Suicide Among Veterans in 16 States, 2005 to 2008: Comparisons Between Utilizers and Nonutilizers of Veterans Health Administration (VHA) Services Based on Data From the National Death Index, the National Violent Death Reporting System, and VHA Administrative Records

摘要

Objectives. We sought to compare suicide rates among veterans utilizing Veterans Health Administration (VHA) services versus those who did not. Methods. Suicide rates from 2005 to 2008 were estimated for veterans in the 16 states that fully participated in the National Violent Death Reporting System (NVDRS), using data from the National Death Index, NVDRS, and VHA records. Results. Between 2005 and 2008, veteran suicide rates differed by age and VHA utilization status. Among men aged 30 years and older, suicide rates were consistently higher among VHA utilizers. However, among men younger than 30 years, rates declined significantly among VHA utilizers while increasing among nonutilizers. Over these years, an increasing proportion of male veterans younger than 30 years received VHA services, and these individuals had a rising prevalence of diagnosed mental health conditions. Conclusions. The higher rates of suicide for utilizers of VHA among veteran men aged 30 and older were consistent with previous reports about which veterans utilize VHA services. The increasing rates of mental health conditions in utilizers younger than 30 years suggested that the decreasing relative rates in this group were related to the care provided, rather than to selective enrollment of those at lower risk for suicide. Since the start of the wars in Afghanistan and Iraq, there has been increasing interest in suicide among American military veterans. This reflects a number of important issues. First, veterans constitute a sizeable population that has been identified as being at increased risk for suicide by some 1,2 but not all, 3 research studies. Second, there is increasing evidence that suicide may be a consequence of the stresses related to the experience of deployment and combat. 4 Third, there have been concerns about the extent to which the Veterans Health Administration (VHA), the Department of Veterans Affairs (VA) health care system, has addressed the needs of veterans, especially those who have returned from service in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), the wars in Afghanistan and Iraq. Since the start of OEF and OIF, there have been a number of reports on rates and risk factors for death from suicide among all American veterans, independent of whether they have received VHA health care services, 1–3,5–9 as well as a greater number of reports on those who utilize VHA services, 10–22 and on mixed samples. 23 Currently, the literature is not clear as to whether rates in veterans as a whole are higher than those for other Americans after controlling for demographic variables. However, there is evidence for increased rates in veterans utilizing VHA health care services. To date, there have been no reports of comparisons between veterans who utilize VHA services (utilizers) and those who do not (nonutilizers). This information is critical to advance a population-based approach to suicide prevention in veterans; to evaluate how the burden of suicide is distributed in the total veteran population; and to assess how completely VHA, the nation’s largest integrated health care system, addresses the needs of the population it was established to serve. Comparisons between suicide rates among veterans who are VHA utilizers versus nonutilizers can also provide information on the impact of recent changes in the VHA and the patients it serves. Toward the end of 2005, VHA began to implement a mental health strategic plan based on recommendations from the President’s New Freedom Commission on Mental Health 24 as well as recognition of the mental health needs of returning veterans. At the same time, VHA began to increase the budget for mental health services to support this strategy. As a result of these enhancements, systemwide VA mental health staffing increased 26.1%, from 13?667 at the start of 2005 to 17?234 at the end of 2008. Over this same period, the total number of veterans seen per year in VHA increased 3.6%, from 5.02 million in 2005 to 5.20 million in 2008; the number with diagnosed mental health conditions increased 15.0%, from 1.45 to 1.69 million; and the percentage of veteran patients with mental health conditions increased by 11.1%, from 28.9% to 32.1%. 25 Veterans returning from OEF and OIF are all eligible for VHA services during the first 5 years after they return from deployment without additional requirements. For veterans who served in previous eras, VHA eligibility is determined by factors such as service-connected health conditions, disability, age, and income. 26 The differences in eligibility requirements, as well as differences in the recency of deployment and the acuity of deployment-related conditions, suggest the importance of testing for differences between age groups both when comparing suicide rates in veterans who are VHA utilizers versus nonutilizers and when evaluating changes in rates over time. For our study, we compared rates of suicide and assessed changes over time