 and the United States.5 However, it is well-established that prisoner suicide rates are elevated compared with age-matched general populations.6 For example, the suicide rate of male prisoners in England and Wales between 1973 and 2003 was found to be 5 times higher than that of the general population,7 and in US jails, it has been reported to be 8 times higher.8 The odds of chronic medical conditions are increased by up to 4 times in US prisons.9 As prison populations are drawn from socioeconomically deprived backgrounds with reduced access to health care and health-seeking behavior when living in the community,10 prison provides an opportunity to provide public health interventions including health education and improving engagement with health services following release.11 For example, targeted health interventions such as medication review12 and HIV health education13,14 have been proposed.The health of prisoners following release from prison is less understood. At the end of 2009 in the United States, 819 308 prisoners were on parole or release following a prison term,15 and in England and Wales 20 895 offenders were released from prison in the first quarter of 2011.16 Despite these high absolute numbers, research has demonstrated that most sampled US jails did not plan for release of prisoners with mental illness, cardiovascular disease, or HIV/AIDS even though they considered it important.17 Mortality from suicide and drug-related causes has been reported to be particularly high in the immediate postrelease period,18,19 and, thus, public health interventions to target this period for those with a history of substance misuse have been outlined.20 The current review aims to synthesize evidence on mortality rates following release from prison and examine possible demographic and methodological factors associated with variation in these rates.     

Protective School Climates and Reduced Risk for Suicide Ideation in Sexual Minority Youths

Objectives. We examined whether sexual minority students living in states and cities with more protective school climates were at lower risk of suicidal thoughts, plans, and attempts.Methods. Data on sexual orientation and past-year suicidal thoughts, plans, and attempts were from the pooled 2005 and 2007 Youth Risk Behavior Surveillance Surveys from 8 states and cities. We derived data on school climates that protected sexual minority students (e.g., percentage of schools with safe spaces and Gay–Straight Alliances) from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention.Results. Lesbian, gay, and bisexual students living in states and cities with more protective school climates reported fewer past-year suicidal thoughts than those living in states and cities with less protective climates (lesbians and gays: odds ratio [OR] = 0.68; 95% confidence interval [CI] = 0.47, 0.99; bisexuals: OR = 0.81; 95% CI = 0.66, 0.99). Results were robust to adjustment for potential state-level confounders. Sexual orientation disparities in suicidal thoughts were nearly eliminated in states and cities with the most protective school climates.Conclusions. School climates that protect sexual minority students may reduce their risk of suicidal thoughts.Suicide is the third leading cause of death among youths aged 15 to 24 years.1 Decades of research have identified multiple risk factors for adolescent suicide ideation and attempts.2 One of the most consistent findings is that lesbian, gay, and bisexual (LGB, or sexual minority) adolescents are more likely than heterosexual adolescents to endorse suicidal thoughts3,4 and to report having a suicide plan.5 Additionally, a recent review of the epidemiological literature found that LGB youths are between 2 and 7 times more likely to attempt suicide than their heterosexual peers.6Given the elevated risk of suicidal ideation, plans, and attempts among sexual minority youths, researchers have focused on identifying factors that explain these marked disparities. Theories of minority stress7 and stigma8 have highlighted the important roles that social-structural contexts as well as institutional practices and policies play in contributing to mental health disparities. Consistent with these theories, LGB adults who live in states with fewer protective social policies have higher rates of psychiatric and substance use disorders than LGB adults living in states with more protective policies.9,10 For instance, LGB adults in states that passed constitutional amendments banning same-sex marriage experienced a 37% increase in mood disorders, a 40% increase in alcohol use disorders, and nearly a 250% increase in generalized anxiety disorders in the year following the enactment of the amendments.10 These and other studies11 have shown that the broader social contexts surrounding LGB adults shape their mental health.Among adolescents, schools are an important social context that contributes to developmental and health outcomes.12 For sexual and gender minority youths in particular, the social context of schools can promote both vulnerability and resilience.13–16 A variety of methodological approaches have been used to evaluate the mental health consequences of school climates for LGB students. The predominant approach is to ask LGB adolescents to report on the supportiveness of their schools.17–19 Studies using this approach have indicated that LGB youths who report greater school connectedness and school safety also report lower suicidal ideation and fewer suicide attempts.18 Although informative, this research may introduce bias because information is self-reported for both the exposure and the outcome.20 Studies using alternative methodologies may therefore improve the validity of the inferences on the relationship between the social environment and individual health outcomes.An alternative methodological approach has been to develop indicators of school climate that do not rely on self-report, such as geographic location of the school (i.e., urban vs rural)21 and the presence of Gay–Straight Alliances in the school.22 Although this approach has received comparatively less attention in the literature, recent studies have documented associations between these more objective measures of school climate and sexual minority mental health. For example, lesbian and gay adolescents are at lower risk for attempting suicide if they live in counties where a greater proportion of school districts have antibullying policies that include sexual orientation.23 Although they provide important initial insights, existing studies have been limited by examining only 1 aspect of school climate (e.g., antibullying policies or presence of Gay–Straight Alliances),16,22,23 relying on nonprobability samples,16,22 and using a single location,16,22,23 all of which can restrict generalizability.We built on this previous research by using data on multiple school climate variables relevant to LGB students that we obtained from the 2010 School Health Profile Survey, compiled by the Centers for Disease Control and Prevention (CDC).24 We then linked this information on school climate to population-based data of adolescents living in 8 states and cities across the United States. We hypothesized that LGB adolescents living in states and cities with school climates that are more protective of sexual minority youths would be less likely to report past-year suicidal thoughts, plans, and attempts than LGB youths living in areas with less protective school climates.     

Clustering of Midlife Lifestyle Behaviors and Subsequent Cognitive Function: A Longitudinal Study

Objectives. We examined the association between individual and clustered lifestyle behaviors in middle age and later in cognitive functioning.Methods. Middle-aged participants (n = 2430) in the Supplémentation en Vitamines et Minéraux Antioxydant study self-reported their low physical activity, sedentary behavior, alcohol use, smoking, low fruit and vegetable consumption, and low fish consumption. We assessed cognition 13 years later via 6 neuropsychological tests. After standardization, we summed the scores for a composite cognitive measure. We estimated executive functioning and verbal memory scores using principal component analysis. We estimated the mean differences (95% confidence intervals [CIs]) in cognitive performance by the number of unhealthy behaviors using analysis of covariance. We identified latent unhealthy behavior factor via structural equation modeling.Results. Global cognitive function and verbal memory were linearly, negatively associated with the number of unhealthy behaviors: adjusted mean differences = −0.36 (95% CI = −0.69, −0.03) and −0.46 (95% CI = −0.80, −0.11), respectively, per unit increase in the number of unhealthy behaviors. The latent unhealthy behavior factor with low fruit and vegetable consumption and low physical activity as main contributors was associated with reduced verbal memory (RMSEA = 0.02; CFI = 0.96; P = .004). No association was found with executive functioning.Conclusions. Comprehensive public health strategies promoting healthy lifestyles might help deter cognitive aging.Noncommunicable diseases with notable lifestyle components are the leading causes of death worldwide.1,2 There is also growing evidence of the critical role of different midlife health and risk behaviors in cognitive aging.3–7 Because lifestyles are inherently modifiable and no treatment of cognitive decline is available, such findings argue for the paramount importance of prevention.8,9Current data support a deleterious effect of alcohol abstinence or abuse (compared with moderate alcohol consumption),10 smoking,7 low fruit and vegetable intake,11 low fish intake,12 and low physical activity (PA) levels13 on cognitive aging. However, it has been widely documented that lifestyle factors are strongly correlated with each other, forming a cluster of healthy or unhealthy behaviors.14 Traditionally, such interrelations have been accounted for by statistical adjustment; however, it is of major public health interest to consider the cumulative and combined effect of the various lifestyle behaviors on health by using multidimensional strategies.14Research that examines the combined effect of lifestyle factors on mortality is plentiful, and data have been colligated in a recent meta-analysis.15 These authors reported a 66% reduction in mortality risk by comparing adherence to 4 or more healthy lifestyle behaviors versus engagement in any number of unhealthy behaviors.The combined effect of lifestyle factors has also been explored in relation to cardiovascular diseases,16–18 cancer,18–22 diabetes,18,23 memory complaints,24 and dementia25–27; however, very few studies have reported findings regarding cognition.28,29 Despite heterogeneity in the definition of a healthy lifestyle, study design, and residual confounding, available, but scarce, data support a critical, protective role of healthy lifestyles in cognitive health through their beneficial properties via oxidative, inflammatory, vascular, and other neuroprotective pathways.30–33Our objectives in this study were to examine the association between individual and clustered lifestyle behaviors and later cognitive functioning. We employed traditional and innovative techniques (structural equation modeling) in our epidemiological pursuit.     

Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: findings from a representative sample of the adult, noninstitutionalized US population

Objectives. We aimed to determine the percentage of suicide attempts attributable to individual Axis I and Axis II mental disorders by studying population-attributable fractions (PAFs) in a nationally representative sample.Methods. Data were from the National Epidemiologic Survey on Alcohol and Related Conditions Wave 2 (NESARC; 2004–2005), a large (N = 34 653) survey of mental illness in the United States. We used multivariate logistic regression to compare individuals with and without a history of suicide attempt across Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I disorders (anxiety, mood, psychotic, alcohol, and drug disorders) and all 10 Axis II personality disorders. PAFs were calculated for each disorder.Results. Of the 25 disorders we examined in the model, 4 disorders had notably high PAF values: major depressive disorder (PAF = 26.6%; 95% confidence interval [CI] = 20.1, 33.2), borderline personality disorder (PAF = 18.1%; 95% CI = 13.4, 23.5), nicotine dependence (PAF = 8.4%; 95% CI = 3.4, 13.7), and posttraumatic stress disorder (PAF = 6.3%; 95% CI = 3.2, 10.0).Conclusions. Our results provide new insight into the relationships between mental disorders and suicide attempts in the general population. Although many mental illnesses were associated with an increased likelihood of suicide attempt, elevated rates of suicide attempts were mostly attributed to the presence of 4 disorders.With almost 1 million deaths worldwide every year and a rate increase of 60% over the past 45 years, suicide is clearly a major public health problem.¹ Although the US Surgeon General has prioritized suicide prevention,² suicidal behavior has not significantly decreased in the United States.³ Suicide attempts are strong risk factors for eventual suicide completion^4–6; therefore, understanding and modifying risk factors for suicide attempts remain a promising approach to reducing suicide rates.Unfortunately, our understanding of the risk factors for suicide attempts is plagued by poor specificity. Vigorous study efforts have identified multiple risk factors, including several sociodemographic factors and mental disorders.^3,7–10 However, significant associations between candidate risk factors and suicide attempts are tempered by low positive predictive values.¹¹ The population-attributable fraction (PAF; also known as the population-attributable risk) has emerged as a promising statistical tool to better quantify the effect of risk factors on a given outcome at the population level. The PAF describes the reduction in incidence of a particular outcome if the entire population was not exposed to the examined risk factor.¹²The PAF has been underused in the study of suicide risk factors.^13,14 A recent review of the PAF in suicide research¹⁵ showed that existing studies examining the PAFs of risk factors for suicide attempts have focused primarily on depression and mood disorders, with PAFs ranging from 28% to 74%.^14,16–21 A small number of studies have investigated the PAFs of substance use disorders and anxiety disorders for suicide attempts, also with mixed findings.^14,18,22 Other findings suggest that the risk of suicide attempts attributable to mental disorders is largely explained by the association between mental disorders and suicidal ideation.⁹ A major limitation in the literature is that relatively few mental disorders have been examined by using PAFs for suicide attempts. Despite substantial evidence for the causative role of personality disorders in suicidal behavior,^23–25 the PAF of personality disorders has been examined in only 1 study to date, and that study was unable to examine the effects of individual personality disorders.¹⁸ Borderline personality disorder is a strong risk factor for suicide attempts,²⁵ yet the PAF of borderline personality disorder for suicide attempts is unknown. Posttraumatic stress disorder (PTSD) is another disorder associated with suicide attempts,^26,27 yet the proportion of suicide attempts attributable to PTSD has not been examined. Furthermore, many previous studies included limited adjustment for confounding factors. Even though several mental disorders have been labeled as risk factors for suicidal behavior,⁷ many studies using the PAF do not adjust for mental disorders other than the disorder of interest. The PAF is based on the assumption that the examined risk factor is causally related to the outcome,¹² and given the high rates of comorbidity of mental disorders,²⁸ multivariate models examining a comprehensive range of mental disorders are needed to provide a more realistic assessment of the PAF for a specific mental illness.Our primary objective was to examine the proportion of suicide attempts attributable to specific mental disorders. To address the limitations of the existing literature, we used the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC),²⁹ wave 2, as the data set. This data set features a very large sample size (N = 34 653), includes a comprehensive assessment of Axis I disorders and all 10 Axis II personality disorders, and is representative of the US population. On the basis of existing literature showing high PAF values for major depressive disorder and other mood disorders, we hypothesized that whereas several mental disorders would be independently associated with suicide attempts, major depressive disorder and other mood disorders would account for the highest proportion of suicide attempts.^16,21 We further hypothesized that anxiety and substance use disorders would have lower PAF values for suicide attempts, on the basis of previous studies that often showed lower PAF values.^14,18,22 The limited literature on the PAFs of personality disorders for suicide attempts suggested that we would find low PAF values; however, because of its consistently demonstrated association with suicide attempts, we anticipated that borderline personality disorder would have a relatively high PAF value.