Time trends and predictors of suicide among mental health outpatients in the department of veterans affairs

Using merged Veterans Affairs (VA) and National Death Index data, this study examined changes in suicide rate among three cohorts of VA mental health outpatients during a time of extensive bed closures and system-wide reorganization (1995, N=76,105; 1997, N=81,512; and 2001, N=102,184). There was a decreasing but nonsignificant trend in suicide rates over time-13.2, 11.4, and 10.3 per 10,000 person-years, respectively. Multivariable predictors of suicide included both younger and older ages (U-shaped association). At the facility level, there was an association between greater per capita outpatient mental health expenditure and reduced suicide risk. The model also showed a protective effect associated with increased mental health 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. Although more chronic patients may have been underrepresented to some extent as a result of the sampling methodology, these findings provide generally reassuring evidence that overall suicide rates have not been adversely affected by VA system changes. Nevertheless, they highlight the importance of funding for mental health services as well as the implications of changing demographics in the VA population.