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In 2008, the Veterans Health Administration (VHA) established a suicide high-risk flag (HRF) for patient records. To inform ongoing suicide prevention activities as part of operations and quality improvement work in the U.S. Department of Veterans Affairs, the authors evaluated suicide risk following HRF activations and inactivations.For annual cohorts of VHA users, HRF receipt and demographic and clinical care contexts in the 30 days before HRF activations were examined for 2014-2016 (N=7,450,831). Veterans were included if they had VHA inpatient or outpatient encounters during the index or previous year. Suicide rates in the 12 months after HRF activations and inactivations were assessed. Using multivariable Cox proportional hazards regression, the authors compared suicide risk following HRF activation and inactivation with veterans without HRFs, adjusted for age, gender, and race-ethnicity.HRF activation (N=47,015) was commonly preceded within 30 days by a documented suicide attempt (39.5%) or inpatient mental health admission (40.1%). Suicide risk was elevated in the 12 months after flag activation (crude suicide rate=682 per 100,000 person-years, adjusted hazard ratio [HR]=21.00, 95% confidence interval [CI]=18.55-23.72) compared with risk among VHA users without HRF activity. Risk after HRF inactivation (N=41,251) was also elevated (crude suicide rate=408 per 100,000 person-years, adjusted HR=12.43, 95% CI=10.57-14.63) compared with risk among VHA users without HRF activity.Suicide risk after HRF activation was substantially elevated and also high after HRF inactivation. Findings suggest the importance of comprehensive suicide risk mitigation and support recent VHA process enhancements to formalize inactivation criteria and support veterans after HRF inactivation.

Introduction Opioid-related overdose risks are elevated after incarceration. The rates of opioid-related overdose mortality have risen in recent years, including among Veterans Health Administration patients. To inform Veteran overdose prevention, this study evaluates whether opioid-related overdose risks differ for Veterans Health Administration patients with versus those without indicators of legal system involvement. Methods This retrospective national cohort study, conducted in 2019–2021, used Veterans Health Administration electronic health records and death certificate data from the Department of Veterans Affairs/Department of Defense Mortality Data Repository to examine opioid-related overdose mortality from January 1, 2013 through December 31, 2017. The cohort included 5,390,902 Veterans with Veterans Health Administration inpatient or outpatient encounters in 2012 who were alive as of January 1, 2013, of whom 32,284 (0.60%) patients had legal system involvement in 2012, indicated by Veterans Justice Programs outpatient encounters. Cox proportional hazards regression models assessed the associations between legal involvement and risk of opioid-related overdose mortality. Results There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among legal-involved Veterans. Veterans with legal involvement had a higher opioid-related overdose mortality rate per 100,000 person-years (191.22, 95% CI=169.40, 213.04 vs 17.76, 95% CI=17.23, 18.29, p Conclusions Among Veterans receiving Veterans Health Administration care in 2012, documented legal system involvement was associated with an increased risk of opioid-related overdose mortality. Targeting overdose education and naloxone distribution programs and integrating opioid overdose prevention efforts into mental health care may reduce opioid overdose deaths among Veterans with legal involvement.

Introduction Little is known regarding long-term mortality outcomes after non-fatal suicide attempts among Veterans Health Administration (VHA) patients, which may inform services delivery and program evaluation. Methods For 4,601,081 Veterans with 2005 VHA encounters, we assessed unadjusted and age-adjusted all-cause and cause-specific mortality through 2017, overall and for Veterans with (N = 8243) versus without (N = 4,592,838) 2005 VHA suicide attempt documentation. Standardized mortality ratios compared mortality rates by suicide attempt status. Multivariable proportional hazards regression models assessed age- and gender-adjusted mortality risk. Results Among Veteran VHA users with non-fatal suicide attempt diagnoses, 1.6% died of suicide, 4.6% of non-suicide external causes, and 30.7% of any cause. In age- and gender-adjusted analyses, Veterans who attempted suicide had increased suicide (hazard ratio [HR] = 4.52, 95% confidence interval [CI] = 3.82-5.36), non-suicide external cause (HR = 3.75, 95% CI = 3.38-4.17), and all-cause (separate due to non-proportional hazards: 2006, HR = 2.05, 95% CI = 1.81-2.31; 2007-2017, HR = 1.72, 95% CI = 1.65-1.80) mortality through 2017. Conclusion Over 12 years, Veteran VHA patients with non-fatal suicide attempt diagnoses had increased risk of suicide, non-suicide external cause, and all-cause mortality. Over 98% of Veteran VHA users who had a diagnosed non-fatal attempt did not die by suicide, highlighting additional program evaluation outcomes and opportunities to support physical and mental health.

Objectives. To evaluate the sensitivity of health care facility documentation of suicide deaths among US veterans with recent Veterans Health Administration (VHA) care and assess variation in identification by veteran, clinical, and suicide death characteristics. Methods. Cross-sectional analyses included 11 148 veterans who died by suicide in 2013 to 2017, per National Death Index death certificate information, with VHA encounters in the year of death or the previous year. Facility suicide ascertainment was assessed per site reports in the VHA Suicide Prevention Applications Network. Bivariate and multivariable analyses assessed ascertainment by decedent demographic, clinical, utilization, and method of suicide characteristics. Results. Site reports identified 3667 suicide decedents (32.9%). Veteran suicide decedents identified by facilities were more likely to be younger and with clinical risk factors and more recent VHA encounters. Suicide deaths involving poisoning were less likely to be identified than deaths involving other methods. Conclusions. VHA facility ascertainment of suicide deaths among recent patients was neither comprehensive nor representative. Findings will inform efforts to enhance facility suicide surveillance and veteran suicide prevention.

Individuals with mental or substance use disorders have higher mortality rates than people in the general population. How excess mortality varies across health care facilities is unknown. The authors sought to investigate facility-level mortality rates among Veterans Health Administration (VHA) patients who had received diagnoses of mental or substance use disorders.An electronic medical records-based retrospective cohort study was conducted, encompassing 8,812,373 unique users of 139 VHA facilities from 2011 to 2016. Covariates included age, sex, and past-year diagnoses of serious mental illness, posttraumatic stress disorder, major depressive disorder, other mental health conditions, or substance use disorders. The outcome was all-cause mortality per comprehensive Veterans Affairs/Department of Defense searches of the National Death Index. Proportional hazards regression was used to calculate overall and facility-specific hazard ratios (HRs) for each diagnosis group, adjusted for age, sex, and comorbid medical conditions.Overall, all-cause mortality was statistically significantly elevated among VHA users with mental health diagnoses (HR=1.21, 95% confidence interval=1.20-1.22). HRs varied across facilities consistently over time. At the VHA facility level, diagnostic groups were significantly correlated with the degree of excess mortality. Results were similar in sensitivity analyses that excluded deaths from suicide or drug or alcohol overdose.VHA users with mental or substance use disorder diagnoses had elevated mortality rates. Correlation in excess mortality across two periods indicated that facility differences in excess mortality were persistent and therefore potentially associated with facility- and community-level factors, which may help inform quality improvement efforts to reduce mortality rates.

While scholars and policy makers have increasingly focused on transnational labour migration (TLM) in Asia, few comparative studies have analysed how TLM shapes poverty, livelihoods, vulnerability, and agrarian-forest change across different rural contexts. Based on focused comparative fieldwork and a critical review of the secondary literature, this paper identifies the salient patterns of TLM-led change affecting rural livelihoods and agrarian-forest landscapes in three migrant-sending Asian countries: Nepal, Indonesia and Laos. Depending on how social relations, including those based on gender and ethnicity, and how specific geographic places are integrated into migration pathways, TLM can result in patterns of changes involving agricultural deactivation and de-agrarianisation, as well as incipient re-agrarianisation. We also find that where remittances are integrated with diversified livelihood portfolios, and where state policies play a supportive role, transnational labour migration may improve household livelihoods. In the absence of these factors, the transformative potential of TLM can be overestimated, and TLM may end up reproducing underlying structural drivers of rural poverty and vulnerability. We, therefore, challenge the simplistic narrative that TLM provides an easy solution to the limitations of rural development in agrarian Asia. We suggest policy innovations that ameliorate critical issues of migrant vulnerability and precarity, and that support the mobilisation of labour remittances for agricultural development and livelihood diversification.

Objectives To assess outcomes for Veterans Health Administration (VHA) patients following calls to the Veterans Crisis Line (VCL). Methods 158,927 VHA patients had an initial VCL call in 2010-2015 with documented identifiers. Multivariable proportional hazards regressions assessed risks of suicide and suicide-related behavior through 12 months. Covariates included age, sex, region, mental health encounters in the prior year, time of day, weekday/weekend status, call outcome, and responder determination of caller risk. Results Annualized suicide rates per 100,000 within 1, 3, 6, and 12 months were 797, 520, 387, and 298, respectively. Average age was 49.9 (SD = 15.2), 86.5% were male, 68.6% received mental health encounters in the prior year, and 5.9% had calls categorized as at high risk. Adjusting for covariates, suicide risk was greater among male callers and those with calls categorized as at high or moderate risk. Conclusions Veterans Crisis Line serves a high-risk population at a critical time. Rates were particularly high within one month and remained substantially elevated through 12 months. Findings have directly informed ongoing efforts to enhance coordination between VCL and VHA to support suicide prevention.

The Veterans Health Administration (VHA) provides a continuum of care over the life course. Among U.S. adults, bipolar disorder and schizophrenia are associated with increased risk of dementia. To inform service planning, this study assessed the incidence of dementia among veteran VHA patients with bipolar disorder or schizophrenia, with adjustment for comorbid medical conditions.Using data from the VHA Corporate Data Warehouse, the authors identified all veterans who received VHA care in 2004 and 2005 without a dementia diagnosis and who were alive and between ages 18 and 100 as of January 1, 2006. Individuals were categorized as having bipolar disorder, schizophrenia, or neither condition on the basis of diagnoses in 2004-2005. Among ongoing VHA users, incidence of dementia was assessed for up to 10 years (2006-2015).The cohort included 3,648,852 individuals. After analyses controlled for baseline comorbid general medical conditions and substance use disorders, the incidence rate ratios (IRRs) for dementia were 2.92 for those with schizophrenia and 2.26 for those with bipolar disorder, compared with VHA patients with neither condition.Among veterans receiving VHA care, diagnoses of bipolar disorder and schizophrenia were each associated with increased risk of receiving a new diagnosis of dementia, even when analyses controlled for baseline medical comorbidities. IRRs were elevated for patients with either condition, compared with those with neither condition, and highest for those with schizophrenia. VHA clinicians should evaluate patients for dementia when signs or symptoms of cognitive impairment are present.

OBJECTIVES Understanding suicide risks among Veteran subpopulations is a national priority. This study assessed risks of suicide, suicide attempts, and other-cause mortality among recipients of Veterans Health Administration (VHA) Veterans Justice Program services as compared to other Veteran VHA users. METHODS Per VHA records, the cohort included 5,401,192 Veterans alive as of January 1, 2013 and with VHA utilization in 2012. Receipt of Veterans Justice Outreach (VJO) or Health Care for Reentry Veterans (HCRV) services in 2012 was assessed using encounter codes. Multivariable proportional hazards regression assessed risks of suicide (per National Death Index search results from the VA/DoD Mortality Data Repository) and attempts (per diagnoses and site reports) in 2013-2016, adjusting for demographic and clinical indicators. RESULTS Compared to other patients, Veterans with VJO encounters had greater risk of suicide (unadjusted HR = 2.80, 95% confidence interval [CI] = 2.30-3.40; adjusted HR = 1.25, 95% CI = 1.02-1.53) and attempts (unadjusted HR = 8.88, 95% CI = 8.45-9.35; adjusted HR = 1.06, 95% CI = 1.00-1.11). Veterans with HCRV encounters had elevated risk of suicide attempts (unadjusted HR = 4.56, 95% CI = 4.00-5.20; adjusted HR = 1.42, 95% CI = 1.24-1.62). Risks were also elevated for other external causes of mortality. CONCLUSIONS Findings document increased risk of suicidal behavior among Veterans Justice Program recipients. These results have informed VHA suicide prevention activities.

Key Points Question Is the Veterans Health Administration Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET) program, which facilitates care enhancements for individuals in the top 0.1% suicide risk tier using a validated algorithm, associated with health care utilization, treatment engagement, suicide attempts, suicide safety plan documentation, and suicide mortality? Findings In this cohort study including 173 313 individuals before and after implementation of the REACH VET program using triple differences, inclusion in the REACH VET program was associated with having more outpatient encounters, increased documentation of new suicide prevention safety plans, and fewer inpatient mental health admissions, emergency department visits, and documented suicide attempts. Meaning These findings suggest that clinical programs using predictive modeling can support care enhancements and risk reduction., This cohort study examines treatment engagement, health care utilization, and suicide-related outcomes associated with the Veterans Health Administration's Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET) suicide risk modeling clinical program., Importance The Veterans Health Administration (VHA) implemented a national clinical program using a suicide risk prediction algorithm, Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment (REACH VET), in which clinicians facilitate care enhancements for individuals identified in local top 0.1% suicide risk tiers. Evaluation studies are needed. Objective To determine associations with treatment engagement, health care utilization, suicide attempts, safety plan documentation, and 6-month mortality. Design, Setting, and Participants This cohort study used triple differences analyses comparing 6-month changes in outcomes after vs before program entry for individuals entering the REACH VET program (March 2017-December 2018) vs a similarly identified top 0.1% suicide risk tier cohort from prior to program initiation (March 2014-December 2015), adjusting for trends across subthreshold cohorts. Subcohort analyses (including individuals from March 2017-June 2018) evaluated difference-in-differences for cause-specific mortality using death certificate data. The subthreshold cohorts included individuals in the top 0.3% to 0.1% suicide risk tier, below the threshold for REACH VET eligibility, from the concurrent REACH VET period and from the pre–REACH VET period. Data were analyzed from December 2019 through September 2021. Exposures REACH VET–designated clinicians treatment reevaluation and outreach for care enhancements, including safety planning, increased monitoring, and interventions to enhance coping. Main Outcomes and Measures Process outcomes included VHA scheduled, completed, and missed appointments; mental health visits; and safety plan documentation and documentation within 6 months for individuals without plans within the prior 2 years. Clinical outcomes included mental health admissions, emergency department visits, nonfatal suicide attempts, and all-cause, suicide, and nonsuicide external-cause mortality. Results A total of 173 313 individuals (mean [SD] age, 51.0 [14.7] years; 161 264 [93.1%] men and 12 049 [7.0%] women) were included in analyses, including 40 816 individuals eligible for REACH VET care and 36 604 individuals from the pre–REACH VET period in the top 0.1% of suicide risk. The REACH VET intervention was associated with significant increases in completed outpatient appointments (adjusted triple difference [ATD], 0.31; 95% CI, 0.06 to 0.55) and proportion of individuals with new safety plans (ATD, 0.08; 95% CI, 0.06 to 0.10) and reductions in mental health admissions (ATD, −0.08; 95% CI, −0.10 to −0.05), emergency department visits (ADT, −0.03; 95% CI, −0.06 to −0.01), and suicide attempts (ADT, −0.05; 95% CI, −0.06 to −0.03). Subcohort analyses did not identify differences in suicide or all-cause mortality (eg, age-and-sex-adjusted difference-in-difference for suicide mortality, 0.0007; 95% CI, −0.0006 to 0.0019). Conclusions and Relevance These findings suggest that REACH VET implementation was associated with greater treatment engagement and new safety plan documentation and fewer mental health admissions, emergency department visits, and suicide attempts. Clinical programs using risk modeling may be effective tools to support care enhancements and risk reduction.

Objective:Studies of patients in the U.S. Department of Veterans Affairs (VA) health system and elsewhere have documented elevated mortality from suicide during a critical period within 30 to 90 da...

The frequency and severity of shocks to food systems is accelerating globally, exemplified by the current COVID-19 outbreak. In low- and middle-income countries, the impacts have exacerbated existing food system vulnerabilities and poverty. Governments and donors must respond quickly, but few tools are available that identify interventions to build food system resilience, or emerging opportunities for transformation. In this paper we reflect on the application of a systems-based rapid assessment which we applied across 11 Indo-Pacific countries in May-July 2020. Our approach was shaped by three design parameters: the integration of key informants' perspectives engaged remotely within the countries, applicability to diverse food systems and COVID-19 experiences across the region, and the consideration of food systems as complex systems. For the rapid assessment we adopted an analytical framework proposed by Allen and Prosperi (2016). To include a development lens, we added the analysis of vulnerable groups and their exposure, impacts, recovery potential and resilience, and pro-poor interventions. We concluded that the framework and approach facilitated integration and triangulation of disparate knowledge types and data to identify priority interventions and was sufficiently flexible to be applied across food systems, at both national, sub-national and commodity scales. The step-wise method was simple and enabled structured inquiry and reporting. Although the systems concepts appeared more easily transferrable to key informants in some countries than others, potentially transformational interventions were identified, and also some risks of maladaptation. We present a refined framework that emphasises analysis of political, economic and institutional drivers of exposure and vulnerability, the constraints that they pose for building recovery potential and resilience, and trade-offs amongst winners and losers inherent in proposed interventions.

INTRODUCTION Veterans who receive Veterans Health Administration (VHA) Home Based Primary Care (HBPC) services and those discharged from VHA Community Living Centers (CLC) may be at increased risk of suicide. No studies to date have assessed suicide risks among HBPC patients. This study examined suicide risks among recipients of VHA HBPC services and following discharge from VHA CLCs, as compared to other Veteran VHA users. METHODS We identified three cohorts of 2013 Veteran VHA patients: 47,842 HBPC users, 17,725 with live discharges from CLCs, and 5,554,635 other VHA users. Using proportional hazards regression, we assessed risk of suicide through 2016. RESULTS Overall, HBPC recipients did not differ from the other cohorts in suicide risk. Although in unadjusted analyses CLC discharged patients had greater suicide risk than the general VHA patient cohort (hazard ratio (HR) = 1.73, 95% confidence interval = 1.25-2.41), this became nonsignificant when controlling for diagnoses. CONCLUSIONS Overall findings did not identify differential suicide risk among VHA HBPC recipients in 2013, when compared to other Veteran VHA patient cohorts. Veterans discharged from VHA CLCs have increased mental health morbidity, which was associated with increased suicide risk.

OBJECTIVE: Single-site studies indicate irregular hospital discharges are associated with elevated suicide risk. As part of ongoing analytics in the Veterans Affairs (VA) health system, the authors evaluated associations between irregular discharge and suicide over a 15-year period. METHODS: All inpatient discharges and discharge types from 2001 through 2014 were identified using VA administrative data. Mortality and cause-of-death data were drawn from comprehensive VA searches of the Centers for Disease Control and Prevention National Death Index. Suicide risk following regular versus irregular discharge was compared by using survival analysis and adjusting for age, gender, and VA facility. RESULTS: Among 5,051,051 discharges, 2.1% (103,995) were irregular. Adjusted suicide risk was higher following irregular discharge compared with regular discharge (hazard ratio [HR]=2.02, 95% confidence interval [CI]=1.78–2.29). Stratified analyses by unit type showed that the association was nonsignificant for psychiatric discharges but significant for general medical discharges (HR=3.01, CI=2.54–3.57). CONCLUSIONS: Patients were at increased suicide risk after irregular hospital discharges.

Objective To determine patterns of mental health service use before and after VA disability compensation awards for posttraumatic stress disorder (PTSD). Data sources A 10 percent random sample of VHA-enrolled Veterans with new or increased PTSD service connection between 2012 and 2014 (n = 22,249). Study design We used latent trajectory analysis to identify utilization patterns and multinomial logistic regression to assess associations between Veteran characteristics and trajectory membership. Data extraction methods We assessed receipt of VHA mental health encounters in each of the 52 weeks prior to and following PTSD disability rating or rating increase. Principal findings The best fitting model had five groups: No Use (36.6 percent), Low Use (37.7 percent), Increasing Use (9.4 percent), Decreasing Use (11.2 percent), and High Use (5.1 percent). Adjusting for demographic characteristics and compared with the No Use group, Veterans in the other groups were more likely to reside closer to a VHA facility, receive a higher PTSD disability rating, and screen positive for military sexual trauma. Conclusions Service use remained stable (80 percent) or increased (9 percent) for the vast majority of Veterans. Service utilization declined for only 11 percent. Data did not indicate substantial service discontinuation following rating. Low VHA service utilization suggests opportunities to enhance outreach for Veterans with PTSD-related disability benefits.

The study examined whether staffing of Primary Care-Mental Health Integration (PCMHI) services in the Department of Veterans Affairs (VA) health system is related to quality of depression care.Site surveys and administrative data from 349 VA facilities for fiscal year 2013 were used to calculate PCMHI staffing (full-time equivalents) per 10,000 primary care patients and discipline-specific staffing proportions for PCMHI psychologists, social workers, nurses, and psychiatric medication prescribers. Multivariable regression analyses were conducted at the facility level and assessed associations between PCMHI staffing ratios and the following indicators of depression treatment in the three months following a new episode of depression: any antidepressant receipt, adequacy of antidepressant receipt, any psychotherapy receipt, and psychotherapy engagement (three or more visits).Higher facility PCMHI staffing ratios were associated with a greater percentage of patients who received any psychotherapy treatment (B=1.16, p.01) and who engaged in psychotherapy (B=.39, p.01). When analyses controlled for total PCMHI staffing, the proportion of social workers as part of PCMHI was positively correlated with the percentage of patients with adequate antidepressant treatment continuation (B=3.16, p=.03). The proportion of nurses in PCMHI was negatively associated with the percentage of patients with engagement in psychotherapy (B=-2.83, p=.02).PCMHI programs with greater overall staffing ratios demonstrated better performance on indicators of psychotherapy for depression but not on indicators of antidepressant treatment. Further investigation is needed to determine whether differences in discipline-specific staffing play a causal role in driving associated differences in receipt of treatment.

Background and Aims Limited information is available regarding links between specific substance use disorders (SUDs) and suicide mortality; however, the preliminary evidence that is available suggests that suicide risk associated with SUDs may differ for men and women. This study aimed to estimate associations between SUDs and suicide for men and women receiving Veterans Health Administration (VHA) care. Design A cohort study using national administrative health records. Setting National VHA system, USA. Participants All VHA users in fiscal year (FY) 2005 who were alive at the beginning of FY 2006 (n = 4 863 086). Measurements The primary outcome of suicide mortality was assessed via FY 2006–2011 National Death Index (NDI) records. Current SUD diagnoses were the primary predictors of interest, and were assessed via FY 2004–2005 VHA National Patient Care Database (NPCD) records. Findings In unadjusted analyses, a diagnosis of any current SUD and the specific current diagnoses of alcohol, cocaine, cannabis, opioid, amphetamine and sedative use disorders were all associated significantly with increased risk of suicide for both males and females [hazard ratios (HRs)] ranging from 1.35 for cocaine use disorder to 4.74 for sedative use disorder for men, and 3.89 for cannabis use disorder to 11.36 for sedative use disorder for women]. Further, the HR estimates for the relations between any SUD, alcohol, cocaine and opioid use disorders and suicide were significantly stronger for women than men (P

Deaths of despair, a composite outcome including suicide and drug- and alcohol-related deaths, have been increasing, especially in subpopulations and geographic areas sensitive to economic and social hardships. The Veterans Health Administration (VHA) has begun evaluating the utility of this concept to guide planning and evaluations of clinical and preventive services for Veterans. In this study, mortality rates for middle-aged American men for 2013 to 2017 were from CDC WONDER, and rates for all Veterans, those using VHA healthcare services (VHA-utilizers), and other (non-VHA) Veterans were derived from National Death Index data. Findings demonstrated that rates for the composite were higher in VHA-utilizers and lower in non-VHA Veterans than middle-aged American men, consistent with use of VHA services by Veterans with the greatest needs. State rates in Veteran men were significantly and positively correlated with state rates for American men, and both were correlated with other characteristics of the social environment. The lack of correlation between rates for suicide and drug-related deaths indicates that deaths of despair cannot be modeled by assuming parallel paths from reactions to community-based stressors to the component outcomes; models should allow for an impact of community characteristics on partitioning between outcomes.

Background and objectives The purpose of this study is to assess trends in opioid-involved overdose mortality among US Veterans. Methods Age-adjusted drug overdose mortality rates, overall and by opioid subtype, were assessed from National Death Index data for US Veterans; statistical significance of trends was assessed for 2010 to 2015 and 2015 to 2016. Results Veteran age-adjusted overdose mortality rates increased 23.7% from 2010 to 2015 (19.7-24.4 of 100 000) and a further 20.4% through 2016 (29.3 of 100 000). Opioid involvement increased from 51.3% in 2010 to 62.1% in 2016, as opioid overdose rates increased from 10.9 to 19.5 of 100 000. Overdose mortality varied substantially by opioid subtype and demographics. Conclusions and scientific significance This report provides the first-ever description of trends and characteristics of overdose mortality and opioid-involved deaths among US Veterans of military service for the period 2010 to 2016. With the exception of female Veterans and Veterans in Western States, it has been found that trends in Veteran overdose mortality paralleled rising rates of drug overdose observed in the United States more broadly. Published 2020. This article is a U.S. Government work and is in the public domain in the USA. (Am J Addict 2020;00:00-00).

12130 Background: Patients diagnosed with cancer are at an increased risk of adverse mental health outcomes including suicidal behavior. Suicide rates among Veterans are 50 percent greater than for non-Veteran US adults. To inform Veterans Affairs (VA) suicide prevention initiatives, it is important to understand associations between cancer and suicide risk among Veterans receiving VA healthcare from the Veterans Health Administration (VHA). Study aims were to assess associations between new cancer diagnoses and suicide among Veterans in VHA care to identify high risk diagnostic subgroups and risk-periods. Methods: We used a cohort study design, identifying 4,926,373 Veterans with VHA use in 2011 and either 2012 or 2013 and without a VHA cancer diagnosis in 2011. Incident cancer diagnoses, assessed between first VHA use in 2012-2013 and 12/31/2018, were characterized by subtype and stage using the VHA Oncology Raw Data. Data from the VA/Department of Defense Mortality Data Repository identified date and cause of death. Cox proportional hazards regression, accounting for time-varying cancer diagnosis, was used to evaluate associations between a new cancer diagnosis and suicide risk. An initial model adjusted for VHA regional network and patient age and sex. Cancer subtypes with significant associations with suicide were further assessed using a model that also adjusted for suicide attempts and mental health, tobacco use disorder, and other substance use disorder diagnoses in the prior year. Crude suicide rates following a new cancer diagnoses were calculated among Veterans with new diagnoses, 2012-2018 (N = 240,410). Rates were assessed up to 84 months following diagnosis. Results: On average, Veteran VHA users were followed for 6.0 years after their first VHA use in 2012-2013 and for 2.7 years following a new cancer diagnosis. Receipt of a new cancer diagnosis corresponded to a 43% (Adjusted Hazard Ratio [AHR] = 1.43, 95% CI: 1.29, 1.58) higher suicide risk, adjusting for covariates. The cancer subtype associated with the highest suicide risk was esophageal cancer (AHR = 5.93, 95% CI: 4.05, 10.51) and other significant subtypes included head and neck (AHR = 3.44, 95% CI: 2.65, 4.46) and lung cancer (AHR = 2.28, 95% CI: 1.79, 2.90). Cancer stages 3 (AHR = 2.29, 95% CI: 1.75, 3.01) and 4 (AHR = 3.45, 95% CI: 2.75, 4.34) at diagnosis were also positively associated with suicide risk. Suicide rates were highest in the first three months following a diagnosis (Rate = 128.3 per 100,000 person-years, 95% CI: 100.4, 161.6) and remained elevated through the first 12 months. Conclusions: Among Veteran VHA users, suicide risk was elevated following a new cancer diagnosis and was especially high in the initial 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer, particularly among those diagnosed with esophageal, head and neck, or lung cancer or at stages 3 or 4.

Introduction The Veterans Health Administration health system uses a clinical reminder in the medical record to screen for military sexual trauma. For more than 6 million Veterans, this study assessed associations between military sexual trauma screen results and subsequent suicide mortality. Methods For Veterans who received Veterans Health Administration services in fiscal years 2007–2011 and were screened for military sexual trauma (5,991,080 men; 360,774 women), proportional hazards regressions evaluated associations between military sexually trauma and suicide risk. Models were adjusted for age, rural residence, medical morbidity, and psychiatric conditions, obtained from medical records at the year military sexual trauma screening occurred. Analyses were conducted in 2014. Results Military sexual trauma was reported by 1.1% of men and 21.2% of women. A total of 9,017 Veterans completed suicide during the follow-up period. Hazard ratios for military sexual trauma were 1.69 (95% CI=1.45, 1.97) among men and 2.27 (95% CI=1.76, 2.94) among women. Suicide risk associated with military sexual trauma remained significantly elevated in adjusted models. Conclusions Study results are among the first population-based investigations to document sexual trauma as a risk factor for suicide mortality. Military sexual trauma represents a clinical indicator for suicide prevention in the Veterans Health Administration. Results suggest the importance of continued assessments regarding military sexual trauma and suicide risks and of collaboration between military sexual trauma–related programs and suicide prevention efforts. Moreover, military sexual trauma should be considered in suicide prevention strategies even among individuals without documented psychiatric morbidity.

The TPSR Alliance has become a vital community of practice for my graduate students and for me personally. During the past decade, I (the first author) have worked with graduate students at Boston University to provide a program for youth development through sports and fitness at a large, high-needs public high school in the Boston area. Our program, “Get Ready,” is inspired by the teaching personal and social responsibility (TPSR) framework and has offered a variety of services to hundreds of students. The Get Ready program is run through the Institute for Athletic Coach Education in the School of Education at Boston University. Our efforts have been supported in part by a collaboration among Boston-area universities named “Step Up.” The goal of this effort is for universities to provide assistance to Boston public schools in closing the achievement gap and “to give our city's students the best education possible and to help them reach their full potential.”The purpose of this article is to describe the ...

Chronic pain is associated with increased risk of suicide, and opioids are commonly used to treat moderate to severe pain. However, the association between opioid dose and suicide mortality has not been examined closely. This retrospective data analysis described the risk of suicide associated with differing prescribed opioid doses. Data were from Veterans Affairs health care system treatment records and the National Death Index. Records analyzed were those of Veterans Affairs patients with chronic pain receiving opioids in fiscal years 2004 to 2005 (N = 123,946). Primary predictors were maximum prescribed morphine-equivalent daily opioid dose and opioid fill type. The main outcome measured was suicide death, by any mechanism, and intentional overdose death during 2004 to 2009. Controlling for demographic and clinical characteristics, higher prescribed opioid doses were associated with elevated suicide risk. Compared with those receiving ≤20 milligrams/day (mg/d), hazard ratios were 1.48 (95% confidence intervals [CI], 1.25-1.75) for 20 to

Key Points Question Are positive results on the Primary Care–Posttraumatic Stress Disorder Screen associated with an increase in the risk of suicide mortality among veterans receiving care in the US Veterans Health Administration system and, if so, does this risk decrease over time? Findings In this cohort study of 1 552 581 veteran patients receiving care in the US Veterans Health Administration system who were followed up through 2016, analyses of 1 693 449 screens for posttraumatic stress disorder administered in 2014 indicated a statistically significant 58% increase in the risk of suicide mortality at 1 day after a positive screening result. This risk of suicide mortality decreased over time. Meaning The study's findings indicate that additional mental health and suicide risk assessment may be warranted after a patient receives a positive result on the Primary Care–Posttraumatic Stress Disorder Screen., Importance Suicide rates are higher among veterans compared with nonveterans, and the prevalence of posttraumatic stress disorder (PTSD) is higher among veterans compared with the general adult population in the US. To date, no study has examined the association between PTSD screening results and suicide mortality among veterans. Objective To examine whether veterans receiving care in the US Veterans Health Administration (VHA) health system who had positive results on the Primary Care–Posttraumatic Stress Disorder Screen (PC-PTSD) had a greater risk of suicide mortality compared with those who had negative results and to assess whether such risk decreased over time. Design, Setting, and Participants Multivariable proportional hazards regression models were used to evaluate suicide mortality risk through December 31, 2016, among a cohort of veterans who received the PC-PTSD in the VHA health system. The VHA administers the PC-PTSD to patients nationwide, and screening results are routinely documented in the VHA Corporate Data Warehouse. The PC-PTSD includes 4 questions regarding PTSD symptoms, to which patients respond with either a positive (yes) or negative (no) answer. All patients who completed the PC-PTSD in 2014 and who did not have a diagnosis of PTSD in the year before screening were included in the analysis. A score of 3 or 4 on the PC-PTSD indicated a positive result, and a score of 0, 1, or 2 indicated a negative result. Data collection and analyses were performed from November 13, 2018, to June 18, 2019. Exposures Primary Care–Posttraumatic Stress Disorder Screen (PC-PTSD). Main Outcomes and Measures Suicide mortality risk, as assessed through data obtained from the US Veterans Affairs/Department of Defense Mortality Data Repository. Results A total of 1 693 449 PC-PTSDs were completed by 1 552 581 individual veteran patients in 2014. Most of the patients were White (73.9%), married (52.2%), male (91.1%), 55 years or older (62.5%), and had completed only 1 PC-PTSD (92.1%). In multivariable analyses, positive PC-PTSD results (ie, total scores of 3 or 4) were associated with a 58% increase in the risk of suicide mortality at 1 day after screening (hazard ratio [HR], 1.58; 95% CI, 1.19-2.10) and a 26% increase in the risk of suicide mortality at 1 year after screening (HR, 1.26; 95% CI, 1.07-1.48). A positive response on item 4 (“felt numb or detached from others, activities, or your surroundings”) of the PC-PTSD was associated with a 70% increase in suicide mortality risk at 1 day after screening (HR, 1.70; 95% CI, 1.27-2.28). Conclusions and Relevance Positive PC-PTSD results, and specifically reports of feeling numb or detached, were associated with increases in the risk of suicide mortality. These associations decreased over time. The findings of this study can inform interpretation of PC-PTSD responses and suggest the importance of recent improvements made to the VHA suicide risk assessment., This cohort study uses data from the Mortality Data Repository to examine the association between positive results on the Primary Care–Posttraumatic Stress Disorder Screen and the risk of suicide mortality among veterans receiving care in the US Veterans Administration health system.

This chapter reviews the long history of using electronic medical records and other types of big data to predict suicide. Although a number of the most recent of these studies used machine learning (ML) methods, these studies were all suboptimal both in the features used as predictors and in the analytic approaches used to develop the prediction models. We review these limitations and describe opportunities for making improvements in future applications. We also review the controversy among clinical experts about using structured suicide risk assessment tools (be they based on ML or older prediction methods) versus in-depth clinical evaluations of needs for treatment planning. Rather than seeing them as competitors, we propose integrating these different approaches to capitalize on their complementary strengths. We also emphasize the distinction between two types of ML analyses: those aimed at predicting which patients are at highest suicide risk, and those aimed at predicting the treatment options that will be best for individual patients. We explain why both are needed to optimize the value of big data ML methods in addressing the suicide problem.

Introduction To inform overdose prevention, this study assessed both recent trends in opioid overdose mortality across opioid categories and receipt of prescription opioid analgesics among Veterans who died from overdose in the Veterans Health Administration. Methods Using Veterans Health Administration records linked to National Death Index data, annual cohorts (2010–2016) of Veterans who received Veterans Health Administration care were obtained and were examined by opioid overdose categories (natural/semisynthetic opioids, heroin, methadone, and other synthetic opioids) on (1) overdose rates and changes in rates adjusted for age, sex, and race/ethnicity; and (2) Veterans Health Administration prescription opioid receipt. Analyses were conducted in 2018. Results The overall rate of opioid overdose among Veterans increased from 14.47 per 100,000 person-years in 2010 to 21.08 per 100,000 person-years in 2016 (adjusted rate ratio=1.65, 95% CI=1.51, 1.81). There was a decline in methadone overdose (adjusted rate ratio=0.66, 95% CI=0.51, 0.84) and no significant change in natural/semisynthetic opioid overdose (adjusted rate ratio=1.08, 95% CI=0.94, 1.24). However, the synthetic opioid overdose rate (adjusted rate ratio=5.46, 95% CI=4.41, 6.75) and heroin overdose rate (adjusted rate ratio=4.91, 95% CI=3.92, 6.15) increased substantially. Among all opioid overdose decedents, prescription opioid receipt within 3 months before death declined from 54% in 2010 to 26% in 2016. Conclusions Opioid overdose rates among Veterans Health Administration Veterans increased because of increases in heroin and synthetic opioid overdose rates. Prescriptions of opioids declined among patients who died from all categories of opioid overdose; by 2016, only a minority received an opioid analgesic from Veterans Health Administration within 3 months of overdose. Future prevention efforts should extend beyond patients actively receiving opioid prescriptions.

The oil palm industry has transformed rural livelihoods and landscapes across wide swathes of Indonesia and Malaysia, generating wealth along with economic, social, and environmental controversy. Who benefits and who loses from oil palm development? Can oil palm development provide a basis for inclusive and sustainable rural development? Based on detailed studies of specific communities and plantations and an analysis of the regional political economy of oil palm, this book unpicks the dominant policy narratives, business strategies, models of land acquisition, and labour-processes. It presents the oil palm industry in Malaysia and Indonesia as a complex system in which land, labour and capital are closely interconnected. Understanding the oil palm complex is a prerequisite to developing better strategies to harness the oil palm boom for a more equitable and sustainable pattern of rural development

This evaluation assessed the effectiveness of the Veterans Health Administration (VHA) program Reengaging Veterans With Serious Mental Illness in Treatment (SMI Re-Engage). The program serves veterans with serious mental illness who experience extended gaps in use of VHA care.Propensity score-weighted survival analysis that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage predicted return to VHA care within 18 months of when clinicians received patient contact information and, among veterans contacted, whether return to VHA care was associated with mortality risk within the 18-month follow-up period. Among all veterans who returned to care, a post hoc propensity score-weighted logistic regression that adjusted for demographic, clinical, and utilization factors assessed whether being contacted via SMI Re-Engage was associated with returning to outpatient care versus inpatient or emergency care.Of veterans contacted (N=886), 42% returned to care, compared with 27% of veterans whom providers attempted to contact but could not reach (N=2,059). When analyses adjusted for covariates, veterans who were contacted had a higher risk of returning to care (hazard ratio (HR)=3.40, 95% confidence interval [CI]=2.70-4.28). Among veterans contacted, the association between return to VHA care and mortality risk was not significant. Post hoc analyses for veterans who returned to care (N=941) indicated that being contacted (versus not being contacted) was associated with higher odds of returning to outpatient care (versus inpatient or emergency care) (odds ratio=2.42, CI=1.68-3.47).SMI Re-Engage contact facilitated return to VHA care. SMI Re-Engage exemplifies how population health strategies can address health care discontinuities among people with serious mental illness.

The Veterans Health Administration (VHA) has achieved substantial national implementation of primary care-mental health integration (PC-MHI) services. However, little is known regarding program characteristics, variation in characteristics across settings, or associations between program fidelity and performance. This study identified core elements of PC-MHI services and evaluated their associations with program characteristics and performance.A principal-components analysis (PCA) of reports from 349 sites identified factors associated with PC-MHI fidelity. Analyses assessed the correlation among factors and between each factor and facility type (medical center or community-based outpatient clinic), primary care population size, and performance indicators (receipt of PC-MHI services, same-day access to mental health and primary care services, and extended duration of services).PCA identified seven factors: core implementation, care management (CM) assessments and supervision, CM supervision receipt, colocated collaborative care (CCC) by prescribing providers, CCC by behavioral health providers, participation in patient aligned care teams (PACTs) for special populations, and treatment of complex mental health conditions. Sites serving larger populations had greater core implementation scores. Medical centers and sites serving larger populations had greater scores for CCC by prescribing providers, CM assessments and supervision, and participation in PACTs. Greater core implementation scores were associated with greater same-day access. Sites with greater scores for CM assessments and supervision had lower scores for treatment of complex conditions.Outpatient clinics and sites serving smaller populations experienced challenges in integrated care implementation. To enhance same-day access, VHA should continue to prioritize PC-MHI implementation. Providing brief, problem-focused care may enhance CM implementation.

Aims To evaluate treatment satisfaction in patients with type 2 diabetes (T2D), not adequately controlled by metformin, randomized to ITCA 650 (continuous exenatide in osmotic mini-pump) versus twice-daily exenatide injections (Ex-BID). Materials and Methods The Diabetes Medication Satisfaction Tool (DM-SAT) was administered and assessments made at baseline, week 8, and week 20 in a 24 week open-label phase 2 trial. In Stage I (weeks 1-12), 155 patients, comprising the ITT population, were randomized to three groups: ITCA 650 20 μg/day, ITCA 650 40 μg/day and Ex-BID 10 μg BID. In Stage II (weeks 13-24), ITCA 650 groups were re-randomized to remain on the Stage I dose or receive a higher dose. Patients treated with Ex-BID were randomized to 40 or 60 μg/day ITCA 650. Results Patients taking ITCA 650 reported significant increases in overall treatment satisfaction by week 8 versus those taking Ex-BID (p

Objectives The US Veterans Health Administration (VHA) has begun using predictive modeling to identify Veterans at high suicide risk to target care. Initial analyses are reported here. Methods A penalized logistic regression model was compared with an earlier proof-of-concept logistic model. Exploratory analyses then considered commonly-used machine learning algorithms. Analyses were based on electronic medical records for all 6,360 individuals classified in the National Death Index as having died by suicide in fiscal years 2009–2011 who used VHA services the year of their death or prior year and a 1% probability sample of time-matched VHA service users alive at the index date (n = 2,112,008). Results A penalized logistic model with 61 predictors had sensitivity comparable to the proof-of-concept model (which had 381 predictors) at target thresholds. The machine learning algorithms had relatively similar sensitivities, the highest being for Bayesian additive regression trees, with 10.7% of suicides occurred among the 1.0% of Veterans with highest predicted risk and 28.1% among the 5.0% of with highest predicted risk. Conclusions Based on these results, VHA is using penalized logistic regression in initial intervention implementation. The paper concludes with a discussion of other practical issues that might be explored to increase model performance.

This evaluation identified factors associated with outreach contact to veterans with serious mental illness (SMI) who were lost to Veterans Health Administration (VHA) care. From March 2012 through September 2013, the VHA SMI Re-Engage initiative identified 4,241 veterans for reengagement outreach; 31% of whom were successfully contacted. Higher odds of contact was associated with older age, married status, no history of homelessness, bipolar disorder diagnosis, having no recent inpatient stay, living closer to a VHA medical center, fewer years since last visit, and having a service-connected disability. Several factors are associated with recontact with veterans with SMI who are lost to VHA care. These may promote treatment engagement and retention. Study findings may inform outreach interventions to enhance access for these veterans. (PsycINFO Database Record

A reading of the social capital literature suggests that the networks and the social relationships which enable collective action can be used to address critical livelihood needs, even in disaster contexts. Yet even when such community-led approaches are combined with substantial resources, too often these interventions (re)produce vulnerabilities without recovering prior levels of development. Examining the outcomes of community-led approaches in post-tsunami Aceh after the gaze of the aid industry has moved elsewhere, this paper finds that in a few cases, interventions worked with social networks to revive livelihoods successfully, albeit in complex, contingent ways. Yet, given the nature of post-disaster contexts and the exigencies driving NGO and donors actions, the research concludes that the capacity for community based approaches to address the underlying drivers of vulnerability remains limited. The paper calls for a rewriting of intervention narratives and a reworking of intervention practices, to address the deeper determinants of disadvantage and vulnerability.

Objective Many interventions to reduce allergen levels in the home are recommended to asthma and allergy patients. One that is readily available and can be highly effective is the use of high performing filters in forced air ventilation systems. Methods We conducted a modeling analysis of the effectiveness of filter-based interventions in the home to reduce airborne asthma and allergy triggers. This work used “each pass removal efficiency” applied to health-relevant size fractions of particles to assess filter performance. We assessed effectiveness for key allergy and asthma triggers based on applicable particle sizes for cat allergen, indoor and outdoor sources of particles 70% for cat dander particles, fine particulate matter (PM2.5) and respiratory virus can lower concentrations of those asthma triggers and allergens in indoor air of the home by >50%. Very high removal efficiency filters, such as those rated a 16 on the nationally recognized Minimum Efficiency Removal Value (MERV) rating system, tend to be only marginally more effective than MERV12 or 13 rated filters. Conclusions The results of this analysis indicate that use of a MERV12 or higher performing air filter in home ventilation systems can effectively reduce indoor levels of these common asthma and allergy triggers. These reductions in airborne allergens in turn may help reduce allergy and asthma symptoms, especially if employed in conjunction with other environmental management measures recommended for allergy and asthma patients.

Since the early 1990s, primary care has been described as the de facto mental health care system in the United States. Most individuals with mental health concerns present in primary care, but the majority are either not identified or do not receive evidence-based services or guideline concordant care. Despite 20 years of research supporting the integration of mental health services into primary care, the translation of this evidence into real-world settings remains limited. The growing impetus to build comprehensive health care systems that provide care for a defined population has recently spurred interest in providing mental health care within primary care. The Department of Veterans Affairs (VA) began to systematically incorporate psychological and other mental health services into primary care in 2007. National evaluation and local program data reviewed here have demonstrated that the initiative has already improved the identification and treatment of mental health disorders in the primary care population, increased the likelihood of receiving guideline concordant care, and enhanced treatment engagement for patients referred into specialty mental health services. These results provide support for expectations that integrated care enhances access to high-quality mental health care. This article summarizes critical factors for success identified in the VA integrated care rollout. These factors are applicable for other health care organizations that seek to improve mental health services delivery.

BACKGROUND AND AIMS: Tobacco use may be a risk factor for suicide mortality; however, prior research has produced equivocal findings, and has been limited by relatively small sample sizes to study the rare event of suicide, as well as a lack of adjustment for other important factors, including psychiatric illness. We estimate the predictive association between tobacco use disorder and the risk of suicide mortality, adjusting for other important variables. DESIGN: A prospective cohort study. SETTING: The United States Veterans Health Administration (VHA). PARTICIPANTS: All individuals who received VHA services in Fiscal Year 2005 and were alive at the start of Fiscal Year 2006 (n= 4,863,086). MEASUREMENTS: Tobacco use disorder was assessed via Fiscal Year 2004-2005 VHA National Patient Care Database records. The outcome of suicide mortality was assessed during the follow-up interval from Fiscal Year 2006 through Fiscal Year 2008 using National Death Index records. FINDINGS: Of the 4,863,086 individuals in the study, 4823 died by suicide during the follow-up interval. In the unadjusted model, tobacco use disorder was associated with an increased risk of suicide (Hazard Ratio=1.88; 95% Confidence Interval=1.76, 2.02). After adjustment for model covariates, the association remained statistically significant, although attenuated (Hazard Ratio =1.36, 95% Confidence Interval =1.27, 1.46). CONCLUSIONS: Tobacco use disorder may confer a modest excess risk of death by suicide. Psychiatric disorders may partially explain the relationship between tobacco use disorder and suicide. Language: en

Comorbid mental disorders are common among suicide decedents. It is unclear if mental disorders in combination confer additive risk for suicide, in other words, if risk associated with two disorders is approximately the sum of the risk conferred by each disorder considered separately, or if there are departures from additivity such that the combined risk is less (i.e., subadditive) or more than additive (i.e., synergistic). Using a retrospective cohort design, all male Department of Veterans Affairs, Veterans Health Administration (VHA) service users who utilized VHA services in fiscal year (FY) 1999 and were alive at the start or FY 2000 (N = 2,962,810) were analyzed. Individuals were followed until death or the end of FY 2006. Using the VHA National Patient Care Database, diagnoses of mental disorders in FY 1999 were grouped into six categories (e.g., posttraumatic stress disorder). In proportional hazards models, 2-way interactions between disorders were used to examine departures from additive risk. There were 7,426 suicide deaths in the study period. Two-way interaction tests were nearly all statistically significant, indicating departures from additivity, and the results of these tests were consistent with subadditive risk. Sensitivity analyses examining the first year of follow-up showed similar results. Subadditive risk may be explained by factors that serve to lower the increased risk associated with a comorbid diagnosis, which may include common underlying causes of mental disorders, difficulties of differential diagnosis, the nature of etiological relationships between mental disorders, and intensive clinical care and monitoring of patients with comorbidity. (PsycINFO Database Record (c) 2012 APA, all rights reserved). Language: en

One reading of the social capital literature suggests that the networks and the social relationships which enable collective action can be used to address critical livelihood needs, even in disaster contexts. This paper concerns post-tsunami Aceh, where following the largest disaster in forty years, one of the biggest reconstruction programmes in history implemented livelihoods projects, making use of community led recovery approaches. This paper fi nds that social capital ideas stabilised policy thinking, legitimised project interventions, and provided a template for project action. Examining the eff ects of community led approaches in two sub-districts eight years after the tsunami, it compares the few instances in which particular livelihood projects led to enduring forms of collective action, with the majority of cases, in which these approaches failed to address the underlying drivers of vulnerability. Community led policy narratives often do not match with the logic of social action embedded in local networked space. As interventions based on social capital ideas may have limited purchase in post-disaster contexts of this kind, eff orts to address vulnerability in post-disaster contexts need to address drivers of vulnerability in agrarian livelihoods in a systematic fashion, several moves beyond the narrowly focused community led livelihood interventions of post-disaster recovery.

Background In large health care systems, decision regarding broad implementation of psychotherapies for inpatients with psychosis require substantial evidence regarding effectiveness and feasibility for implementation. It is important to recognize challenges in conducting research to inform such decisions, including difficulties in obtaining consent from and engaging inpatients with psychosis in research. We set out to conduct a feasibility and effectiveness Hybrid Type I pilot randomized controlled trial of acceptance and commitment therapy (ACT) and a semi-formative evaluation of barriers and facilitators to implementation. Findings We developed a training protocol and refined an ACT treatment manual for inpatient treatment of psychosis for use at the Veterans Health Administration. While our findings on feasibility were mixed, we obtained supportive evidence of the acceptability and safety of ACT. Identified strengths of ACT included a focus on achievement of valued goals rather than symptoms. Weaknesses included that symptoms may limit patient’s understanding of ACT. Facilitators included building trust and multi-stage informed consent processes. Barriers included restrictive eligibility criteria, rigid use of a manualized protocol, and individual therapy format. Conclusions are limited by our randomization of only 18 patient participants (with nine completing all aspects of the study) out of 80 planned. Conclusions Future studies should include (1) multi-stage informed consent processes to build trust and alleviate patient fears, (2) relaxation of restrictions associated with obtaining efficacy/effectiveness data, and (3) use of Hybrid Type II and III designs.

Background Elevated percent positivity (≥30%) of Legionella in hospital domestic water systems has been suggested as a metric for assessing the risk of health care–acquired Legionnaires' disease (LD). Methods We examined the validity of this metric by analyzing data from peer-reviewed studies containing reports of Legionella prevalence in hospital water (ie, percent positivity) and temporally matched reports of patients with health care–acquired LD. Results Our literature review identified 31 peer-reviewed publications reporting matched data. We abstracted a total of 206 data points, representing 119 hospitals, from these articles. We determined that the proposed 30% positivity metric has 59% sensitivity and 74% specificity (ie, a 41% false-negative rate and a 26% false-positive rate). These notable error rates could have significant implications, given that we identified 16 peer-reviewed articles and 6 government guidance documents that referenced the 30% positivity metric as a risk assessment tool. Conclusions Environmental sampling of hospital water distribution systems for Legionella can be an important component of risk management for LD. However, the possible consequence of using a percent positivity metric with low sensitivity and specificity is that many hospitals might fail to mitigate when a true risk is present, or might unnecessarily allocate limited resources to deal with a negligible risk.

Over recent years, systems of civil or private regulation have emerged across several commodity sectors in developing countries. This paper compares two regulatory systems applied to parallel food and forestry problems: the Forest Stewardship Council (FSC) and the Roundtable on Sustainable Palm Oil (RSPO). Analysing these regulations as attempts to extend procedural and distributional justice into contested forested and agricultural spaces, the paper examines the paradox that, despite successful advocacy campaigns using these regulatory standards, oil palm and timber estates and associated land conflicts continue to proliferate in Indonesia. These regulatory processes provide leverage within bounded spaces, yet they are limited by an incommensurability of values and interests that reflect underlying structural problems. At best these certification schemes provide limited learning tools. Addressing the underlying problems will require legal reforms, effective State engagement and supporting forms of accountability.

BACKGROUND: Studies report mixed findings regarding antidepressant agents and suicide risks, and few examine suicide deaths. Studies using observational data can accrue the large sample sizes needed to examine suicide death, but selection biases must be addressed. We assessed associations between suicide death and treatment with the 7 most commonly used antidepressants in a national sample of Department of Veterans Affairs patients in depression treatment. Multiple analytic strategies were used to address potential selection biases. METHODS: We identified Department of Veterans Affairs patients with depression diagnoses and new antidepressant starts between April 1, 1999, and September 30, 2004 (N = 502,179). Conventional Cox regression models, Cox models with inverse probability of treatment weighting, propensity-stratified Cox models, marginal structural models (MSM), and instrumental variable analyses were used to examine relationships between suicide and exposure to bupropion, citalopram, fluoxetine, mirtazapine, paroxetine, sertraline, and venlafaxine. RESULTS: Crude suicide rates varied from 88 to 247 per 100,000 person-years across antidepressant agents. In multiple Cox models and MSMs, sertraline and fluoxetine had lower risks for suicide death than paroxetine. Bupropion had lower risks than several antidepressants in Cox models but not MSMs. Instrumental variable analyses did not find significant differences across antidepressants. DISCUSSION: Most antidepressants did not differ in their risk for suicide death. However, across several analytic approaches, although not instrumental variable analyses, fluoxetine and sertraline had lower risks of suicide death than paroxetine. These findings are congruent with the Food and Drug Administration meta-analysis of randomized controlled trials reporting lower risks for "suicidality" for sertraline and a trend toward lower risks with fluoxetine than for other antidepressants. Nevertheless, divergence in findings by analytic approach suggests caution when interpreting results. Language: en

Assertive Community Treatment (ACT) is a mobile team-based outpatient service model for providing comprehensive psychiatric care and case management supports to persons with serious mental illnesses. Clients suitable for ACT services are severely ill and intensively use inpatient psychiatric care. For these individuals traditional outpatient services may not be adequate to prevent the need for acute care (Stein and Test 1980; Phillips et al. 2001). It has become accepted wisdom that ACT programs are cost-neutral or cost-saving (Phillips et al. 2001), a perception that may be based on dramatic reductions of psychiatric inpatient use in early experiments with ACT during the late 1970s and early 1980s (Weisbrod, Test, and Stein 1980), an era when lengthy psychiatric inpatient stays were still prevalent (Manderscheid et al. 1985). However, this perception could be outdated because of the dramatic reductions in inpatient mental health use by the population of disabled persons with serious mental illness in most state public mental health systems and the U.S. Department of Veterans Affairs (VA) health care system (Witkin, Atay, and Manderscheid 1996; Sturm and Bao 2000; Zuvekas 2001; Greenberg and Rosenheck 2010). Using data from the VA health care system, this study estimates the effects of ACT services on VA costs and inpatient mental health services utilization, examining whether cost savings from ACT were affected by a decline in VA inpatient mental health utilization. The ACT is considered one of the most effective approaches for delivering services to people with severe and persistent mental illness (Rosenheck and Neale 1998a, b; Latimer 1999; Phillips et al. 2001). ACT brings together essential services and staff members from different disciplines in order to support clients in the community rather than in inpatient settings (Bond et al. 2001). The ACT model requires a clinician team leader, normally a social worker or psychologist, as well as one or more nurses, a psychiatrist, and a substance abuse specialist (Teague, Bond, and Drake 1998). Teams maintain a low client–staff ratio (the model-specified maximum ratio is 12 : 1) and accept complete responsibility for the care of clients (Stein and Test 1980). Services are available 24 hours a day, 7 days a week, and care is fully mobile. In 2010, more than 65,000 persons with serious mental illness were enrolled in more than 800 ACT programs in 38 U.S. states and in the VA health care system (NASMHPD Research Institute, I. 2009; Neale et al. 2009). ACT services can cost from $6,000 to more than $12,000 per client annually (Latimer 1999), and clients may continue receiving ACT services indefinitely. Since the early 1980s, several evaluations have demonstrated that, despite ACT's substantial up-front costs, enrollment in an ACT program can result in lower overall mental health costs, primarily because ACT clients use less inpatient mental health care (Weisbrod, Test, and Stein 1980; Latimer 1999; Phillips et al. 2001). This body of evidence supported rapid dissemination of ACT programs into public mental health systems during the 1980s and 1990s (Richardson 1999; Veterans Health Administration 2004). Although ACT services can be cost-neutral, evidence suggested that the cost neutrality of ACT depends critically on whether programs select clients whose number of inpatient bed days immediately prior to ACT entry is sufficiently high (Rosenheck, Neale, and Frisman 1995; Rosenheck et al. 1995). This evidence influenced the VA's decision to limit entry into ACT services to patients with “high hospital use,” defined as having more than 30 inpatient mental health bed days or at least 3 inpatient mental health admissions in the previous 12 months (Veterans Health Administration 2004). The mediating impact of ACT program entrants' prior inpatient mental health use on the cost consequences of ACT may have become more salient over time as a result of the dramatic declines in use of inpatient care by persons with severe and persistent mental illness (Witkin, Atay, and Manderscheid 1996; Sturm and Bao 2000; Zuvekas 2001; Greenberg and Rosenheck 2010). These changes were driven by various factors, including widespread dissatisfaction with institutional care in state psychiatric hospitals (Geller 2000a) and states' increased use of Medicaid as a source of financing for inpatient mental health care (Geller 2000b); Medicaid generally excludes coverage for non-elderly adults' stays in “institutions for mental diseases” (Geller 2000b). As a result of these declines, ACT-related cost savings from reduced inpatient use as well as the number of potential ACT clients for whom ACT services would be cost-saving would be expected to decline. Such changes may have critical implications for public financing of ACT services and other ACT-like intensive case management models. Meanwhile, evidence on the impacts of ACT on costs and inpatient use is almost entirely based on data from experimental ACT programs rather than on “real-world” ACT programs deployed into public mental health systems. The effectiveness of ACT services could be more variable in practice than has been shown in experimental settings, because real-world ACT programs both in the VA and elsewhere do not have uniform fidelity to the ACT model (Salyers et al. 2003). Data from all VA ACT programs in fiscal years 2001–2004 (FY01–FY04) were used to examine the impacts of entry into an ACT program on newly enrolled clients' inpatient utilization and mental health costs during the first 12 months of enrollment. We examined both the average program impact and differential (i.e., marginal) program impacts for clients with greater versus fewer inpatient bed days before program entry. VA ACT clients' mental health services utilization and health care costs were compared with the services utilization and costs of a similar group of VA patients who met administrative eligibility criteria for VA ACT services during the same time period but did not enroll in ACT. To address selection bias, we combined two analytic approaches, propensity score matching (Rosenbaum and Rubin 1983; Ho et al. 2007) and instrumental variables estimation (Angrist, Imbens, and Rubin 1996; Heckman 1996; Hogan and Lancaster 2004). While propensity score matching resulted in a comparison group that was similar to ACT enrollees in terms of measured characteristics, the instrumental variables method was needed to address selection bias due to unmeasured confounders. The study's instrumental variables were based on variations in VA patients' access to ACT services during fiscal years 2001–2004, a period of rapid dissemination of new VA ACT programs.

Objectives. Using national patient cohorts, we assessed rural–urban differences in suicide rates, risks, and methods in veterans. Methods. We identified all Department of Veterans Affairs (VA) patients in fiscal years 2003 to 2004 (FY03–04) alive at the start of FY04 (n = 5 447 257) and all patients in FY06–07 alive at the start of FY07 (n = 5 709 077). Mortality (FY04–05 and FY07–08) was assessed from National Death Index searches. Census criteria defined rurality. We used proportional hazards regressions to calculate rural–urban differences in risks, controlling for age, gender, psychiatric diagnoses, VA mental health services accessibility, and regional administrative network. Suicide method was categorized as firearms, poisoning, strangulation, or other. Results. Rural patients had higher suicide rates (38.8 vs 31.4/100 000 person-years in FY04–05; 39.6 vs 32.4/100 000 in FY07–08). Rural residence was associated with greater suicide risks (20% greater, FY04–05; 22% greater, FY07–08). Firearm deaths were more common in rural suicides (76.8% vs 61.5% in FY07–08). Conclusions. Rural residence is a suicide risk factor, even after controlling for mental health accessibility. Public health and health system suicide prevention should address risks in rural areas.

Objectives. We sought to examine rates of suicide among individuals receiving health care services in Veterans Health Administration (VHA) facilities over an 8-year period. Methods. We included annual cohorts of all individuals who received VHA health care services from fiscal year (FY) 2000 through FY 2007 (October 1, 1999–September 30, 2007; N = 8 855 655). Vital status and cause of death were obtained from the National Death Index. Results. Suicide was more common among VHA patients than members of the general US population. The overall rates of suicide among VHA patients decreased slightly but significantly from 2000 to 2007 (P Conclusions. VHA health care system patients are at elevated risk for suicide and are appropriate for suicide reduction services, although the rate of suicide has decreased in recent years for this group. Comprehensive approaches to suicide prevention in the VHA focus not only on recent returnees from Iraq and Afghanistan but also on middle-aged and older Veterans.

Despite dramatic increases in the rate of fatal accidental overdose in recent years, risk factors for this outcome remain poorly understood, particularly in clinical populations. The authors examined the association of psychiatric and substance use diagnoses with death from accidental overdose.The study followed a cohort of patients from 2000 to 2006. The cohort included all patients treated in Veterans Health Administration facilities during fiscal year 1999 who were alive at the start of fiscal year 2000 (N=3,291,891). Death by accidental overdose was determined using National Death Index records and defined as a death with underlying cause of death coded to ICD-10 codes X40-X45 (N=4,485). Diagnoses were determined by patient medical records.Adjusting for demographic and clinical characteristics, hazard ratios of death by accidental overdose associated with prior psychiatric and substance use disorder diagnoses ranged from 1.8 to 8.8. Significant associations of non-substance-related psychiatric disorders with risk of death by accidental overdose persisted after additional adjustment for substance use disorders (hazard ratios from 1.2 to 1.8). Depressive disorders and anxiety disorders other than posttraumatic stress disorder had stronger associations with risk of medication-related overdose death (hazard ratios, 3.02 and 3.07, respectively) than with risk of overdose death related to alcohol or illegal drugs (hazard ratios, 1.89 and 1.23, respectively).Among patients receiving care from the Veterans Health Administration, death from accidental overdose was found to be associated with psychiatric and substance use disorders. The study findings suggest the importance of risk assessment and overdose prevention for vulnerable clinical subpopulations.