Trend and predictors of suicide among VA mental health outpatients: The influence of individual and facility characteristics

Objectives: Mental health service delivery in the VA system changed dramatically during the mid-1990s, largely through extensive bed closures and increased emphasis on outpatient treatment. We sought to examine the trend in suicide rate among VA mental health outpatients during this time period and to identify both individual- and facility-level characteristics associated with suicide risk.

Methods: Using VA administrative data, we identified three cohorts of unduplicated mental health service users who had had an outpatient visit during the month of January in 1995 (N=76,105), 1997 (N=81,512), and 2001 (N=102,184). One-year mortality data were assembled through linkage with the National Death Index.

Results: There was a modest but non-significant trend toward declining suicide rates over time -- 13.2, 11.4, and 10.3 per 10,000 person-years, respectively. Using multivariate Poisson regression, individual-level predictors of suicide included younger and older ages (U-shaped association), white race, bipolar disorder, and past-year psychiatric inpatient stay. At the facility level, there was an inverse association between per-capita outpatient mental health expenditure and suicide. We also found a protective effect of increased spending on inpatient services and that outpatients at facilities with larger mental health programs, as measured by patient volume, were at greater risk for suicide than were those in smaller programs.

Conclusions: This study provides reassuring evidence that overall suicide rates have not been adversely affected by ongoing efforts to restructure the VA mental health system. Nevertheless, more work is needed to address the individual and facility characteristics that may influence suicide risk among mental health outpatients.