Stimulant medication and suicide mortality in attention-deficit hyperactivity disorder.

Patients diagnosed with attention-deficit hyperactivity disorder (ADHD) are at an elevated risk for suicide. No prior work has assessed the association between stimulant prescriptions and death by suicide in this population. This retrospective cohort study included Department of Veterans Affairs patients with an active ADHD diagnosis that received stimulant medications between 2016 and 2019. We found that months with active stimulant medication prescription was associated with decreased risk of suicide mortality compared with months without stimulant medication (odds ratio 0.57, 95% CI 0.36-0.88). Our results suggest that prescribing stimulant medications for patients diagnosed with ADHD is associated with decreased risk of suicide mortality.

Development and validation of a prognostic index for mental health and substance use disorder burden.

OBJECTIVE: To develop an accessible index which quantifies MHSUD burden among patients of Veterans Affairs hospitals. METHOD: We used 21 disorder categories provided by the diagnostic and statistical manual (DSM) to characterize diagnoses among primary care (PC) patients. For each patient, we generated counts of unique disorder categories present during the PC encounter or in the year prior. We used these counts to generate multiple indexes, which we compared in a 60% training sample of our population. Using model fit statistics generated from ordered multinomial logistic regressions, we identified the subset of DSM categories which, structured as index, were most predictive of MHSUD hospitalization and death. We validated and fine-tuned the form of the selected index in the full population using measures of calibration and discrimination. RESULTS: In model development, the index (I-6) which best fit the data (R2 = 0.191) included the following six disorder categories: substance use, depressive, psychotic, bipolar, trauma, and personality. When applied in the full population and weighted by disorder severity, this index demonstrated good predictive discrimination for MHSUD death (C = 0.66) and hospitalization (C = 0.88) and was well calibrated in comparisons of observed versus predicted outcomes. CONCLUSIONS: We recommend the I-6 as a parsimonious and effective tool for MHSUD burden risk adjustment.

Examination of increasing suicide rates among rural Hispanic VA patients.

PURPOSE: Death by suicide is increasing more rapidly among Hispanics than non-Hispanics who use United States Department of Veterans Affairs (VA) health services, and the increase is most rapid among those living in rural areas. Our goal was to identify characteristics of rural Hispanic VA patients that contribute to this emerging disparity. METHODS: We linked electronic medical records from the VA, personnel data from the US Department of Defense, mortality data from the US National Death Index, and data on area characteristics from the US Census Bureau to examine suicide trends among Hispanic VA patients from 2005 through 2019. After identifying the strongest predictors of suicide in the rural and urban Hispanic populations, we examined how those characteristics changed over time. FINDINGS: Age and sex-adjusted suicide mortality rates were consistently higher for rural versus urban Hispanic patients beginning in 2012, with the most recent rolling 5-year average rates being 31.0 per 100,000 for rural compared to 20.3 per 100,000 for urban in 2019. Models to predict suicide had fair performance in the rural (accuracy = 0.62, 95% CI: 0.51, 0.73) and urban (accuracy = 0.67, 95% CI: 0.63, 0.70) groups. Mental health diagnoses were predictive of suicide among rural Hispanic patients, but there was no evidence that mental health diagnoses were increasing more rapidly in rural compared to urban patients. CONCLUSIONS: While we confirmed that there is a higher rate of death by suicide among rural Hispanic VA patients relative to their urban counterparts, we were unable to identify clear drivers of this finding.

A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder.

OBJECTIVE: Mortality from opioid use disorder (OUD) can be reduced for patients who receive opioid agonist treatment (OAT). In the United States (US), OATs have different requirements including nearly daily visits to a dispensing facility for methadone but weekly to monthly prescriptions for buprenorphine. Our objective was to compare mortality rates for buprenorphine and methadone treatments among a large sample of US patients with OUD. METHODS: We measured all-cause mortality, overdose mortality, and suicide mortality among US Department of Veterans Affairs patients with a diagnosis of OUD who received OAT from 2010 through 2019. We leveraged substantial and sustained regional variation in prescribing buprenorphine versus methadone as an instrumental variable (IV) and used inverse propensity of treatment weighting to balance relevant covariates across treatment groups. We compared mortality with true two-stage IV using both probit and linear probability models, as well as a reduced form IV model, adjusting for demographics and health status. RESULTS: Our cohort consisted of 61,997 patients with OUD who received OAT, of whom 92.7% were male with a mean age of 47.9 (SD = 14.1) years. Patients were followed for a median of 2 (IQR = 1,4) calendar years. Across regional terciles, mean methadone prescribing was 4.8%, 19.5%, and 75.1% of OAT patients. All models identified significant reductions in all-cause and suicide mortality for buprenorphine relative to methadone. For example, predicted all-cause mortality from the probit model was 169.7 per 10,000 person years (95% CI, 157.8, 179.6) in the lowest tercile of methadone prescribing compared with 206.1 (95% CI, 196.0, 216.3) in the highest tercile. No difference was identified for overdose mortality. CONCLUSION: We found significantly lower all-cause mortality and suicide mortality rates for buprenorphine compared with methadone. Our results support the less restrictive prescribing practices for buprenorphine as OAT in the US.

Rural and Urban Hispanic Patients of the Veterans Health Administration.

Hispanic Veterans are the largest growing racial and ethnic minority group in the Veterans Health Administration (VA) system. Though recent research has found increasing suicide rates in this population and a growing rural-urban disparity, literature on core population characteristics remains sparse. We used extensive patient demographic and clinical data from VA's electronic medical record repository to examine geographic and longitudinal variation in Hispanic VA patients from 2001 to 2018. As the first such detailed characterization of this population, this study was largely descriptive in nature, and included heatmaps of Hispanic patient residence across rural and urban US counties, along with descriptive measures of patient characteristics by rurality, and first year of VA use. We found that Hispanic patients (n = 722,893) represented 5.2% of new VA users between 2001 and 2018, a proportion which grew nearly 90% from 4.0% (2001-2006) to 7.5% (2013-2018). Hispanic patients were largely White, male, under age 50, and had minimal illness or disability. The highest prevalence of Hispanic patients was in the Southwest US/Mexico border region, while the Midwest experienced the largest growth of Hispanic patients. Rural Hispanic patients were more likely to be older, male, and to live in areas characterized by small foreign-born populations and high socioeconomic deprivation. Compared with Hispanic patients entering the VA system in 2001-2006, patients in 2013-2018 were younger, more likely to be female, and to live in urban areas. These findings illustrate the wide range of demographic, clinical, and geographic experiences in the growing VA Hispanic population and demonstrate that culturally competent care for Hispanic Veterans must reflect their intra-ethnic diversity.

National cross-sectional cohort study of the relationship between quality of mental healthcare and death by suicide.

BACKGROUND: Patient safety-based interventions aimed at lethal means restriction are effective at reducing death by suicide in inpatient mental health settings but are more challenging in the outpatient arena. As an alternative approach, we examined the association between quality of mental healthcare and suicide in a national healthcare system. METHODS: We calculated regional suicide rates for Department of Veterans Affairs (VA) Healthcare users from 2013 to 2017. To control for underlying variation in suicide risk in each of our 115 mental health referral regions (MHRRs), we calculated standardised rate ratios (SRRs) for VA users compared with the general population. We calculated quality metrics for outpatient mental healthcare in each MHRR using individual metrics as well as an Overall Quality Index. We assessed the correlation between quality metrics and suicide rates. RESULTS: Among the 115 VA MHRRs, the age-adjusted, sex-adjusted and race-adjusted annual suicide rates varied from 6.8 to 92.9 per 100 000 VA users, and the SRRs varied between 0.7 and 5.7. Mean regional-level adherence to each of our quality metrics ranged from a low of 7.7% for subspecialty care access to a high of 58.9% for care transitions. While there was substantial regional variation in quality, there was no correlation between an overall index of mental healthcare quality and SRR. CONCLUSION: There was no correlation between overall quality of outpatient mental healthcare and rates of suicide in a national healthcare system. Although it is possible that quality was not high enough anywhere to prevent suicide at the population level or that we were unable to adequately measure quality, this examination of core mental health services in a well-resourced system raises doubts that a quality-based approach alone can lower population-level suicide rates.

Electroconvulsive Therapy and Death by Suicide.

Background: It is currently unclear if a course of electroconvulsive therapy (ECT) is associated with a decreased risk of death by suicide. The limited literature based on evidence either does not reflect contemporary practice or else includes patients receiving as few as one treatment. We sought to examine the association of an adequate exposure to ECT treatment with risk of death by suicide in a present-day sample.Methods: We conducted a study using electronic medical record data from the Department of Veterans Affairs health system from between 2000 and 2017. We compared all-cause and suicide mortality among patients who received an index course of ECT with a comparison group created through propensity score matching.Results: Our sample included 5,157 index courses of ECT. The suicide death rate in those receiving ECT was 137.34 deaths per 10,000 in 30 days and 804.39 per 10,000 in 365 days. The rate of death by suicide in the control group was 138.65 per 10,000 in 30 days and 564.52 per 10,000 in 1 year. The relative risk of death by suicide comparing those receiving an index course of ECT and the matched group was 0.96 (95% CI, 0.38-1.55; P = .994) in 30 days and 1.38 (95% CI, 0.88-1.87; P = .10) in 1 year.Conclusion: The risk of suicide mortality 30 days and 1 year following treatment was similar in patients treated with an index course ECT and in a matched group. There was no evidence that an ECT course decreased the risk of death by suicide.

Optimizing Data on Race and Ethnicity for Veterans Affairs Patients.

INTRODUCTION: Maintaining accurate race and ethnicity data among patients of the Veterans Affairs (VA) healthcare system has historically been a challenge. This work expands on previous efforts to optimize race and ethnicity values by combining multiple VA data sources and exploring race- and ethnicity-specific collation algorithms. MATERIALS AND METHODS: We linked VA patient data from 2000 to 2018 with race and ethnicity data from four administrative and electronic health record sources: VA Medical SAS files (MedSAS), Corporate Data Warehouse (CDW), VA Centers for Medicare extracts (CMS), and VA Defense Identity Repository Data (VADIR). To assess the accuracy of each data source, we compared race and ethnicity values to self-reported data from the Survey of Health Experiences of Patients (SHEP). We used Cohen's Kappa to assess overall (holistic) source agreement and positive predictive values (PPV) to determine the accuracy of sources for each race and ethnicity separately. RESULTS: Holistic agreement with SHEP data was excellent (K > 0.80 for all sources), while race- and ethnicity-specific agreement varied. All sources were best at identifying White and Black users (average PPV = 0.94, 0.93, respectively). When applied to the full VA user population, both holistic and race-specific algorithms substantially reduced unknown values, as compared to single-source methods. CONCLUSIONS: Combining multiple sources to generate race and ethnicity values improves data accuracy among VA patients. Based on the overall agreement with self-reported data, we recommend using non-missing values from sources in the following order to fill in race values-SHEP, CMS, CDW, MedSAS, and VADIR-and in the following order to fill in ethnicity values-SHEP, CDW, MedSAS, VADIR, and CMS.

Veteran drug overdose mortality, 2010-2019.

BACKGROUND: Prior work documents that Veteran drug overdose mortality increased from 2010 to 2016. The present study assessed trends from 2010 to 2019, by drug type and recent receipt of Veterans Health Administration (VHA) services, and compared rates for Veteran and non-Veteran US adults. METHODS: This retrospective cross-sectional study used data from Veterans Affairs (VA) medical records, the VA/Department of Defense Mortality Data Repository, and CDC WONDER. Trends were compared using Joinpoint regression. RESULTS: From 2010-2019, age-adjusted overdose mortality rates increased 53.2% among Veterans and 79.0% among non-Veterans. Age-adjusted rates of overdose mortality among Veterans rose from 19.8/100,000 in 2010 to 32.6/100,000 in 2017, before falling to 30.3/100,000 in 2019. Despite the decrease from 2017 to 2019 in overall overdose mortality, rates of overdose deaths involving synthetic opioids other than methadone and involving psychostimulants continued to increase through 2019. In 2019, overdose mortality was lower for male Veterans than male non-Veterans (standardized rate ratio (SRR) = 0.81, 95% confidence interval (CI): 0.77-0.84). Among male Veterans, rates were higher in all years for those with recent VHA use than those without (2019: SRR=1.69, 95% CI: 1.56-1.83). From 2010-2019, overdose mortality rates increased faster among female Veterans without VHA use than those with VHA use. CONCLUSIONS: From 2015 onward, Veteran men experienced lower age-adjusted overdose rates than non-Veteran men. In all years, overdose rates were higher among male Veterans with recent VHA use than those without recent use. While overall rates of Veteran overdose deaths declined from 2017 to 2019, rates involving psychostimulants and synthetic opioids continued to rise.

Influence of contextual factors on death by suicide in rural and urban settings.

PURPOSE: To examine the association between contextual factors, represented by geographic and community health variables, and suicide among rural and urban Department of Veterans Affairs health care users (VA users). METHODS: We performed a retrospective cohort study of 12,700,847 VA users between 2003 and 2017. We assigned contextual factors based on individuals' home address at the ZIP Code (area deprivation), county (sunlight exposure, altitude, and community health), and state level (firearm ownership), using publicly available data sources. We grouped contextual factors by quintiles or prespecified thresholds, depending on the nature of each variable. We obtained mortality data from the National Death Index. We measured the effect of living in a place with the highest versus lowest level of each contextual factor on odds of suicide using logistic regression, adjusting for individual compositional factors abstracted from VA electronic medical records data. We used random forest modeling to build prediction models for suicide based on contextual factors among rural and urban veterans. FINDINGS: Almost all contextual factors we examined were significantly associated with suicide among rural and urban VA users, even after adjusting for individual compositional factors. However, no contextual variables were strong protective or risk factors (0.52.0), and prediction models leveraging these contextual factors had poor accuracy among both rural (0.51, 95% CI: 0.48-0.54) and urban (0.53, 95% CI: 0.51-0.55) VA users. CONCLUSIONS: A wide variety of contextual factors is significantly associated with suicide among rural and urban VA users. However, the factors we measured contributed very little to individual-level suicide risk.

Suicide Mortality Among Veterans Health Administration Care Recipients With Suicide Risk Record Flags.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

The role of race in rural-urban suicide disparities.

PURPOSE: To assess the role that race-ethnicity plays in modifying the observed rural-urban disparity in suicide among Veteran Health Administration (VHA) users. METHODS: We performed a retrospective cohort study of 10,737,864 VHA users between 2003 and 2017, using cross-linked VHA medical records and National Death Index mortality data to assess longitudinal race-stratified rural-urban differences in age- and sex-adjusted annual suicide rates. We used Poisson regression and generated incident rate ratios (IRRs) to formally assess the impact of race on the rural-urban suicide disparity. Given evidence of effect modification, we performed additional race-stratified Poisson regression models. FINDINGS: Rurality is significantly associated with a higher risk of suicide in models which do not control for race (IRR = 1.14, 95% CI: 1.10-1.17). However, when race is added to the model, rural residence is no longer significant (0.98, CI: 0.95-1.01). Stratified models demonstrate that rural residence is significantly associated with a higher suicide risk among Hispanic VHA users (1.41, CI: 1.11-1.79), but it is not substantially associated with suicide among White (0.97, CI: 0.94-1.00) and Black (1.03, CI: 0.86-1.23) VHA users. White VHA users have considerably higher suicide rates than Black and Hispanic VHA users, though the suicide rate among Hispanic VHA users, particularly those in rural settings, increased markedly over the period of observation. CONCLUSIONS: Race significantly modifies the relationship between rural residence and suicide risk. Studies seeking to assess suicide disparity between rural and urban VHA user populations must include adjustment or stratification by race.

Effects of Electroconvulsive Therapy on Suicidal Behavior and Emergency Department Use Among Homeless Veterans: A Propensity Score-Matched Study.

Objective: This study examined the effects of electroconvulsive therapy (ECT) on suicidal ideation, suicide attempt, and emergency department use among homeless veterans receiving services in the Veterans Affairs (VA) health care system.Methods: National VA administrative data from 2001 to 2017 were analyzed using propensity score matching to compare 1,524 homeless veterans who received ECT and 3,025 homeless veterans discharged from psychiatric inpatient units serving as matched controls.Results: Homeless veterans who received ECT were significantly less likely to have used any ED services 30 and 90 days after their first ECT session compared to homeless veterans who did not receive ECT (OR = 0.65, 95% CI = 0.60-0.71; OR = 0.86, 95% CI = 0.81-0.93, respectively). Homeless veterans who received ECT showed reductions in suicidal ideation and suicide attempts after ECT, but these reductions were significantly less than homeless veterans who did not receive ECT 30 days, 90 days, and 1 year later (OR = 1.48-2.00).Conclusions: ECT has the potential to reduce ED use among homeless veterans with ECT-responsive psychiatric conditions. Further study is needed on whether the treatment engagement required of ECT participants indirectly reduces use of acute services in this population.

Small Area Analysis of Veterans Affairs Mental Health Services Data.

OBJECTIVE: To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment. METHODS: MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period. RESULTS: A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles. CONCLUSIONS: MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.

Recent trends in the rural-urban suicide disparity among veterans using VA health care.

There is an elevated risk of suicide among people living in rural areas, and the rural-urban disparity in death by suicide is growing in the general United States population. The department of Veterans Affairs (VA) implemented programs targeting rural health in 2007 and suicide prevention in 2008. Rural-urban differences in suicide rates among VA users have not been examined since 2010. We sought to understand whether the rural-urban disparity in suicide risk among VA users decreased during a time of contemporaneous VA efforts to improve access to mental health care for rural Veterans and to improve the effectiveness of mental health services at preventing suicide. We performed a retrospective cohort study examining differences in the raw and adjusted annual suicide rate among rural and urban VA users between 2003 and 2017. All VHA users 2003-2017. Descriptive statistics are presented for all VHA users in 2017. This includes 6,120,355 unique VA users, 32.0% (n = 1,955,935) of whom lived at a rural address. Raw rates of death by suicide were higher in rural VA users than urban VA users overall (33.3 vs. 29.1 deaths per 100,000 population) and across years, but the age, sex, and race-adjusted rates converged in 2005. White VA users had over triple the rate of death by suicide as black VA users, and lived disproportionally in rural areas. The rural-urban suicide disparity among VA users persists. However, the disparity appears to be driven by differences in the racial composition of rural and urban patients, which were not accounted for in prior studies.

Mortality after electroconvulsive therapy.

BACKGROUND: There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths. AIMS: We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year. METHOD: We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching. RESULTS: Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79-1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66-0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65-1.73) for all-cause mortality, and 1.02 (95% CI 0.58-1.8) for all-cause mortality excluding suicide deaths. CONCLUSIONS: There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.

Effects of Electroconvulsive Therapy on Short-Term Suicide Mortality in a Risk-Matched Patient Population.

OBJECTIVE: Although evidence has suggested that electroconvulsive therapy (ECT) is effective in reducing suicidal ideation, research establishing the effectiveness of ECT in reducing short-term risk of death by suicide is less conclusive. This study assessed whether receipt of ECT reduced suicide mortality among patients seeking healthcare in Veterans Health Administration hospitals. METHODS: Annual cohorts of patients who received ECT between 2006 and 2015 were propensity score matched with mental health patients who did not receive ECT. After matching, population averaged adjusted odds were calculated to assess the risk of suicide in the year after receipt of ECT, compared with a control group. RESULTS: The study population consisted of 14,810 patients in the ECT cohort and 58,369 matched controls. Matching successfully reduced clinical and demographic differences between cohorts of patients who received ECT and those who did not (asymptotic Kolmogorov-Smirnov statistic = 0.02, P > 0.99). After matching and controlling for remaining between-group differences in an adjusted logistic regression, the odds of suicide in the year after receipt of ECT were not statistically different from those of matched patients who did not receive the procedure (odds ratio = 1.31, 95% confidence interval = 0.94-1.96, P = 0.095). CONCLUSIONS: Patients who received ECT were at a high risk for suicide. Electroconvulsive therapy did not seem to have a greater effect on decreasing short-term risk for suicide than other types of mental health treatment provided to patients with similar baseline risk.

Brief Report: Opioid-Involved Overdose Mortality in United States Veterans.

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).

Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics.

OBJECTIVES: The body of large-scale, epidemiological research on electroconvulsive therapy (ECT) in the United States is limited. To address this gap, we assessed demographic, clinical, pharmacological, and mental health treatment history as well as 2-year mortality outcomes associated with ECT use in the largest U.S. health care system. METHODS: Among all patients who sought mental health care at Veterans Health Administration (VHA) hospitals in 2012, we used bivariate analyses to compare patients who did and not receive ECT during 2 years of follow-up. Among the population who received ECT, descriptive statistics were calculated to characterize prior mental health treatment patterns and ECT receipt. RESULTS: 0.11% (N = 1616) of all VHA mental health patients in 2012 (N = 1,457,053) received ECT in 2 years of follow-up. There was significant regional variation in provision of ECT. Those who received ECT were more likely to have diagnoses of major depressive, bipolar, and personality disorders and were significantly more likely to have had a recent mental health inpatient stay (risk ratio, 6.94). Receipt of ECT was not associated with a difference in all-cause mortality (risk ratio, 0.88). Thirty-two percent of those who received ECT had no substantial antidepressant or therapy trial in the year before index mental health encounter. CONCLUSIONS: Use of ECT in the VHA is rare. Patients who receive ECT have a complex and high-risk profile, not necessarily consistent with the most common indications for ECT.

Causes of Excess Mortality in Veterans Treated for Posttraumatic Stress Disorder.

INTRODUCTION: Published research indicates that posttraumatic stress disorder (PTSD) is associated with increased mortality. However, causes of death among treatment-seeking patients with PTSD remain poorly characterized. The study objective was to describe causes of death among Veterans with PTSD to inform preventive interventions for this treatment population. METHODS: A retrospective cohort study was conducted for all Veterans who initiated PTSD treatment at any Department of Veterans Affairs Medical Center from fiscal year 2008 to 2013. The primary outcome was mortality within the first year after treatment initiation. In 2018, collected data were analyzed to determine leading causes of death. For the top ten causes, standardized mortality ratios (SMRs) were calculated from age- and sex-matched mortality tables of the U.S. general population. RESULTS: A total of 491,040 Veterans were identified who initiated PTSD treatment. Mean age was 48.5 (±16.0) years, 90.7% were male, and 63.5% were of white race. In the year following treatment initiation, 1.1% (5,215/491,040) died. All-cause mortality was significantly higher for Veterans with PTSD compared with the U.S. population (SMR=1.05, 95% CI=1.02, 1.08, p<0.001). Veterans with PTSD had a significant increase in mortality from suicide (SMR=2.52, 95% CI=2.24, 2.82, p<0.001), accidental injury (SMR=1.99, 95% CI=1.83, 2.16, p<0.001), and viral hepatitis (SMR=2.26, 95% CI=1.68, 2.93, p<0.001) versus the U.S. POPULATION: Of those dying from accidental injury, more than half died of poisoning (52.3%, 325/622). CONCLUSIONS: Veterans with PTSD have an elevated risk of death from suicide, accidental injury, and viral hepatitis. Preventive interventions should target these important causes of death.