With Depression, Vets Face Higher Suicide Risk

MONDAY Jan. 12, 2009 -- About a third of the veterans treated in Veterans Affairs hospitals suffer from depression, putting them at much greater risk of suicide than non-depressed veterans, University of Michigan researchers report.

But is that risk greater at certain times, and might it be related to their use of antidepressants, the researchers wondered?

Their five-year study of veterans with depression revealed a spike in suicide risk after discharge from a psychiatric hospital and a relatively short-term increase in risk after beginning treatment with an antidepressant. The findings were published in the January issue of the Journal of Affective Disorders.

"The goal of this study was to determine suicide rates during potentially high risk periods for patients with depressive disorders," said lead researcher Dr. Marcia Valenstein, a clinical psychiatrist at the VA Ann Arbor Healthcare System and an associate professor of psychiatry at the University of Michigan Health System.

Valenstein's research team collected data on 887,859 VA hospital patients being treated for depression from April 1999 to September 2004. They calculated the suicide rate for several 12-week periods, including after the start of treatment with antidepressants, after treatment changes, and upon discharge from a psychiatric hospital.

"The possibility of increased suicide risks with antidepressant use has received much media attention, and there have been governmental recommendations for close clinical monitoring during these periods," Valenstein said.

The study confirmed what others have shown: that the first 12 weeks after starting antidepressants is a higher risk period for patients, with 210 suicides per 100,000 person-years, but that the risk returns to normal thereafter.

"However, patients were at very high risk for suicide immediately following psychiatric hospitalizations, where the suicide rate was 568 per 100,000 person-years," Valenstein said. The risk for suicide after psychiatric hospitalization does not return to normal for a year, she said.

Veterans 61 to 80 years of age were found to have the highest risk of suicide, the researchers noted.

There are currently no governmental recommendations for close monitoring after someone is discharged from a psychiatric hospital, although one widely used protocol suggests one visit in the first seven days after discharge, Valenstein said.

"To have the greatest impact on suicide, health systems should prioritize suicide prevention efforts following psychiatric hospitalizations," she said. "If resources allow, closer monitoring during the first 12 weeks after an antidepressant start may be warranted."

Valenstein said that to help stem the tide of suicide among veterans, the Department of Veterans Affairs is spending $300 million for suicide prevention and other mental health services.

Simon Rego, associate director of psychology training at Montefiore Medical Center and an assistant professor at Albert Einstein College of Medicine in New York City, agreed that there's a need for better monitoring of depressed patients after they leave the hospital.

"Although the results of this study are limited, in that they are based on a largely male and older VA population of depressed patients, they still provide an important contribution to an area of extreme importance to the entire mental health system in the United States: suicide prevention," Rego said.

The study highlights the importance of moving some of the responsibility traditionally placed on clinicians to the entire mental health care system in order to shift the focus of prevention efforts from individual patients to entire at-risk populations, he added.

"In terms of suicide prevention, the results indicate that there are readily identifiable high-risk periods following specific events, such as being discharged from an inpatient psychiatric stay or starting a new antidepressant medication, and contrary to previously held notions, that these risk periods are not just for younger patients," Rego said.

In addition, the finding that suicide risk is highest in the first 12 weeks after discharge from a psychiatric hospitalization calls into question current policies that require minimal contact after a patient has been discharged, Rego said.

"The data from this study would suggest that the current monitoring is neither intense enough nor long enough in duration, and that the best use of our mental health resources would be to target efforts at frequent reassessment of suicide risk, offering of support, and establishing a connection to outpatient services during the entire 12-week period after discharge from a psychiatric hospitalization," Rego said.

More information

For more on suicide, visit the U.S. National Institute of Mental Health.

Posted: January 2009


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