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Suicidal Behaviors in Veterans with Substance Use Disorders

Suicidal Behaviors in Veterans with Substance Use Disorders. Mark Ilgen, Ph.D. VA Serious Mental Illness Treatment Research and Evaluation Center Assistant Professor of Psychiatry, University of Michigan. Acknowledgements.

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Suicidal Behaviors in Veterans with Substance Use Disorders

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  1. Suicidal Behaviors in Veterans with Substance Use Disorders Mark Ilgen, Ph.D. VA Serious Mental Illness Treatment Research and Evaluation Center Assistant Professor of Psychiatry, University of Michigan

  2. Acknowledgements • This work was supported by the Department of Veterans Affairs Office of Mental Health Services, Patient Care Services as well as funding for research from VA HSR&D (MRP 05-137, IAC 09-047 & XVA 41-033) • Thanks to colleagues in Washington DC, Ann Arbor, MI, Denver, CO & Canandaigua, NY • I have no conflicts of interest to declare

  3. Overview • Provide data on overall risk for suicide in Veterans • Substance misuse and suicide • Why might individuals who misuse substances be at risk for suicide? • What role could treatment play in reducing suicide in those with substance-related problems?

  4. General Information on Suicide • Over 30,000 suicides occur each year in the United States (CDC, 2010) • In 2001, over 1,600 VA health system patients died by suicide (McCarthy et al., 2009) • Epidemiological research: suicidal ideation and suicide attempts are common • (Kessler, et al., 1999): • 14% lifetime ideation • 5% lifetime attempt

  5. Why Study Suicide in Military Veterans? • Military Veterans have characteristics associated with increased suicide risk: • E.g., male, access to firearms, exposure to trauma • Concerns about impact of recent conflicts (and multiple deployments) on risk for suicide • Highly visible suicides attract attention from media, the public and lawmakers • Sense of moral responsibility to care for those who have served in the military

  6. Are Veterans at Greater Risk for Suicide than Non-Veterans? • Some conflicting findings: Does being a Veteran increase your risk for suicide? • Yes (Kaplan et al., 2007; McCarthy et al., 2009) • No (Kang & Bullman, 2008; Miller et al., 2009) • Sources of confusion in research on Veterans and suicide • 24.5 million individuals in the US are Veterans • 5.4 million unique individuals received care from the Veterans Health Administration • Over 1.7 million individuals have served in Iraq/Afghanistan since October 2001 • 1.3 million individuals currently on active duty • Is risk for suicide changing over time in VHA patients?

  7. Rates of Suicide per 100,000 from 2000 to 2007

  8. Standardized Mortality Ratios: VHA Patients vs. General US Population

  9. What is Associated with Increased Risk for Suicide in VHA Patients? • Beyond demographic characteristics, little is known about risk factors for suicide in VHA patients • Psychopathology consistently linked to greater risk of suicide (~90% of those who die by suicide are diagnosed with at least one disorder). This research on suicide mortality is limited and not specific to Veterans • The follwing set of analyses examine the association between psychiatric diagnoses and suicide in VHA patients

  10. Methods to Study Psychopathology and Suicide • A cohort of VA patients was defined as all individuals who utilized VA services in FY99 and were alive at the start of FY00, which resulted in a total sample size of 3,291,891 individuals. Vital status was obtained by linking VA clinical records with data from the National Death Index (NDI) • Diagnostic characteristics. Based on ICD-9 codes given during a visit in 1998 or 1999. The psychiatric diagnoses examined were: • depression • schizophrenia • bipolar disorder I or II • substance use disorders (alcohol or drug use disorders) • posttraumatic stress disorder (PTSD) • other anxiety disorder • Suicide examined through the end of FY06

  11. Percent of VHA Suicides with Psychiatric Conditions Ilgen MA, Bohnert ASB, Ignacio R, McCarthy J, Valenstein M, Kim HM, Blow F. Psychiatric Diagnoses and Risk of Suicide in Patients Treated by the Department of Veterans Affairs. Archives of General Psychiatry (in press)

  12. Age-Adjusted Hazard Ratios of Suicide during FY1999 to 2006 Ilgen MA, Bohnert ASB, Ignacio R, McCarthy J, Valenstein M, Kim HM, Blow F. Psychiatric Diagnoses and Risk of Suicide in Patients Treated by the Department of Veterans Affairs. Archives of General Psychiatry (in press)

  13. Psychiatric Conditions as Risk Factors for Suicide • The percentage of patients with a psychiatric condition (~50%) was significantly lower than what has been reported in psychological autopsy studies – suggesting a need for better identification of psychiatric conditions • All psychiatric conditions were associated with increased risk for suicide • Substance use disorders were common and had one of the strongest associations with suicide

  14. Overall Association between Substance Misuse and Suicide • Why might substance misuse be related to suicide?

  15. Model for the Relationship between Substance Use and Suicide Conner KR, Ilgen MA (in press). Substance use disorders and suicidal behavior. In R O’Connor, S Platt, J Gordon (Editors), The International Handbook of Suicide Prevention: Research, Policy and Practice. Wiley Blackwell: Oxford, England

  16. Factors Associated with Suicidal Behaviors in those with Substance Use Disorders • Discuss four studies of risk for suicidal behaviors in those with substance use disorders to highlight risk factors related to substance use severity, prior violence and impulsivity.

  17. Psychopathology and Severity of Substance Use as Predictors of Suicidal Behaviors • A national sample of 8,807 patients presenting for treatment of substance use disorders (SUDs) in the VA healthcare system were assessed at treatment intake and follow-up. Predicting increased risk of 1-year suicide attempt • Strongest predictors: • Composite measure of psychiatric symptoms (prior suicide attempt and depression) • Criminal justice system involvement • Years of cocaine use • Days of alcohol problems at baseline Ilgen, MA, Harris, AHS, Moos, R, Tiet, Q. Predictors of a suicide attempt one year after entry into substance use disorder treatment. Alcoholism: Clinical and Experimental Research, 31:635-642, 2007.

  18. Prevalence of violence among substance use disorder patients by prior suicide status. Violence as a Marker of Risk for Suicidal Behaviors (N = 6,233) Ilgen MA, Conner KR, Valenstein M, Austin KL, Blow FC. Violent and non-violent suicide in Veterans with substance use disorders. Journal of Studies on Alcohol and Drugs, 71: 473-479 2010.

  19. Impulsivity Associated with Impulsive Suicide Attempts • Sample of 154 men seeking treatment for alcohol dependence in Poland • 43% reported a lifetime suicide attempt; 62% of these suicide attempts were “impulsive” • Participants completed a stop-signal task (a behavioral measure of impulsivity) • Greater behavioral impulsivity was not associated with greater likelihood of a suicide attempt. However, it was significantly associated with greater likelihood of an impulsive suicide attempt relative to no attempt or non-impulsive attempts Wojnar M, Ilgen MA, Czyz E, Strobbe S, Klimkiewicz A, Jakubczyk A, Nowosad I, Glass J, Brower KJ. Impulsive and non-impulsive suicide attempts in patients treated for alcohol dependence. Journal of Affective Disorders, 115: 131-139 2009.

  20. Violent and non-violent suicide in those with a substance use disorder • Identified all VA patients who died by suicide with a substance use disorder in their treatment record and a control group of those with a substance use disorder who did not die by suicide • Classified suicides into: violent and non-violent

  21. Ilgen MA, Conner KR, Valenstein M, Austin KL, Blow FC. Violent and non-violent suicide in veterans with substance use disorders. Journal of Studies on Alcohol and Drugs, 71: 473-479 2010.

  22. Model for the Relationship between Substance Use and Suicide Conner KR, Ilgen MA (in press). Substance use disorders and suicidal behavior. In R O’Connor, S Platt, J Gordon (Editors), The International Handbook of Suicide Prevention: Research, Policy and Practice. Wiley Blackwell: Oxford, England.

  23. Role of Treatment System • What does this mean for the treatment system? • Improve identification and treatment of substance use disorders • Other points of contact to identify Veterans with substance use disorders at risk for suicide

  24. Type of Treatment Received Prior to Suicide in VHA patients with Substance Use Disorders (N=2,773)

  25. Addictions Treatment in Suicidal Individuals with Substance Use Disorders • Addictions treatment programs can be hesitant to accept “high risk” patients • However, suicidal patients seem to respond well to addictions treatment (Ilgen et al., 2004) • Are any aspects of addictions treatment related to decreased likelihood of post-treatment suicide attempts? • In non-Veteran sample, during treatment suicide attempts less likely in a residential setting • Length of treatment predicted lower likelihood of post-treatment suicide attempt (Ilgen et al., 2007)

  26. Addictions Treatment Engagement Associated with Lower Risk of Suicide Attempt (N = 8,807) Ilgen, MA, Harris, AHS, Moos, R, Tiet, Q. Predictors of a suicide attempt one year after entry into substance use disorder treatment. Alcoholism: Clinical and Experimental Research, 31:635-642, 2007.

  27. Limitations • All data presented are observational • Mostly focused on those with an identified substance use disorder • Findings are based on earlier cohorts of Veterans (prior to 2007) • Measures of suicidal behaviors are limited by: • Accuracy of recall in self-report data • Quality of the data in the death record for measures of suicide mortality

  28. Summary and Future Directions • Prediction of suicide is still far from ideal • However, certain patients emerge as being at elevated risk for suicide. Targeted intervention programs could focus on these patients • Many patients who die by suicide are in contact with VHA providers prior to death • Veterans with substance misuse are one group at particularly high risk for suicide

  29. Summary and Future Directions • Increased risk for suicide in Veterans with substance misuse is likely due to a combination of distal and proximal risk factors • Attending to available measures of substance use, depressed mood and impulsivity could help to better understand risk • It is possible that improving addictions treatment could help reduce suicide but this is unlikely to fully address the problem • Comprehensive approaches are needs to identify at risk-patients in other settings and address both substance use and other co-occurring problems

  30. Thank You! marki@umich.edu

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