title: Correlates of suicide among veterans treated in primary care: case-control study of a nationally representative sample.
abstract: BACKGROUND
  Veterans receiving Veterans Affairs (VA) healthcare have increased suicide risk compared to the general population. Many patients see primary care clinicians prior to suicide. Yet little is known about the correlates of suicide among patients who receive primary care treatment prior to death.
  
  
  OBJECTIVE
  Our aim was to describe characteristics of veterans who received VA primary care in the 6 months prior to suicide; and to compare these to characteristics of control patients who also received VA primary care.
  
  
  METHODS
  This was a retrospective case-control study.
  
  
  METHODS
  The investigators partnered with VA operations leaders to obtain death certificate data from 11 states for veterans who died by suicide in 2009. Cases were matched 1:2 to controls based on age, sex, and clinician.
  
  
  METHODS
  Demographic, diagnosis, and utilization data were obtained from VA's Corporate Data Warehouse. Additional clinical and psychosocial context data were collected using manual medical record review. Multivariate conditional logistic regression was used to examine associations between potential predictor variables and suicide.
  
  
  RESULTS
  Two hundred and sixty-nine veteran cases were matched to 538 controls. Average subject age was 63 years; 97 % were male. Rates of mental health conditions, functional decline, sleep disturbance, suicidal ideation, and psychosocial stressors were all significantly greater in cases compared to controls. In the final model describing men in the sample, non-white race (OR = 0.51; 95 % CI = 0.27-0.98) and VA service-connected disability (OR = 0.54; 95 % CI = 0.36-0.80) were associated with decreased odds of suicide, while anxiety disorder (OR = 3.52; 95 % CI = 1.79-6.92), functional decline (OR = 2.52; 95 % CI = 1.55-4.10), depression (OR = 1.82; 95 % CI = 1.07-3.10), and endorsement of suicidal ideation (OR = 2.27; 95 % CI = 1.07-4.83) were associated with greater odds of suicide.
  
  
  CONCLUSIONS
  Assessment for anxiety disorders and functional decline in addition to suicidal ideation and depression may be especially important for determining suicide risk in this population. Continued development of interventions that support identifying and addressing these conditions in primary care is indicated.
authors.affiliation: Center to Improve Veteran Involvement in Care, Portland Veterans Affairs Medical Center, P.O. Box 1034 (R&D 66), Portland, OR, 97207, USA, steven.dobscha@va.gov.
authors.forename: Steven K
authors.initials: SK
authors.lastname: Dobscha
authors.forename: Lauren M
authors.initials: LM
authors.lastname: Denneson
authors.forename: Anne E
authors.initials: AE
authors.lastname: Kovas
authors.forename: Alan
authors.initials: A
authors.lastname: Teo
authors.forename: Christopher W
authors.initials: CW
authors.lastname: Forsberg
authors.forename: Mark S
authors.initials: MS
authors.lastname: Kaplan
authors.forename: Robert
authors.initials: R
authors.lastname: Bossarte
authors.forename: Bentson H
authors.initials: BH
authors.lastname: McFarland
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D005260:Female; D006302:Health Services Research / Q000379:methods; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000453:epidemiology / Q000523:psychology; D008875:Middle Aged; D011320:Primary Health Care; D013405:Suicide / Q000523:psychology* / Q000706:statistics & numerical data; D014481:United States / Q000453:epidemiology; D014728:Veterans / Q000523:psychology* / Q000706:statistics & numerical data; D058014:Veterans Health / Q000706:statistics & numerical data