April 11 2018 Jaimie L Gradus DSc MPH Epidemiologist National Center for PTSD VA Boston Healthcare System Associate Professor Psychiatry and Epidemiology Departments Boston University Overview ID: 760221
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Posttraumatic Stress Disorder and Suicidal Behavior: Current Understanding and Future Directions
April 11, 2018
Jaimie L. Gradus, DSc, MPH
Epidemiologist, National Center for PTSD, VA Boston Healthcare SystemAssociate Professor, Psychiatry and Epidemiology Departments, Boston University
Slide2Overview
PTSD and death from suicideConflicting findingsPTSD and suicide attemptsMore consistent findingsAFSP-funded study on MA veteransFuture directions and summary
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Slide3Overview
PTSD and death from suicideConflicting findingsPTSD and suicide attemptsMore consistent findingsAFSP-funded study on MA veteransFuture directions and summary
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Slide4PTSD and Death from Suicide
Topic of great interest due to concern about the suicide rate among military members and veterans
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Slide5PTSD and Death from Suicide
PTSD common in this population Natural hypothesis is that perhaps the greater suicide rate in this population is due at least in part to PTSD, or traumatic experiencesGrowing body of literature on the association between PTSD and death from suicideBut…this is a difficult topic to study….Availability of registry-based data on these populations enables work to be done The role of comorbid psychopathology is complicating
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Slide6PTSD and Death from Suicide
Active duty military membersEntire active duty military population in 2005 (n = 2,064,183) and 2007 (n = 1,981,810) Sample sizes were too small to calculate an association for service members in the Marines or NavyDid not examine the role of comorbid psychopathology (Hyman et al., 2012)
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Air Force
2005
Air Force 2007
Army
2005
Army 2007
Odds
Ratio
7.4
10.57
1.86
4.51
Slide7PTSD and Death from Suicide
Active duty military membersUS Army service members from 2001 – 2009 874 persons died by suicide Those who died by suicide were almost 13 times more likely to have been diagnosed with PTSD previously compared to all Army service members in the same time period Did not examine the role of comorbid psychopathology (Black et al., 2011)
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Slide8PTSD and Death from Suicide
Active duty military membersSample from the Millennium Cohort Study (n = 151,560), including current and former military personnelSex- and age-adjusted association for PTSD and suicide of 1.8 Not statistically significant, likely due to sample size, so not included in adjusted model (LeardMann et al., 2013)
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Slide9PTSD and Death from Suicide
VeteransVietnam veterans included in VA Agent Orange Registry Veterans with PTSD (n = 4,247) had an approximately 4 times higher suicide rate than veterans without PTSD (n = 12,010), adjusting only for age and raceAlso examined the association between PTSD and suicide among 3,246 veterans who had no comorbid diagnosesAmong these veterans the suicide rate was almost 6 times as high as the expected rate in general population US males (Bullman & Kang, 1994)
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Slide10PTSD and Death from Suicide
VeteransAll veterans who used VA care in FY 1999 from fiscal year 1999 to FY 2006 (n = 3,291,891) Adjusting for age, male veterans with PTSD had 1.8 times the rate of suicide than male veterans without PTSDFemale veterans with PTSD had 3.5 times the rate of suicide than female veterans without PTSDDid not examine the role of comorbid psychopathology (Ilgen et al., 2010)
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Slide11PTSD and Death from Suicide
VeteransVeterans who received VHA services during FY 2007 or FY 2008 (n = 5,772,282) Found a an association between PTSD and suicide, adjusting for sex, age, and VISN Did not examine the role of comorbid psychopathology (Ilgen et al., 2012)
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Slide12PTSD and Death from Suicide
VeteransAll male patients who used VA services in fiscal year 1999 (n = 2,962,810) Patients with PTSD and any psychiatric comorbidity had 2.6 times the rate of suicide than those with no psychiatric diagnoses Those with PTSD and no other psychiatric disorders had 1.6 times the rate of suicide than male veterans without any psychiatric diagnoses (Conner et al., 2013)
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Slide13PTSD and Death from Suicide
VeteransVHA patients from FY 2007 – 2008 (n = 5,913,648) In unadjusted analyses and demographically-adjusted analyses PTSD was associated with suicide with odds ratios that were approximately 1.3 After adjustment for comorbid psychiatric diagnoses the association was reduced to 0.77, indicating a protective effect of PTSD on suicide (Conner et al., 2014)
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Slide14PTSD and Death from Suicide
We know PTSD can have negative, long-term, consequences There is evidence of an association between PTSD and suicide from well-done epidemiologic studiesBUT…the 2014 study by Conner and colleagues is not the only one that has documented a protective association
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Slide15PTSD and Death from Suicide
Active dutyAll US military personnel from 2001 – 2011 (n = 3,795,823) Examined suicide during military service or post-separation Found a protective effect of PTSD across a range of time periods between diagnosis and death (effect estimates ranged from 0.63 to 0.82) compared to persons with no PTSD diagnoses These estimates were adjusted for demographics, military variables, and comorbid psychopathology (Shen et al., 2016)
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Slide16PTSD and Death from Suicide
VeteransVA patients who were discharged from an inpatient unit between 1994 – 1998 (n = 1,057) PTSD was protective against death from suicide when adjusting for demographics and psychiatric comorbidity (adjusted risk ratio = 0.62) (Desai et al., 2008)
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Slide17PTSD and Death from Suicide
VeteransAll male veterans discharged from VA inpatient units from FY 2005 to FY 2010 (n = 346,662) Association between PTSD and suicide was 0.66 for the year following discharge, after adjustment for demographics and psychiatric comorbidity (Britton et al., 2017)
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Slide18PTSD and Death from Suicide
VeteransVA patients receiving treatment for depression from 1999 – 2004 (n = 807,694) Also found the association between PTSD and suicide to be protective (adjusted hazard ratio = 0.77). (Zivin et al., 2007)
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Slide19PTSD and Death from Suicide
Understanding disparate findingsMost studies have documented that PTSD is associated with an increased risk for suicide Still…more than a few well-done studies have found no association or a protective associationPotential explanations span etiologic and methodologic reasoningAssessment of psychiatric comorbidity Reflect true differences across people, place and time
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Slide20Overview
PTSD and death from suicideConflicting findingsPTSD and suicide attemptsMore consistent findingsAFSP-funded study on MA veteransFuture directions and summary
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Slide21PTSD and Suicide Attempt
5877 general population participants in the National Comorbidity SurveyPTSD was associated with:suicidal ideation (OR = 5.1, 95% CI = 3.9, 6.8) suicide attempts (OR = 6.0, 3.4, 10.7), adjusting for demographic variablessuicide plans among those with suicidal ideation (OR = 2.4, 95% CI = 1.7, 3.3) impulsive attempts among those with suicidal ideation (OR = 1.7, 95% CI = 1.1, 2.7)Adjusted for psychiatric comorbidity (Kessler et al., 1999)
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Slide22PTSD and Suicide Attempt
Data from people in 21 countries included in the WHO World Mental Health Surveys (n = 108,664) Adjusting for demographics and other psychiatric disorders, PTSD was associated withsuicidal ideation in developed countries (OR = 2.7, 95% CI = 2.2, 3.2) suicidal ideation in developing countries (OR = 3.9, 95% CI = 2.7, 5.6)suicide attempt in developed countries (OR = 3.0, 95% CI = 2.3, 3.8) suicide attempt in developing countries (OR = 5.6, 95% CI = 3.5, 8.8) (Nock et al., 2009)
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Slide23PTSD and Suicide Attempt
9,282 general population participants in the NCS-Replication (NCS-R) In multivariate models, those with PTSD had greater odds of:suicidal ideation (OR = 1.7, 95% CI = 1.4., 2.0) suicide attempts (OR = 2.1, 95% CI = 1.5, 2.9) Among those with suicidal ideation, PTSD was associated with suicide plans (OR = 1.6, 95% CI = 1.2, 2.3) and unplanned attempts (OR = 2.4, 95% CI = 1.3, 4.5) (Nock et al., 2010)
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Slide24Overview
PTSD and death from suicideConflicting findingsPTSD and suicide attemptsMore consistent findingsAFSP-funded study on MA veteransFuture directions and summary
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Slide25PTSD and Suicide Attempt
Goals of study:Examine the association between PTSD and suicide attempt in a population-based sample of veterans who use VA servicesExamine the interactions between PTSD and depression and PTSD and substance abuse in predicting suicide attemptsExamine gender differences in these associations
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Slide26PTSD and Suicide Attempt
SampleBase population : patients who received care at a Massachusetts VA hospital between 2000 and 2008VHA health care user: at least one primary care and one other health care visit in the twelve months prior PTSD diagnosis
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Slide27PTSD and Suicide Attempt
SamplePTSD cohort: patients who received a PTSD diagnosis (ICD-9-CM code 309.81) at a Massachusetts VA facility between 2000 and 2008 (n = 16,004)Comparison cohort: veterans who received care at a Massachusetts VA facility, but never received a PTSD diagnosis (n = 52,502) Matched to PTSD patients, with a ratio of up to 5 to 1, on five-year age categories and gender
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Slide28PTSD and Suicide Attempt
Data Sources Data were obtained for the following variables during the study period: depression diagnoses (ICD-9-CM codes: 296.2-296.3) substance use disorders (ICD-9-CM codes: 303.xx-305.9) anxiety disorders (ICD-9-CM codes: 300, 300.01-300.02)suicide attempt resulting in an inpatient hospitalization (ICD-9-CM codes: E950-E959) Veteran’s person-time was measured from date of PTSD diagnosis (or the index date for comparison group members) to the first suicide attempt resulting in hospitalization, death, or end of the last fiscal year in which a patient fulfilled the study definition of a VA health care user, whichever came first
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Slide29PTSD and Suicide Attempt
AnalysesDescriptive analysesUnadjusted rate ratios and corresponding confidence intervalsRate ratios then calculated adjusting for marital status, depression, alcohol or drug abuse or dependence, anxiety disorder diagnoses, and prior suicide attemptInteraction between PTSD and depression diagnoses and PTSD and substance abuse diagnoses were assessed by calculating the interaction contrast (IC) while adjusting for identified confounders
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Slide30PTSD and Suicide Attempt
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PTSD
(N = 16,004)
Comparison Group
(N = 52,502)
Males
(N = 15,056)
Females
(N = 948)
Males
(N = 48,042)
Females
(N = 4,460)
Demographics
Race, n (%)
White
Black
Asian
American Indian
Unknown
12,872 (88.0%)
1,314 (9.0%)
46 (0.3%)
30 (0.21%)
368 (2.5%)
755 (83.0%)
126 (13.9%)
6 (0.7%)
3 (0.3%)
20 (2.2%)
36,599 (85.2%)
2,958 (6.9%)
149 (0.4%)
106 (0.3%)
3,168 (7.4%)
2,297 (68.3%)
306 (9.1%)
42 (1.3%)
12 (0.4%)
705 (21.0%)
Marital Status
Married
Divorced
Never/Single
Widowed
Single
Unknown
6,800 (46.9%)
3.532 (24.4%)
3,110 (21.4%)
659 (4.5%)
247 (1.7%)
157 (1.1%)
211 (23.3%)
286 (31.5%)
333 (36.7%)
47 (5.2%)
14 (1.5%)
16 (1.8%)
22,267 (47.1%)
9,910 (21.0%)
10,092 (21.3%)
3,068 (6.5%)
265 (0.6%)
1,708 (3.6%)
923 (20.8%)
593 (13.4%)
796 (18.0%)
156 (3.5%)
18 (0.4%)
1,948 (43.9%)
Age, Mean (SD, range)
56.4 (13.8, 19.8 – 96.7)
44.3 (12.2, 19.4 – 85.5)
59.4 (15.1,
17.3 – 97.4)
44.8 (12.1, 16.7 – 89.6)
Comorbidities
Depression diagnosis, n (%)
1,704 (11.3%)
175 (18.5%)
1,135 (2.4%)
117 (2.6%)
Alcohol abuse/dependence, n (%)
2,381 (15.8%)
97 (10.2%)
2,604 (5.4%)
49 (1.1%)
Drug abuse/dependence, n (%)
2,729 (18.1%)
153 (16.1%)
4,350 (9.1%)
162 (3.6%)
Anxiety disorders, n (%)
1,949 (13.0%)
132 (13.9%)
1,660 (3.5%)
124 (2.8%)
Prior suicide attempt, n (%)
44 (0.3%)
5 (0.5%)
8 (0.02%)
3 (0.07%)
Slide31PTSD and Suicide Attempt
Results*adjustment for baseline marital status, depression, alcohol and drug abuse/dependence, anxiety disorder diagnoses and prior suicide attemptPattern of results among the subsample without prior suicide attempt was consistent with presented results
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Men
Women
Unadjusted
5.0 (3.7, 6.8)
24 (8.2, 68)
Adjusted*
3.2 (2.3, 4.5)
16
(4.8, 56)
Slide32PTSD and Suicide Attempt
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Men PTSD +PTSD -Depression +211.9142.3Depression -82.624.6 aIC = 11.6Women PTSD +PTSD -Depression +940.680.5Depression -137.425.0 aIC = 747.7
Gender-stratified Incident Rates and Interaction Contrast for Depression and PTSD
Note: All per 100,000 person-years.
aIC
= adjusted interaction contrast; PTSD = posttraumatic stress disorder
Analyses adjusted for depression, anxiety disorders, and prior ISH.
Slide33PTSD and Suicide Attempt
Gender-Stratified Incident Rates and Interaction Contrast for Alcohol Abuse and Dependence and PTSD Diagnoses
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Men PTSD +PTSD -Alcohol Abuse/Dependence +205.13131.99Alcohol Abuse/Dependence -65.0013.35 aIC = 21.49Women PTSD +PTSD -Alcohol Abuse/Dependence +691.89220.73Alcohol Abuse/Dependence -424.4615.65 aIC = 62.35
Note: All per 100,000 person-years.
aIC
= adjusted interaction contrast; PTSD = posttraumatic stress disorder
Analyses adjusted for depression, anxiety disorders, and prior ISH.
Slide34PTSD and Suicide Attempt
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Men
PTSD +PTSD -Drug Abuse/Dependence +87.2248.18Drug Abuse/Dependence -60.9819.16 aIC = -2.78Women PTSD +PTSD -Drug Abuse/Dependence +700.0386.33Drug Abuse/Dependence -375.7518.38 aIC = 256.33
Gender-Stratified Incident Rates and Interaction Contrast for Drug Abuse and Dependence and PTSD Diagnoses
Note: All per 100,000 person-years
aIC
= adjusted interaction contrast; PTSD = posttraumatic stress disorder
Analyses adjusted for depression, anxiety disorders, and prior ISH.
Slide35PTSD and Suicide Attempt
ConclusionsEvidence of a strong association between PTSD and suicide attempt among MA veterans who use VA servicesWhen PTSD and depression co-occur or PTSD and substance abuse co-occur risk of suicide attempt is increased, especially for female VHA patients
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Slide36Overview
PTSD and death from suicideConflicting findingsPTSD and suicide attemptsMore consistent findingsAFSP-funded study on MA veteransFuture directions and summary
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Slide37Future Directions and Summary
Novel methodsMachine learningSequence analysisMultiple sources of dataUltimate goal: better prediction and prediction tools
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Slide38Future Directions and Summary
Majority of studies point to an increased risk of suicide associated with PTSDStudies that do not corroborate these findings are too many to be discountedFurther research is needed to understand this potentially critical associationThe association between PTSD and suicide attempt is more substantiatedGender differences is an important area for research on both outcomes to explore furtherMachine learning and other novel methods will expand what we know about these areas Also result in risk assessment tools
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Slide39Acknowledgements
This work was supported by grant YIG-1-069-11 (PI: Gradus) from the American Foundation for Suicide Prevention and grant 1R01MH109507 (PI: Gradus) from the National Institute of Mental HealthCollaboratorsRyan Ferguson, DScSarah Leatherman, PhDMatthew Miller, MDLisa Myers, PhDAndrew CurreriSanjay Raju
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Slide40Additional Readings
Gradus, J. L. (2017). PTSD and Death from Suicide. PTSD Research Quarterly, 28(4).Gradus, J. L., Leatherman, S., Raju, S., Ferguson, R. E., Miller, M. (2014). Posttraumatic stress disorder, depression, and non-fatal intentional self-harm in Massachusetts veterans. Injury Epidemiology, 1, 20. Gradus, J. L., Leatherman, S., Curreri, A., Myers, L. G., Ferguson, R., Miller, M. (2017). Gender Differences in Substance Abuse, PTSD and Intentional Self-Harm among Veterans Health Administration Patients. Drug and Alcohol Dependence, 171, 66-69.
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