title: Predicting suicides after outpatient mental health visits in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).
abstract: The 2013 US Veterans Administration/Department of Defense Clinical Practice Guidelines (VA/DoD CPG) require comprehensive suicide risk assessments for VA/DoD patients with mental disorders but provide minimal guidance on how to carry out these assessments. Given that clinician-based assessments are not known to be strong predictors of suicide, we investigated whether a precision medicine model using administrative data after outpatient mental health specialty visits could be developed to predict suicides among outpatients. We focused on male nondeployed Regular US Army soldiers because they account for the vast majority of such suicides. Four machine learning classifiers (naive Bayes, random forests, support vector regression and elastic net penalized regression) were explored. Of the Army suicides in 2004-2009, 41.5% occurred among 12.0% of soldiers seen as outpatient by mental health specialists, with risk especially high within 26 weeks of visits. An elastic net classifier with 10-14 predictors optimized sensitivity (45.6% of suicide deaths occurring after the 15% of visits with highest predicted risk). Good model stability was found for a model using 2004-2007 data to predict 2008-2009 suicides, although stability decreased in a model using 2008-2009 data to predict 2010-2012 suicides. The 5% of visits with highest risk included only 0.1% of soldiers (1047.1 suicides/100 000 person-years in the 5 weeks after the visit). This is a high enough concentration of risk to have implications for targeting preventive interventions. An even better model might be developed in the future by including the enriched information on clinician-evaluated suicide risk mandated by the VA/DoD CPG to be recorded.
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: R C
authors.initials: RC
authors.lastname: Kessler
authors.affiliation: Departments of Psychiatry and Family and Preventive Medicine, University of California San Diego, La Jolla, CA, USA.|VA San Diego Healthcare System, San Diego, CA, USA.
authors.forename: M B
authors.initials: MB
authors.lastname: Stein
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: M V
authors.initials: MV
authors.lastname: Petukhova
authors.affiliation: Darla Moore School of Business, University of South Carolina, Columbia, SC, USA.
authors.forename: P
authors.initials: P
authors.lastname: Bliese
authors.affiliation: Post Deployment Health Service, Department of Veterans Affairs, Washington DC, USA.
authors.forename: R M
authors.initials: RM
authors.lastname: Bossarte
authors.affiliation: Department of Psychiatry and Behavioral Science, Stony Brook School of Medicine, Stony Brook, NY, USA.
authors.forename: E J
authors.initials: EJ
authors.lastname: Bromet
authors.affiliation: Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA.
authors.forename: C S
authors.initials: CS
authors.lastname: Fullerton
authors.affiliation: Health Behavior Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.|Departments of Epidemiology and Social and Behavioral Sciences, Harvard TH Chan School of Public Health, Boston, MA, USA.
authors.forename: S E
authors.initials: SE
authors.lastname: Gilman
authors.affiliation: US Army Medical Command, Behavioral Health Service Line, Bethesda, MD, USA.
authors.forename: C
authors.initials: C
authors.lastname: Ivany
authors.affiliation: Institute for Social Research, University of Michigan, Ann Arbor, MI, USA.
authors.forename: L
authors.initials: L
authors.lastname: Lewandowski-Romps
authors.affiliation: US Army Public Health Command, Aberdeen Proving Ground, MD, USA.
authors.forename: A
authors.initials: A
authors.lastname: Millikan Bell
authors.affiliation: Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Naifeh
authors.affiliation: Department of Psychology, Harvard University, Cambridge, MA, USA.
authors.forename: M K
authors.initials: MK
authors.lastname: Nock
authors.affiliation: Children's Hospital Boston and Harvard Medical School, Boston, MA, USA.
authors.forename: B Y
authors.initials: BY
authors.lastname: Reis
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: A J
authors.initials: AJ
authors.lastname: Rosellini
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: N A
authors.initials: NA
authors.lastname: Sampson
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors.forename: A M
authors.initials: AM
authors.lastname: Zaslavsky
authors.affiliation: Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University School of Medicine, Bethesda, MD, USA.
authors.forename: R J
authors.initials: RJ
authors.lastname: Ursano
mesh_terms: D000328:Adult; D001499:Bayes Theorem; D003198:Computer Simulation; D005544:Forecasting / Q000379:methods*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000523:psychology; D008603:Mental Health; D008889:Military Personnel; D010045:Outpatients; D055500:Resilience, Psychological; D018570:Risk Assessment; D012307:Risk Factors; D013405:Suicide / Q000523:psychology* / Q000706:statistics & numerical data; D013406:Suicide, Attempted / Q000523:psychology; D014481:United States; D000092864:Suicide Prevention