Suicide screening protocols implemented in veteran and general populations reduced suicides, but making such screening tools more efficient remains a challenge, according to a pair of studies.
After the Veterans Health Administration implemented the Veterans Affairs Suicide Risk Identification Strategy (Risk ID) in 2018, results were positive in outpatient visits for 3.5% and 0.4% of primary and secondary screenings, respectively, and results were positive in emergency settings for 3.6% and 2.1% of primary and secondary screenings, respectively, reported Nazanin Bahraini, PhD, Rocky Mountain Regional VA Medical Center in Aurora, Colorado, and colleagues.
Compared to patients in ambulatory care, patients screened in the emergency department were more likely to endorse suicidal ideation with intent (odds ratio 4.55, 95% CI 4.37-4.74, P<0.001), have a specific plan (OR 3.16, 95% CI 3.04-3.29, P<0.001), and report recent suicidal behavior (OR 1.95, 95% CI 1.87-2.03, P<0.001) during secondary screening, Bahraini’s group wrote in JAMA Network Open.
Risk ID includes three tiers of screening starting with the nine-item Patient Health Questionnaire, followed by the Columbia Suicide Severity Rating Scale Screener and the VHA’s Comprehensive Suicide Risk Evaluation.
“The greater acuity of suicide risk among patients in the ED or [urgent care clinics] cohort compared with those in the [ambulatory care] cohort supports national implementation of evidence-based suicide prevention programs, such as Safety Planning in the ED,” Bahraini and co-authors wrote.
Suicide screening is recommended for all veterans, who have a 21% higher risk of dying by suicide than the general population.
However, close to two-thirds of veterans who die by suicide do not seek healthcare from the VA, indicating that many suicides will still be missed in VA screening initiatives, noted Roy H. Perlis, MD, MSc, of Massachusetts General Hospital and Harvard Medical School in Boston, and Stephan D. Fihn, MD, MPH, of the University of Washington in Seattle, in an accompanying editorial.
“Although the VA is not representative of general clinical practice, these numbers provide a useful reference for estimating the yield of routine screening in these settings,” Perlis and Fihn wrote.
Another study published in JAMA Network Open, from the Kaiser Permanente system in California and Washington, examined the practicality of a risk-based alert system to identify patients who may attempt suicide.
The tool was developed from electronic health records and included characteristics such as depression symptoms, mental health visits, and past suicide attempts to estimate suicide risk. When patients entered a certain adjustable risk threshold, the tool would deploy an alert to physicians.
Using the 95th percentile threshold, the tool yielded 162 daily alerts and demonstrated a positive predictive value of 6.4%. (That works out to a number-needed-to-screen of 17 to prevent one suicide attempt, Perlis and Fihn calculated.) In contrast, the system sent out four alerts per day at the 99.5th risk percentile.
“While this provides useful estimates for planning, many key effectiveness, clinical, operational, ethical and legal questions remain,” the study’s lead author Andrea H. Kline-Simon, MS, of Kaiser’s research division in Oakland, California, told MedPage Today in an email.
Regardless of the accuracy of screening tools, such prevention measures will only be effective if there are also interventions available to reduce suicides, Perlis and Fihn noted in their editorial.
A third study in JAMA Network Open, focusing on a program called “Wingman-Connect” for U.S. Air Force personnel, provided insight into what such interventions might look like.
The program built kinship and mentorship among Air Force personnel classes and taught young enlistees who had just finished basic training what mental health and institutional resources were available to them.
Compared to airmen assigned to a control stress management program, those in Wingman-Connect reported significantly lower suicidal ideation severity (effect size −0.23, 95% CI −0.39 to −0.09, P=0.001), reduced depression symptoms (ES −0.24, 95% CI −0.41 to −0.08, P=0.002), and fewer occupational problems at one month follow-up (ES −0.14, 95% CI −0.31 to −0.02, P=0.02), reported Peter A. Wyman, PhD, of the University of Rochester School of Medicine and Dentistry in New York.
By 6 months, however, only the effects on depression remained significant (ES -0.16, 95% CI -0.34 to -0.02, P=0.03), Wyman said. Notably, the program was shown to strengthen cohesive, healthy class units, which was identified as a pathway in reducing suicidal ideation severity and depression.
“The fact that gains in cohesive healthy class units was a mechanism indicates we need more interventions like this, and to expand them to focus beyond individual training on the strengths of the natural groups military people are a part of,” Wyman told MedPage Today. “There is a need to extend this program upward to follow airmen through their careers.”
While the study adds to the literature that group-based interventions are effective in reducing depressive symptoms and could be advantageous in resource-constrained environments, it does not explicitly demonstrate prevention of suicide, Perlis and Fihn noted.
Also, groups were not blinded to their intervention, Wyman’s group acknowledged, and the network building was performed by researchers and not Air Force personnel, as it would be in the field.
“Whether targeted strategies to reduce suicide are worthwhile, rather than simply developing better treatments for depression, remains to be studied,” Perlis and Fihn wrote.
They suggested that reducing suicides will require a “multipronged approach,” including “concerted initiatives” from government and healthcare agencies to address the underlying problems that contribute to suicide risk, like substance use and depression.
“The studies in this issue underscore the challenges; if the will to invest in mental health is there, these represent hard but ultimately tractable problems,” Perlis and Fihn wrote.
Bahraini reported receiving grants from the VA Office of Mental Health and Suicide Prevention, and the VA Suicide Risk Identification Strategy was funded by the VHA Office of Mental Health and Suicide Prevention.
One of Kline-Simon’s co-authors reported receiving grants from the National Institute of Mental Health, and her study was funded by the Kaiser Foundation Hospitals and The Permanente Medical Group.
Wyman’s co-authors reported many ties with industry and his study was funded by the Office of the Assistant Secretary of Defense for Health Affairs.
Finally, Perlis reported receiving funding from RID Ventures, Takeda, Genomind, Outermost Therapeutics, Psy Therapeutics, and Burrage Capital.