标题：Suicide Mortality Among Individuals Receiving Treatment for Depression in the Veterans Affairs Health System: Associations with Patient and Treatment Setting Characteristics
摘要：Objectives. We sought to report clinical and demographic factors associated with suicide among depressed veterans in an attempt to determine what characteristics identified depressed veterans at high risk for suicide. Methods. We used longitudinal, nationally representative data (1999–2004) to determine suicide rates among depressed veterans, estimating time until suicide using Cox proportional hazards regression models. Results. Of 807694 veterans meeting study criteria, 1683 (0.21%) committed suicide during follow-up. Increased suicide risks were observed among male, younger, and non-Hispanic White patients. Veterans without service-connected disabilities, with inpatient psychiatric hospitalizations in the year prior to their qualifying depression diagnosis, with comorbid substance use, and living in the southern or western United States were also at higher risk. Posttraumatic stress disorder (PTSD) with comorbid depression was associated with lower suicide rates, and younger depressed veterans with PTSD had a higher suicide rate than did older depressed veterans with PTSD. Conclusions. Unlike the general population, older and younger veterans are more prone to suicide than are middle-aged veterans. Future research should examine the relationship between depression, PTSD, health service use, and suicide risks among veterans. Suicide is a complex, multidetermined phenomenon. 1 There are individual-level biological and psychological contributors, in addition to social, environmental, and economic risk factors. 2 – 4 Rates of suicide also differ based on demographic and clinical characteristics. In the general population, the incidence of suicide is higher among older than among younger individuals 5 and among males than among females. 6 Whites are more likely to commit suicide than are African Americans, and older White men have the highest risk of suicide among all age and race groups. 6 Suicide rates vary with rates of gun ownership, poverty, employment status, geographical location, and levels of social support, 4 , 7 , 8 as well as other clinical and demographic characteristics. The US Surgeon General, 9 the Institute of Medicine, 4 and the Department of Veterans Affairs 10 (VA) recognize suicide as a key public health problem in need of a national strategy for suicide prevention. Patients with psychiatric disorders, particularly depressive disorders, are at much greater risk for suicide than those in the general population. 11 – 16 Approximately 5% to 12% of men and 10% to 25% of women will have a major depressive episode during their lifetimes, and higher percentages will experience significant depressive symptoms, which increases their risk for suicide. 17 , 18 Of patients treated for depression in a variety of settings, approximately 2% to 7% die from suicide, 19 , 20 with higher rates of suicide occurring among patients who have been hospitalized for depression. 3 , 14 , 19 , 21 Patients with co-occurring disorders, such as depression and alcohol abuse or depression and posttraumatic stress disorder (PTSD), have been reported to be at much higher risk for suicide than patients with only 1 of these disorders. 11 , 12 , 22 , 23 Patients with prior hospitalizations for psychiatric disorders, such as depression or prior suicide attempts, are also at higher risk of suicide. 24 – 26 The relationship between depression and other risk factors for suicide is likely complex. Qin et al. found that having a psychiatric disorder increased suicide risk more among women than among men. 7 Major depression also may increase suicide risk more among older adults than among younger adults. 14 As a group, veterans may be at particularly high risk for suicide as a result of their high prevalence of depressive disorders and comorbid psychiatric conditions. According to the Veterans Health Study, the prevalence of significant depressive symptoms among veterans is 31%, 2- to 5-times higher than among the general US population. 27 In 2002, 12% of veterans treated in VA health care facilities were diagnosed with depressive disorders by a health care provider during an encounter. 28 Among veterans, as in the general population, completed suicide is usually associated with a mental disorder, most often depressive disorders and alcohol or substance use disorders; those with comorbid psychiatric disorders are at highest risk. 29 , 30 Because of limited research examining completed suicide, little is known about the relative risks of suicide associated with demographic and clinical factors among depressed veterans. Among depressed patients, the relative risk of suicide among men compared with among women appears to be smaller than that seen for the same comparison among the general population. 7 , 31 Pokorny reported that, among former VA psychiatric inpatients, older patients did not have a greater suicide risk than did younger patients. 32 Thompson et al. reported that the relative risk of suicide deaths in the VA was 2.3 for Whites compared with African Americans, 26 which is the same as relative risk of suicide between Whites and African Americans in the general population. 6 However, among former VA medical center psychiatric inpatients, Desai et al. reported relative risks for suicide of only 1.5 among men compared with those among women, but relative risks of 3.8 among Whites compared with those among African Americans 33 —a race disparity that is substantially higher than that observed in the general population. 6 Several investigators have noted the importance of determining risk profiles for the particular population being targeted. 26 Clinicians use this information as “background knowledge” when completing suicide assessments. Administrators also need this information to be able to design, evaluate, and target interventions to decrease suicide risks. In this study, we examined associations between demographic and clinical characteristics and risk of suicide among veterans treated for depression in the VA health system. Based on previous studies of veterans, we hypothesized that the differential risks for suicide associated with being older, male, White, and having medical comorbidities would be smaller within the depressed VA patient population than has been reported for the general population. We also hypothesized that patients with depression and comorbid substance use, PTSD, or a recent psychiatric hospitalization would be at higher risk for suicide than would be patients who have depression without these psychiatric comorbidities.
