摘要：Objectives . We examined self-reported suicidal behavior of older homeless veterans to establish frequencies and predictors of recent suicidal behaviors, and their impact on transitional housing interventions. Methods . We analyzed the records of a national sample of 10 111 veterans who participated in a transition housing program over a 6-year period, ending in 2008. Results . Approximately 12% of homeless veterans reported suicidal ideation before program admission; 3% reported a suicide attempt in the 30 days before program admission. Older homeless veterans exhibiting suicidal behavior had histories of high rates of psychiatric disorders and substance abuse. Regression analyses showed that self-report of depression was the primary correlate of suicidal behavior. Suicidal behavior before program entry did not predict intervention outcomes, such as program completion, housing outcome, and employment. Conclusions . Suicidal behavior was prevalent in older homeless veterans and was associated with a history of psychiatric disorder and substance abuse. Self-reported depression was associated with these behaviors at the time of housing intervention. Despite the association with poor mental health history, suicidal behavior in older homeless veterans did not impact outcomes of transitional housing interventions. Across all age groups, suicide is the 11th leading cause of death and seventh leading cause of death among men. 1 Historically, the rate of suicide has been highest in the elderly, and the rate among older men is approximately 7 times that among women. Suicide attempts among the elderly are more likely to be lethal than among younger age groups. This finding has been attributed to declines in physical condition, making survival less likely, social isolation reducing the probability of successful rescue, and suicide attempts that are more carefully planned. 2 Several factors constitute notable risk factors for suicide among the elderly. 3 These include the presence of physical health factors, alcohol abuse, stressful life events, social isolation, and Axis I psychiatric disorders (especially depressive disorders). In interviews with surviving relatives of older suicide victims, Duberstein et al. 4 found that being unmarried, unemployed, financially disabled, and having a psychiatric disorder were the most common factors. Suicidal ideation is typically, but not always, a precursor to suicide attempts or self-harm and provides an estimate of the population that is usually considered to be at immediate risk. In analyses of data from the Canadian Community Health Survey, Corna et al. 5 reported relatively low general population rates (slightly more than 2%) of suicidal ideation occurred in the past year. Estimates of lifetime suicide ideation and attempts among a nationally representative sample of US adults suggested a similar presence. Results from analyses of data obtained from the 2008 National Survey of Drug Use and Health reported that 3.7% of adults thought about suicide in the past 12 months, and 0.5% reported a suicide attempt. 6 Because US veterans are predominantly older individuals with substantial medical morbidities, high levels of substance abuse and mental illness, and increased knowledge of and access to firearms, 7–9 it is not surprising that some research reported that male veterans were at approximately twice the risk for suicide than male nonveterans. 10 However, the associations between history of military service and risk for suicide are not clear. 11 For example, subsequent studies of male veterans in the general population failed to identify increased risk among middle-aged and elderly males. 12 Among veterans receiving care from the Veterans Health Administration (VHA), suicide risk for men and women combined across all age groups was estimated to be 66% higher than that observed in the general population. 13 For male veterans, the risk in age groups 50 to 70 years was 56% to 108% greater than that in the general male population. The frequency of suicidal ideation also appeared to be higher in veterans receiving VHA health services. In a study of older veterans receiving services in Veterans Affairs (VA) primary care clinics, Ayalon et al. 14 found that 5% of veterans reported suicidal ideation in the 2 weeks before assessment. Notably, this same study found that poorer cognitive functioning contributed to the occurrence of suicidal ideation. From the standpoint of health risk, a particularly vulnerable group of veterans are those that are homeless. The most recent estimates 15 indicate that approximately one seventh of the adult homeless population consists of veterans. Current point-in-time population estimates suggest that 75 000 or more veterans are homeless on any given night, and about twice as many experience homelessness at some point during the course of a year. Veteran status is associated with increased risk for homelessness; a larger percentage of veterans are homeless than in either the general population or the population living in poverty. Studies of homeless veterans revealed exceptionally high rates of significant psychiatric disorders, alcohol and drug abuse, and chronic medical conditions. 16 These factors are potentiated by the impact of aging in the veteran population. Current estimates show that more than 20% of homeless veterans are aged 55 years or older. Thus, cognitive decline because of aging and possible early onset of degenerative dementias adds to the cumulative impact of health risks in older homeless veterans. Although it is anticipated that the increasing health vulnerability produced by these risk factors increases morbidity and reduces life expectancies because of all-cause mortality, few studies have approached these issues in a programmatic manner. Much of what we know about homeless suicidal behavior is based on data from the Access to Community Care and Effective Services and Supports (ACCESS) program. 17 The ACCESS program provided clinical mental health services to 7224 individuals in 15 cities across the country. All participants were homeless adults with evidence of serious mental illness who self-reported a suicide attempt in the 30 days before admission to the program or a 2-week period of persistent serious thoughts of suicide in the same 30-day period. In the aged 55 years and older ACCESS group, 3.5% of participants reported a suicide attempt, and 19.0% reported persistent suicidal ideation in this 30-day period. 18 Roughly equivalent estimates were obtained in studies of veterans. In a sample of 34 245 veterans (mean age = 46.6 years) who sought treatment of substance abuse or psychiatric disorders, 3.4% of veterans reported an attempted suicide in the month before seeking services. 19 A similar study of 600 veterans (mean age = 56.3 years) who sought treatment of substance abuse at a Midwestern VA revealed that 40.0% reported current suicidal ideation as determined by an established cutoff score on a suicidal ideation self-report scale. 20 The limited research to date suggests that older homeless veterans may be at substantively greater risk for suicidal behavior than are individuals in the general population. We attempted to expand the research literature on suicidal behavior in this target group by reporting analyses of self-reported suicidal behavior (ideation and attempts) in a large sample of older homeless veterans admitted into a nationwide VA housing intervention program. The data set allowed us to provide estimates of the frequencies of recent suicidal behaviors, predictors of suicidal behaviors, and the impact of suicidal behaviors on interventional outcomes.
