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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.

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model.

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.

The purpose of this article is to first provide PE teachers with an understanding of the different types of trauma students face, including traumatic events, historical trauma experienced by member...

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.

Among veterans in Veterans Health Administration (VHA) care, patients with mental health and substance use conditions experience elevated suicide rates. However, despite previously demonstrated high rates of suicidal behavior, little is known regarding suicide rates among veteran VHA users with personality disorders (PDs) as a whole, or by PD clusters (A: Eccentric; B: Dramatic; C: Fearful; and PD-not otherwise specified). PD prevalence and suicide rates were assessed through 2017; overall and by clusters for 5,517,024 veterans alive as of 12/31/2013 and with more than 2 VHA encounters in 2012-2013. In all, 46,050 (.83%) had a PD diagnosis in 2012-2013. Suicide risk was examined using proportional hazards regressions adjusted for age, sex, veteran status, clustering within a geographic region, and other mental health diagnoses. Patients with PDs had greater suicide risk than those without (156.5 vs. 46.7 per 100,000 person-years). Individuals in Cluster B, which includes borderline and antisocial PDs, were at the highest risk (178.5 per 100,000 person-years), followed by PD-not otherwise specified and Cluster C (152.6 and 121.4 per 100,000 person-years, respectively). Rates of PDs in the VHA system were lower than those usually found in community samples. Veterans with a PD diagnosis had an increased risk of suicide, which was especially elevated for those with Cluster B diagnoses. Study findings document the importance of enhancing diagnosis and treatment for veterans with PDs and targeted suicide prevention services. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Community advocates for land rights justice in post-reformasi Indonesia frame their claims in terms of either indigenous (adat) rights or agrarian justice discourses. This study considers how these...

Despite economic growth in middle-income countries across the global south, pockets of food poverty persist in the countryside. An accepted account suggests that many of the poor are stuck in a 'tr...

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...