Veterans at High Risk for Post–COVID-19 Suicide Attempts or Other Self-Directed Violence
This study analyzed a large cohort of 285,235 US veterans who contracted COVID-19 to identify subgroups at heightened risk for suicide attempts or self-directed violence in the following year. Ultimately, the study highlights the long-term mental health impact of COVID-19 on vulnerable veteran populations and underscores the importance of targeted prevention efforts.
College of Health researcher(s)
Highlights
Question
Which subgroups of veterans are at high risk for suicide attempt or other forms of self-directed violence (SDV) after COVID-19 infection?
Findings
By use of a cohort study design and latent class analysis, among a total of 285 235 veterans with COVID-19, 2 subgroups with high rates of post–COVID-19 suicide attempts and SDV were identified. The subgroups had distinct demographics, health profiles, and health care utilization.
Meaning
Given the increased risk of suicide attempt and SDV after COVID-19, these results could inform ways to tailor suicide prevention to veterans at highest risk.
Abstract
Importance
US veterans have a higher risk of suicide than the general civilian population. Research suggests that COVID-19 infection is associated with increased risk of suicide attempts or other forms of self-directed violence (SDV) among veterans.
Objective
To identify subgroups of veterans with high risk of post–COVID-19 suicide attempts or SDV.
Design, Setting, and Participants
This is a retrospective cohort study conducted using data from the Veteran Health Administration (VHA). Participants included VHA enrollees with a first case of COVID-19 between May 1, 2021, and April 30, 2022, residing in the 50 states or Washington, DC.
Exposure
COVID-19 infection.
Main Outcomes and Measures
The main outcome was a suicide attempt or SDV 12 months after COVID-19 infection. Latent class analysis was used to identify subgroups. Outcome rates and 95% CIs per 10 000 veterans were calculated. Multinomial regressions were used to model outcome risk and marginal risk ratios with 99.5% CIs to compare outcome risk across latent classes.
Results
The cohort included 285 235 veterans with COVID-19 and was predominantly male (248 118 veterans [87.0%]) and younger than 65 years (171 636 veterans [60.2%]). Chronic pain (152 788 veterans [53.6%]), depression (98 093 veterans [34.4%]), and posttraumatic stress disorder (79 462 veterans [27.9%]) diagnoses were common. The 12-month outcome rate was 73.8 events per 10 000 (95% CI, 70.7-77.0 events per 10 000). Two latent classes with high rates of suicide attempt or SDV were identified. The first high-risk subgroup (46 693 veterans [16.4%]) was older (34 472 veterans [73.8%] aged ≥65 years) and had a high prevalence of physical conditions (43 329 veterans [92.8%] had hypertension, and 36 824 veterans [78.9%] had chronic pain); the 12-month outcome rate was 103.7 events per 10 000 (95% CI, 94.7-113.3 events per 10 000). The second high-risk subgroup (82 309 veterans [28.9%]) was generally younger (68 822 veterans [83.6%] aged <65 years) with a lower prevalence of physical conditions but high prevalence of mental health conditions (61 367 veterans [74.6%] had depression, and 50 073 veterans [60.8%] had posttraumatic stress disorder); the 12-month outcome rate was 162.9 events per 10 000 (95% CI, 154.5-171.8 events per 10 000), and compared with the lowest risk subgroup, the 12-month risk of suicide attempts or SDV was 14 times higher in this subgroup (risk ratio, 14.23; 99.5% CI, 10.22-19.80).
Conclusions and Relevance
In this cohort study of veterans with COVID-19, 2 veteran subgroups with distinct health profiles had high rates of suicide attempts and SDV, suggesting that different groups may require different approaches to suicide prevention after COVID-19.
FAQ: COVID-19 and Suicide Risk Among Veterans
What was the primary goal of this study?
This study aimed to identify specific subgroups of US veterans who had contracted COVID-19 and were at a heightened risk for suicide attempts or other forms of self-directed violence (SDV) in the 12 months following their infection. The researchers utilized electronic health records from the Veteran Health Administration (VHA) to analyze a large cohort of veterans and identify distinct risk profiles. The ultimate goal was to provide insights that could inform more tailored and effective suicide prevention strategies within the VHA.
How was the study designed and who were the participants?
The study employed a retrospective cohort design, analyzing data from VHA enrollees who had a first confirmed case of COVID-19 between May 1, 2021, and April 30, 2022, and resided in the US or Washington, DC. The researchers used latent class analysis (LCA), a statistical method to identify unmeasured subgroups within a population based on a set of observed characteristics. The cohort consisted of 285,235 veterans, predominantly male (87.0%) and under 65 years old (60.2%). The analysis considered a range of sociodemographic factors, pre-existing physical and mental health conditions (such as chronic pain, depression, and PTSD), and healthcare utilization patterns.
What were the main findings regarding high-risk subgroups?
The study identified two distinct subgroups of veterans with significantly elevated rates of suicide attempts or SDV after COVID-19 infection. The first high-risk subgroup (16.4% of the cohort) was characterized by older age (primarily 65 years and older), a high prevalence of physical comorbidities like hypertension and chronic pain, and a substantial mental health burden. The second high-risk subgroup (28.9% of the cohort) was generally younger (under 65 years), had a lower prevalence of physical conditions, but a high prevalence of mental health conditions such as depression and PTSD. Notably, the 12-month risk of suicide attempts or SDV in this younger subgroup with mental health challenges was 14 times higher compared to the lowest-risk subgroup.
How did mental and physical health conditions relate to the identified high-risk groups?
Mental health conditions played a crucial role in defining both high-risk subgroups. The younger high-risk group (Class 3) had a particularly high prevalence of depression (74.6%) and PTSD (60.8%), along with a high rate of mental health care utilization prior to COVID-19. The older high-risk group (Class 1) also had a considerable prevalence of mental health diagnoses, although slightly lower than Class 3, but was distinguished by a high burden of physical comorbidities, including hypertension (92.8%) and chronic pain (78.9%). This suggests that both mental and physical health, often in combination, contribute significantly to the increased risk of suicide attempts and SDV post-COVID-19.
Were there any notable disparities in risk based on demographic factors?
Yes, the study highlighted significant disparities in the risk of suicide attempts and SDV based on sex and race within the veteran population post-COVID-19. Female veterans generally exhibited a higher risk compared to male veterans, particularly in the older, high physical comorbidity group. Furthermore, higher rates of suicide attempts and SDV were observed across all minoritized racial groups. Alarmingly high 12-month outcome rates were found among American Indian or Alaska Native veterans in the older, high comorbidity class and among Asian veterans in the younger, high mental health burden class.
What implications do these findings have for suicide prevention among veterans?
The identification of these distinct high-risk subgroups suggests that a one-size-fits-all approach to suicide prevention among veterans post-COVID-19 may not be the most effective. The study indicates a need for tailored prevention strategies that consider the specific health profiles and demographic characteristics of these groups. For the older subgroup with high physical comorbidities, increased suicide screening in medical care settings (given their higher utilization of primary and inpatient care) might be beneficial. For the younger subgroup with high mental health burdens, continued monitoring of suicidal ideation and ensuring access to mental health services are crucial. The pronounced disparities among female and minoritized racial groups underscore the urgent need for culturally appropriate and trauma-informed prevention programs that address their unique risk factors.
What were some of the limitations of the study?
The study had several limitations that should be considered when interpreting the findings. The data was limited to veterans who sought testing within VHA facilities during the study period, potentially underrepresenting those with milder COVID-19 cases or those who primarily used home antigen tests. The latent class analysis did not include all potentially relevant risk factors for suicide attempts and SDV, such as measures of loneliness, housing insecurity, depressive symptoms, and medication use, which could have provided a more comprehensive understanding of the subgroups. Additionally, the LCA models were based on baseline data prior to the 12-month follow-up, and changes in patient characteristics over time were not accounted for.
What is the main takeaway message from this research?
The primary takeaway is that among veterans who contracted COVID-19, the risk of suicide attempts and self-directed violence is concentrated in two distinct subgroups: an older group with significant physical and mental health comorbidities, and a younger group with a high burden of mental health conditions. These findings emphasize the need for targeted suicide prevention efforts that are tailored to the specific profiles of these high-risk groups and that address the identified disparities among female and minoritized racial veteran populations. Implementing increased suicide screening, ensuring access to mental health care, and developing culturally appropriate interventions are crucial steps in mitigating this elevated risk.