Clinical Scorecard: VHA Care Use and Suicide Risk Among Veterans After Military Separation
At a Glance
Category
Detail
Condition
Suicide mortality after military separation among Army veterans
Key Mechanisms
The study compared age-adjusted suicide rates and time-dependent suicide hazards by VHA service use, timing of care, and type of care; it did not assess causal mechanisms.
Target Population
649,811 Army soldiers who returned from deployment to Afghanistan or Iraq during fiscal years 2008–2014 and separated from service by September 2017
Care Setting
Postseparation VHA care, including outpatient and inpatient services, and VA-paid fee-for-service community care
Key Highlights
Among VHA users, the age-adjusted average annual suicide rate was 28.77 per 100,000 person-years, compared with 35.92 among nonusers (rate ratio, 0.80; 95% CI, 0.68–0.94).
Nonusers had higher time-dependent suicide hazard rates during the first 2 years after separation; estimates showed no difference in year 3, were higher among users in year 4, and showed no subsequent difference.
Among VHA users, those initiating care within 12 months had higher early hazard-rate point estimates than those whose initial use was delayed; the delayed-use estimate was based on fewer than 16 events. The relationship generally continued through years 2–6, while delayed users’ estimates rose and were highest among timing categories in years 6–11.
First-year VHA inpatient care was associated with substantially elevated suicide hazard-rate point estimates that remained higher in later follow-up periods.
The authors reported that findings support enhanced suicide prevention care delivered by the VHA, while noting limitations including selection bias, misclassification, residual confounding, and historical cohort data.
Guideline-Based Recommendations
Diagnosis
Suicide fatalities were identified through the National Death Index and VA and Defense mortality data using ICD-10 codes X60–X84 and Y87.0.
Management
The authors state that the findings support enhanced suicide prevention care delivered by the VHA.
Monitoring & Follow-up
The study assessed suicide mortality from October 1, 2007, through December 31, 2018, with a maximum follow-up of 11.3 years.
Suicide rates and hazards varied over time after separation and by VHA service-use category.
Risks
Interpretation is limited by selection bias, possible suicide misclassification, less complete clinical information among nonusers, and residual confounding.
The authors note that care patterns and suicide prevention initiatives have changed since this historical cohort.
Patient & Prescribing Data
The cohort included 649,811 separated Army veterans who had returned from deployment to Afghanistan or Iraq during fiscal years 2008–2014; 488,362 used VHA services and 161,449 did not.
This observational study compared outcomes by VHA use, timing of initial care, and service type; it did not evaluate a prescribed treatment or establish that VHA use caused differences in suicide risk.
by Lisa A. Brenner, Jeri E. Forster, Claire A. Hoffmire, Jaimie L. Gradus, Trisha A. Hostetter, Mary Jo Larson, Alexandra L. Schneider, Alexandra A. Smith, Colin G. Walsh, Rachel Sayko Adams
