摘要：Objectives. We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89 995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006. Methods. We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes. Results. African Americans (18% of sample; 16 252) were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI] = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI. Conclusions. The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity. The Veterans Health Administration (VHA) recognizes suicide as a key public health concern and prioritizes outreach to suicidal veterans with implementation of effective prevention measures. 1 In civilian and veteran populations, suicide claims more than 36 000 lives each year or 100 lives a day, including approximately 18 veterans; the suicide rate has been increasing since 2000. 2–4 Although individuals who commit suicide constitute a small proportion of the population, suicidal thoughts and behaviors are among the strongest predictors of suicide. 5 People may become suicidal in response to a life event or psychosocial stressor that overwhelms their ability to cope and control, especially in the presence of a psychiatric disorder. 6 Although susceptibility to suicidal behavior and ideation (SBI) may vary across major subgroups in the community, such as racial or ethnic groups, little research on this variability exists, especially under conditions of known stress. Historically, suicidal behavior in African Americans and Latinos has received little attention because of the limited number of documented suicides among these subgroups. 7,8 A full exploration of potential underreporting of SBI by race/ethnicity is beyond the scope of this article, but the role of race/ethnicity in risk of SBI can be explored in the context of receiving care in the VHA. The VHA treats a large patient population, including 25% to 30% non-White veterans 9 ; eliminating known disparities in care is a great concern and high priority. Furthermore, veterans in the general US population may be at greater risk for suicide compared with nonveterans, 10 and this trend is not limited to younger veterans. Older veterans continue to have completed suicides rates that exceed those of younger veterans, as noted in both popular and scientific publications. 11,12 Veterans with severe mental illness appear to undergo surgery at high rates, 13 and it is well-established that those with mental health diagnoses are at higher risk for presenting with SBI. 1,14–16 Although we know that many risk factors for suicide have been identified, such as the curvilinear relationship of age with suicide, male gender, and physical and mental disorders, no reports that we know of have explored whether the months following surgery are a time of heightened risk for suicidal behavior, and whether this risk varies by racial/ethnic minority status. Both pain and depression are commonly experienced by patients who have undergone surgical procedures; symptoms may arise at various times postoperatively, varying from immediately after surgery to months later. Depression in response to an illness or injury that requires surgery can have an added impact on the emotional state of a person and potentiate SBI following surgery. Some studies suggest that pain management is influenced by a patient’s race, with varying pain sensitivity 17–19 and treatment 20,21 observed among different racial and ethnic subgroups. Studies have shown that African American and Hispanic persons report a lower tolerance for experimentally-induced pain compared with White adults. 22,23 There have been, to our knowledge, no assessments of SBI in association with postoperative pain in civilians or in veterans in the VHA system. Because of the high prevalence of mental health comorbidity and chronic pain among VHA surgery patients, they may be an exceptionally at-risk group with multiple risk factors for SBI. These factors are also treatable, so that identifying surgery-related risk factors may provide new intervention points for suicide prevention. To provide the best integrated medical–mental health care, health care systems need to know whether postoperative SBI risk varies by preoperative factors, suggesting the need to provide interventions to those at high risk for SBI in the context of a health care–related life stressor: major surgery. We investigated SBI as a postsurgical outcome among VHA surgery patients by pre-existing severe mental illness status, race and ethnicity, as well as other demographic characteristics and clinical covariates.
