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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., (© Published 2021. This article is a U.S. Government work and is in the public domain in the USA.)

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., (© Published 2021. This article is a U.S. Government work and is in the public domain in the USA.)

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.

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.