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Medical, psychiatric and demographic factors associated with suicidal behavior in homeless veterans
Psychiatry Research 199 (2012) 37–43
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Medical, psychiatric and demographic factors associated with suicidal behavior in homeless veterans Gerald Goldstein a,b,n, James Francis Luther a,b, Gretchen Louise Haas a,b a b
Mental Illness Research, Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA University of Pittsburgh, PA, USA
a r t i c l e i n f o
abstract
Article history: Received 28 November 2011 Received in revised form 27 February 2012 Accepted 18 March 2012
This study assessed potential for suicidal behaviors associated with sociodemographic, predisposing physical and mental health factors and self-reported psychological problems among homeless veterans in a large northeastern region. Data were obtained from a demographic and clinical history interview conducted with 3595 homeless veterans. Odds-ratio (OR) statistics were used to assess potential for suicidal behavior. Statistically significant ratios were similar for ideation and attempts. The highest ratios were for self-report of depression and difficulty controlling violence, but statistically significant ratios were found for reporting sleeping in a treatment facility the night before the interview, receiving VA support for a psychiatric condition, and the diagnoses of Alcoholism, Mood Disorder and Post Traumatic Stress Disorder (PTSD). Low but statistically significant odds-ratios were obtained for most of the physical health items. A negative odds-ratio was obtained for African–American ethnicity. Logistic regression results indicated that for ideation and attempts items entered first involved subjective report of trouble controlling violent behavior and experiencing depression. High odds ratios for the interview items concerning experiencing serious depression and having difficulties controlling violence may have strong implications for treatment and management of homeless veterans. There may be up to 14–1 odds that an individual who reports being seriously depressed or having difficulty inhibiting aggression may have a serious potential for suicidal behaviors. Published by Elsevier Ireland Ltd.
Keywords: Suicide Homelessness Logistic regression
1. Introduction Given that psychiatric and medical disorders are common among the homeless (Herman et al., 1998; Wan et al., 2006), it is not surprising that mortality rates, including rates of suicide are elevated in this population. The causal relationship between psychiatric conditions and homelessness is the subject of some debate (e.g., Cohen and Thompson, 1992). However, it is likely that homelessness is associated not only with substantial economic, social and quality of life handicaps, but also the state of homelessness itself introduces substantial physical, social and psychological stressors to individuals who have no stable residence. From several reports, US military veterans are over-represented among the homeless population in the US (Gamache et al., 2001; Tessler et al., 2002). Veterans may be particularly vulnerable to homelessness, perhaps because of disabilities and health problems developed when in military service, and in part, because of the
n Corresponding author at: Mental Illness Research, Educational and Clinical Center, VA Pittsburgh Healthcare System, 7180 Highland Drive (151R), Pittsburgh, PA 15206, USA. E-mail address: [email protected] (G. Goldstein).
0165-1781/$ - see front matter Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.psychres.2012.03.029
many problems of social readjustment typically associated with discharge from the military (Rosenheck and Fontana, 1994). Homelessness is known to be a risk factor for suicidal behaviors (Mann et al., 2008). Findings from interview studies of homeless individuals suggest that the incidence of suicidal ideation and/or attempts may be higher among homeless individuals as compared with the general population. Eynan et al. (2002) reported a 61% prevalence of suicidal ideation and a 34% prevalence of suicide attempts in a large sample of homeless. Likewise, Desai et al. (2003) found a 66.2% lifetime prevalence of suicidal ideation, a 51.3% lifetime prevalence of suicide attempts and 26.9% of the cases reported an attempt resulting in psychiatric hospitalization. Elevated risk for suicidal behavior among the homeless may be attributable to the significant life stress and degraded quality of life typically associated with homelessness. However, it is also likely that the mental and physical health problems so prevalent among homeless populations and associated with elevated risk for suicide in the general population introduce increased risk for suicidal behavior among the homeless. Mann et al. (1999, 2008) have presented a model that links state-related variables, depression and impulsivity, to suicidal behaviors. The information provided by this study may be relevant to that model which integrates psychiatric disorder and subjective state with suicidal behaviors.
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G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
Interestingly, in the same sample of 7224 homeless individuals with severe mental illness recruited for study through the multisite ACCESS outreach program and described by Desai et al. (2003), Prigerson et al. (2003) found that some demographic correlates of suicidal behavior differed from robust demographic correlates reported for the non-homeless population in the US. For example, they observed an increased rate of self-reported suicidal behavior among those between the ages of 30–39 as contrasted with elevated risk among younger and older age groups in the general population; they also reported that among the elderly homeless in the sample, risk for suicidal behavior increased in the presence of drug and alcohol abuse (Fischer and Breakey,1991). Langhinrichsen-Rohling et al. (2011) reported that in individuals on active military duty, significant predictors of suicidal ideation included depressive symptoms, alcohol problems, family matters including relationship satisfaction and intimate partner victimization, hours worked and community level social support. The present study was an effort to find such predictors among homeless veterans. This study aims to assess potential for suicidal ideation and attempt behaviors associated with (1) sociodemographic factors, (2) predisposing health factors (the existence of chronic or acute physical, mental and substance use conditions) and (3) proximal, state-related psychological risk factors (self-reported psychological problems) among homeless veterans in a large northeastern region of the US.
2. Material and methods As part of a nation-wide outreach effort to provide services to the large population of homeless veterans, the Department of Veterans Affairs (DVA) designed and administered an interview-based questionnaire with several sections covering pertinent areas to veterans who were presently or recently homeless. Data from this survey were made available to the authors from a consecutive series of 3595 interviews conducted over a two-year period (October 1, 2001– September 30, 2003) in one VA regional network. 2.1. Participants Data were collected by DVA outreach workers using a demographic and clinical history interview conducted with 3595 homeless veterans from the Veterans Integrated Services Network 4 (VISN 4) which includes all of Pennsylvania, Delaware and parts of West Virginia, New Jersey and Ohio. The sample included all presently or recently homeless veterans identified and contacted in various settings located in both urban and rural areas within VISN 4, including community facilities for the homeless, VA hospitals, outpatient clinics, prisons, and veteran’s centers in the community for the purpose of providing information about DVA-sponsored health services. The majority of participants lived in shelters (n¼ 1665) or with acquaintances on a temporary basis (n¼ 657). The data were collected as a national survey of veterans under conditions that assured privacy and confidentiality. Participants were contacted by the DVA as part of an outreach program and were asked to volunteer to take the interview without penalty for refusal. The present investigators were given access to these data by the DVA Northeast Program Evaluation Center (NEPEC). Written informed consent was obtained from participants prior to interview (as described in the previous published reports of McGuire and Rosenheck (2004) and Rosenheck et al. (2000)). Data were transmitted to the current investigators in de-identified form with review and approval to conduct the analysis by the Institutional Review Board (IRB) at the local site (VA Pittsburgh Healthcare System, Pittsburgh, PA, 15206). 2.2. Interview procedures Interviews were conducted by experienced health workers, mainly social workers and psychiatric nurses, associated with the DVA-sponsored Healthcare for Homeless Veterans (HCHV) program that routinely performs assessments for identifying and tracking veterans in need of services. A personal interview with the homeless veteran was conducted by these workers who were trained in the administration of this semi-structured procedure The interviews included sections on demographic information, characteristics of the contact with the veteran, military history, living situation, medical history, substance abuse, psychiatric status, employment status, and observations made by the interviewer covering the areas of clinical psychiatric disorder and needs for referral and treatment. Several studies have appeared in the literature utilizing data obtained from this survey process that were reported on beginning in 1991 (e.g., Kasprow and Rosenheck, 1998).
With regard to the present study, two interview items concerned suicidal behaviors—one inquires about suicidal ideation and the other about suicidal attempts. (During the past 30 days, have you had a period (that was not the direct result of alcohol or drug use) in which you had serious thoughts of suicide or attempted suicide?). These items were studied in relation to a set of selected items from the interview that appeared to have possible relevance to suicidal behaviors. These included demographic and historical questions, presence or absence ratings of a set of psychological and emotional problems, physical disorders, and inquiries about several psychiatric difficulties. Diagnostic ratings were made by the interviewers based on self-report information provided by the veteran and supplemented by medical chart information, when available. As indicated in the Kasprow and Rosenheck study, these ratings were made on the basis of unstructured assessments and therefore relied upon clinical judgment sometimes supported by record review. While they should not be construed as being formal International Classification of Diseases (ICD) or Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) diagnoses based upon a standard structured interview, or full medical evaluation, in previous large sample studies these clinical ratings have been associated to meaningful clinical and socio-cultural variables in homeless individuals such as ethnicity (Lim et al., 2006) and suicide risk (Desai et al., 2005). In any event, the diagnostic ratings used in the present study were for broad groups of psychiatric disorders including alcohol and drug substance abuse, schizophrenia and other psychoses, mood disorders, PTSD, personality disorder, and adjustment disorder and broad categories of physical problems such as heart or liver disease without further specificity. Specific DSM-IV or ICD were not used as bases for classification. While computer-based medical records were available to the interviewers for determination of presence/absence of medical and mental health disorders, we do not have information concerning how frequently medical records were used. Interviewers were trained clinicians and knowledgeable concerning the disorders coded, and therefore capable of making accurate determinations regarding the presence/absence of the broad diagnostic categories used here based upon self-report during a clinical interview. Kasprow and Rosenheck (1998) pointed out that when large samples are obtained by report from numerous clinicians, as was the case in the present study, the potential impact of interviewer-specific diagnostic biases should be attenuated. In addition to obtaining these diagnoses, the psychiatric status section of the interview included direct questions for respondent self-report regarding current psychological symptoms and problems, including depression, anxiety, hallucinations, concentration and memory problems, violent behavior and recent (30-day) history of suicidal ideation or suicide attempt behaviors. Contacts with the outreach interviewing program were made through DVA-initiated outreach, referrals from shelter staff, and referrals from DVA patient care facilities, through the veteran’s community centers or through special programs for the homeless. The sample for which complete diagnostic data were available contained 3595 participants. The data analysis was based upon 3429 individuals who had a complete data set. They were collated and entered into computer databases by staff from the DVA Northeast Program Evaluation Center (NEPEC).
2.3. Statistical analyses The design of the study was an odds-ratio (OR) analysis in which an attempt was made to elicit associations between information contained in several sections of the interview and self-reported presence or absence of recent (30-days history) suicidal behaviors, both thoughts of committing suicide and actual attempts. The interview was divided into several separate subsections that included a description of the veteran and circumstances of contact for the interview, military history, living situation, medical status, substance abuse, psychiatric status, employment status and a section called interviewer observations that contains subsections on need for care, psychiatric diagnoses, and plans for referral and treatment. The psychiatric subsection covers self-reported symptoms such as anxiety, but diagnoses are also noted in this last section. The items considered here were selected socio-demographic questions contained in the first section, military history, living situation, medical and psychiatric status descriptive and diagnostic items. All individual items listed in this paper are categorical except for age. For simplicity, age was dichotomized using a median split. The study was directed toward evaluating predictive capacity of interview responses for suicidal behavior, both ideation and attempts. Predictor variables were various socio-demographic and clinical interview items taken from various sections of the interview. In an effort to determine which the most powerful predictors were, a stepwise binary logistic regression analysis was performed. A strict tolerance test (po0.001 to enter the regression equation; po0.01 to remove) was used in order to assure that the most robust items entered the prediction equation. Following this procedure, odds-ratios were recomputed for the entered variables providing probability estimates for the entered variables after accounting for the influence of the other variables in the equation. This procedure evaluates the possibility that probability associated with some individual variable such as being homeless for more than one year may be attenuated by another variable in which the odds-ratio indicates a reduced potential, thereby constituting a possible protective factor.
G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
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Table 1 Odds ratio (OR) and 95% confidence intervals (CI) for demographic and residence measures of homeless veterans with suicidal ideation in the past 30 days (N¼ 482) or attempted suicide in the past 30 days (N ¼149) compared to homeless veterans with neither (N¼ 2947). Measure
In the past 30 days Suicidal ideation
Suicide attempt
N (%)
OR
95% CI
p
Age 448 Yes No
229 (14.0) 253 (14.1)
0.99
(0.81, 1.19)
Sex Male Female
465 (14.0) 17 (15.9)
0.86
(0.51, 1.46)
Race White Black Other
261 (16.8) 215 (11.8) 3 (8.3)
Service period Pre-Vietnam Vietnam Post-Vietnam Persian Gulf
30 (9.3) 248 (15.3) 181 (14.1) 23 (11.6)
Employment status, past three years Employed/service Unemployed/student Retired/disabled
222 (12.6) 114 (15.3) 142 (15.5)
Service connected, psychiatry Yes No
N (%)
OR
95% CI
58 (3.9) 91 (5.6)
0.69
(0.50, 0.97)
138 (4.6) 11 (10.9)
0.40
(0.21, 0.76)
o0.04
0.89
o0.01
0.59
o 0.01 0.66 0.45
(0.54, 0.80) (0.14, 1.48)
o 0.01 0.19
o0.01 85 (6.2) 63 (3.8) 1 (2.9)
0.60 0.46
(0.43, 0.83) (0.06, 3.41)
o 0.03 1.77 1.61 1.29
(1.19, 2.64) (1.07, 2.42) (0.73, 2.29)
o 0.01 o 0.03 0.39
2.61 3.36 6.72
(1.04, 6.56) (1.34, 8.44) (2.48, 18.2)
49 (24.6) 424 (13.2)
2.15
(1.53, 3.02)
Service connected, other Yes No
56 (16.5) 419 (13.6)
1.25
(0.92, 1.69)
Non-service connected pension Yes No
58 (16.9) 421 (13.7)
1.28
(0.95, 1.73)
Non-VA disability (e.g. SSDI) Yes No
92 (17.5) 385 (13.3)
1.38
(1.08, 1.78)
Other public support Yes No
92 (17.1) 385 (13.5)
1.32
(1.03, 1.70)
Marital status Never married Married/remarried Divorced/separated Widowed
163 (13.6) 18 (12.4) 287 (14.5) 14 (13.1)
1.11
(0.66, 1.87)
1.20 1.06
(0.72, 1.99) (0.50, 2.24)
Where slept last night Own place Relative/friend Shelter No residence Institution Prison/jail
19 (14.7) 108 (17.1) 166 (10.4) 83 (15.8) 86 (21.6) 11 (15.9)
0.92 1.09 0.61
(0.53, 1.58) (0.80, 1.49) (0.46, 0.82)
o 0.01 0.76 0.58 o 0.01
1.46 1.01
(1.04, 2.04) (0.51, 2.00)
o 0.03 0.99
Homeless 4one year Yes No
93 (12.2) 384 (14.6)
0.81
(0.64, 1.03)
Received combat zone fire Yes No
103 (16.0) 366 (13.5)
1.22
(0.97, 1.55)
1.45 1.22
(0.97, 2.17) (0.82, 1.81)
13 (8.0) 135 (4.6)
1.79
(0.99, 3.24)
14 (4.7) 134 (4.8)
0.98
(0.56, 1.72)
17 (5.6) 131 (4.7)
1.21
(0.72, 2.03)
31 (6.7) 116 (4.4)
1.55
(1.03, 2.33)
36 (7.5) 111 (4.3)
1.79
(1.22, 2.65)
58 (5.3) 10 (7.3) 77 (4.4) 3 (3.1)
0.71
(0.36, 1.43)
0.58 0.41
(0.29, 1.15) (0.11, 1.53)
6 (5.2) 22 (4.0) 58 (3.9) 23 (5.0) 33 (9.5) 3 (4.9)
1.05 0.80 0.77
(0.42, 2.63) (0.44, 1.46) (0.47, 1.27)
o0.01 0.93 0.48 0.31
2.02 0.99
(1.16, 3.51) (0.29, 3.41)
o0.02 0.99
32 (4.6) 115 (4.9)
0.93
(0.62, 1.39)
37 (6.4) 112 (4.6)
1.44
(0.98, 2.11)
o 0.01
0.06
0.16
0.94
0.11
0.48
o 0.02
o0.04
o 0.03
o0.01
0.82
0.29
0.09
0.73
0.10
3. Results 3.1. Individual odds-ratios The individual odds-ratios and their associated probability levels are presented in Tables 1 and 2. In most cases the statistically significant ratios were about the same for ideation and attempts.
o0.05 o0.01 o0.01 0.19
67 (4.2) 40 (6.0) 41 (5.0)
(0.98, 1.59) (1.01, 1.59)
o0.01 0.45 o0.01
5 (1.7) 61 (4.3) 63 (5.4) 20 (10.3)
0.07 1.25 1.27
p
0.07
For the demographic data the highest ratios (p o0.01) were associated with having a service connected disability, receiving other public support and being a Vietnam veteran. Location where the participant slept the night before the interview, particularly if it was an institutional setting, also produced a highly significant odds ratio. Self-report of psychological problem items, notably depression, difficulty controlling violent behavior,
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G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
Table 2 Odds ratios (OR) for psychiatric items for suicidal ideation in the past 30 days (N ¼482) or attempted suicide in the past 30 days (N ¼ 149) compared to homeless veterans with neither (N ¼2947). Measure
I Suicidal ideation
Suicide attempt
N (%)
OR
95% CI
p
Hospitalized for psychiatric problem Yes No
307 (23.3) 172 (8.2)
3.41
(2.79, 4.17)
Psychiatric problem Depression Yes No
447 (23.1) 34 (2.3)
12.8
(8.99, 18.3)
Anxiety/tension Yes No
441 (21.9) 41 (2.9)
9.35
(6.73, 13.0)
Hallucinations Yes No
145 (35.5) 336 (11.2)
4.39
(3.48, 5.54)
Cognitive trouble Yes No
360 (27.6) 121 (5.7)
6.31
(5.06, 7.86)
Violent behavior Yes No
152 (43.6) 328 (10.7)
6.46
(5.08, 8.22)
Prescription meds Yes No
292 (27.3) 187 (8.0)
4.35
(3.56, 5.32)
Psychiatric diagnosis Alcohol abuse/dependency Yes No
329 (15.8) 153 (11.4)
1.45
(1.18, 1.78)
Drug abuse/dependency Yes No
271 (16.2) 211 (12.1)
1.41
(1.16, 1.71)
Schizophrenia Yes No
62 (16.4) 420 (13.8)
1.23
(0.92, 1.65)
Other psychotic disorder Yes No
37 (25.0) 445 (13.6)
2.12
(1.45, 3.12)
Mood disorder Yes No
332 (20.9) 150 (8.2)
2.97
(2.41, 3.65)
Personality disorder Yes No
71 (23.9) 411 (13.1)
2.08
(1.56, 2.77)
PTSD from combat Yes No
65 (27.8) 417 (13.1)
2.56
(1.89, 3.47)
Adjustment disorder Yes No
208 (16.4) 274 (12.7)
1.35
(1.11, 1.64)
N (%)
OR
95% CI
119 (10.5) 30 (1.5)
7.58
(5.05, 11.4)
140 (8.6) 9 (0.6)
15.2
(7.71, 29.9)
134 (7.9) 15 (1.1)
7.76
(4.53, 13.3)
48 (15.4) 101 (3.6)
4.83
(3.35, 6.97)
109 (10.4) 39 (1.9)
5.92
(4.08, 8.61)
61 (23.6) 88 (3.1)
9.66
(6.76, 13.8)
111 (12.5) 37 (1.7)
8.36
(5.71, 12.2)
93 (5.0) 56 (4.5)
1.12
(0.80, 1.58)
84 (5.6) 65 (4.0)
1.41
(1.02, 1.97)
21 (6.3) 128 (4.6)
1.37
(0.85, 2.21)
14 (11.2) 135 (4.5)
2.65
(1.48, 4.74)
95 (7.0) 54 (3.1)
2.36
(1.68,3.32)
21 (8.5) 128 (4.5)
1.98
(1.22, 3.20)
17 (9.1) 132 (4.5)
2.12
(1.25, 3.59)
51 (4.6) 98 (4.9)
0.92
(0.65, 1.31)
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
0.51
o0.01
o0.05
0.16
0.20
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
and cognitive problems were associated with particularly high odds ratios based on their magnitude (e.g. 12.8 and 15.2 for depression), but highly significant ratios (p o0.01) were found for many of the psychiatric items. Low, but statistically significant, odds-ratios were obtained for most of the physical health measures. A negative odds-ratio was obtained for African–American ethnicity, suggesting that being African–American may be a protective factor. An important limitation of the study ruling out any consideration of a potentially significant influence was that the very small number of female participants precluded any
P
0.66
meaningful consideration of gender differences. Using our sample of 118 women we ran odds-ratios for ideation and attempts. For ideation, the OR was 1.47 (Confidence intervals (CI) ¼0.95–2.28), which was not significant. An OR of 2.48 (CI¼1.30–4.72) was found for attempts, which is significant. In actual values, 9.3% of the female participants made an attempt while 4% of the males did so. Thus, the probability of making an attempt was significantly higher among women than men. This clearly provocative preliminary finding should provide a focus for future study with larger samples of female veterans.
G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
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Table 3 Odds Ratios (OR) for items entered into the stepwise logistic regression analysisa. Variable
OR
95% CI
OR at final step
95% CI
Ideation Controlling violence Depression Concentration Mood disorder Hallucinations Slept treatment facility
7.303 14.488 6.442 2.950 4.601 2.038
5.859–9.102 10.351–20.277 5.273–7.870 2.449–3.554 3.719–5.691 1.614–2573
3.849 6.786 2.442 1.715 1.920 2.303
2.939–5.040 4.610–9.988 1.912–3.119 1.363–2.158 1.468–2.512 1.706–3.110
Attempts Controlling violence Depression Slept treatment facility Concentration Medical problem-Oral
6.114 11.955 2.188 4.547 0.715
4.331–8.630 6.073–23.536 1.464–3.271 3.134–6.597 0.513–0.996
6.678 8.895 2.488 2.255 0.512
4.631–9.629 3.188–14.276 1.585–3.840 1.462–3.478 0.363–0.741
Variable
OR
CI
OR at final step
CI
Ideation eliminating attempters Concentration Depression Violence Slept treatment facility Hallucinations Mood disorder
6.307 12.838 6.46 1.825 4.388 2.968
5.061–7.859 8.992–18.330 5.078–8.217 1.405–2.371 3.478–5.535 2.415–3.647
2.422 6.331 3.258 2.011 1.905 1.721
1.856–3.162 4.190–9.567 2.428–4.372 1.443–2.804 1.428–2.543 1.341–2.208
Items meeting entry criteria. Violence: In the last 30 days have you had trouble controlling violent behavior? Depression: In the last 30 days have you experienced a serious depression? Slept treatment facility: Where did you sleep last night? Institution (hospital or residential treatment facility). Concentration: In the last 30 days have you experienced trouble understanding, concentrating or remembering? Mood disorder: Which of the following psychiatric diagnoses apply to the veteran? Mood disorder. Medical problem-oral: Does the veteran have or has the veteran complained of any of the following medical problems? Oral/Dental problems. Hallucinations: In the last 30 days have you experienced hallucinations? a
Note: All entered items are statistically significant (p o 0.01).
3.2. Logistic regression Results of the stepwise logistic regression analysis of the variables entered are presented for ideation and attempts in Table 3 in order of entry. For both ideation and attempts, the items entered first involved subjective report of trouble controlling violent behavior and experiencing depression. As can be seen in Table 3, the order entered and the variables themselves are somewhat different between ideation and attempts. Odds-ratios are presented for each variable (ideation and attempts) considered separately and for what was obtained at the final step of the analysis in which the influence of all entered variables can alter the odds-ratio obtained when each variable is considered independently. Clearly, the highest odds-ratios are still obtained for the self-report interview items concerning depressed mood and difficulty controlling violence. These odds-ratios are substantially attenuated when they are calculated in combination with the other entered variables. Thus, for example, the estimated risk associated with suicidal ideation is attenuated by presence of a diagnosed Mood Disorder or not sleeping the previous night in a treatment facility. Nevertheless, the odds-ratios for subjective experience of depression and low violence control remain reasonably high. A secondary stepwise analysis was conducted involving participants who just reported ideation without an actual attempt. The results are also presented in Table 3. The same variables entered with some change in their ordering. Difficulty concentrating was entered first and diagnosis of Mood Disorder was entered last but otherwise the order and the magnitude of the odds-ratios remained about the same. These results indicate that the greatest potential for suicidal behavior is clearly in the realm of subjective reports of current
psychological problems, notably depression with an independent odds-ratio of 14.48 for ideation and 11.96 for attempts. Problems with controlling violence produced an odds-ratio of 7.3 for ideation and 6.1 for attempts. Other odds-ratios for the entered variables, while significant, were substantially more modest.
4. Discussion This study of interview-based data analyzed for suicidality potential found that suicidal behaviors including ideation and actual attempts in the past thirty days are most predictable from subjective reports of the individual’s current state, notably depression and difficulty with controlling violent behavior, with significant but substantially lower predictability associated with certain socio-demographic factors and medical or psychiatric diagnostic variables. Importantly, an interviewee’s complaint of feeling depressed within 30 days of the time of the interview was a substantially more powerful predictor than an established diagnosis of a Mood Disorder. These findings are consistent with a literature based upon more extensive assessment and observation indicating that suicidality is more highly associated with impulsivity and acute depression than it is with established psychiatric illness that may or may not be active (Mann et al., 1999, 2008). These reports of subjective states were by far the most powerful predictors of both ideation and attempts. With regard to depression, the odds ratio for an established diagnosis of Mood Disorder was 2.95 for ideation and in the logistic regression did not enter the regression equation for attempts; however, it is notable that self-report of depression within the last 30 days produced exceptionally high odds-ratios.
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A useful way of conceptualizing these results is to consider the view that state characteristics of an individual at some particular moment is a more powerful predictor than stable, longstanding trait characteristics. Support for this view may also be found in the relatively high odds ratios (2.04 for ideation and 2.17 for attempts) for the interview item indicating that the subject spent the night before the interview in a hospital or other institutional setting. This situation may reflect the severe stress that is associated with suicidal behaviors. Odds ratios associated with spending the night before the interview in prison (OR¼ 0.88 for thoughts; 1.0 for attempts) were not statistically significant whereas ‘spent night before in an institutional setting’ was included in the regression equation. Similarly, being homeless for a year or more was not associated with statistically significant odds ratios. In fact, ideation was negatively associated with being homeless for more than a year. Older age and ethnicity appeared to be protective factors. As can be seen in Table 1, relative risk is at its lowest in the older age group (OR¼0.99 for thoughts and 0.69 for attempts). 7.6% of the participants who spent the previous night in an institutional setting reported making an actual suicidal attempt as compared with 4.2% of those who spent the previous night outdoors or in prison. The impact of medical illness on suicidality was modest, but often statistically significant. The substance abuse variables produced minimally significant odds ratios, but failed the tolerance test for entry into the logistic regression equation. These results are consistent with the model proposed by Mann et al. (1999, 2008) that links state-related variables, depression and impulsivity, to suicidal behaviors. The finding in this study of exceptionally high odds ratios for subjective reports of current depression and difficulty controlling violent behavior, in contrast to the lower ratios for objective diagnostic indices of depression and psychosis suggest that these self-reported state-related variables represent proximal risk factors that weigh more heavily than indicators that meet diagnostic threshold for a mood disorder. Also important, substance abuse or dependence may be a contributing factor but the high prevalence of those conditions in the sample would suggest that it is not a specific predictor since there were many individuals who had substance abuse problems but did not engage in suicidal behaviors. As indicated in the Mann et al. model, substance abuse and other disinhibiting disorders may induce impulsivity leading to aggressive or suicidal behaviors. The findings are also consistent with an extensive literature on the relation between depression and violence and suicidality. For example, Williams et al. (2006) reported finding s significant association between severity ratings of symptoms of recurrent depression and suicidality. Antypa et al. (2010) found that during a depressive episode suicidality was associated with increased cognitive reactivity to sad mood during periods of remission. Olgiati et al. (2009) found that in non-psychotic Major Depressive Disorder, symptoms of excessive self reproach, diurnal changes, poor appetite and hypomanic symptoms were associated with suicidal thoughts. With regard to violence, as an example of an extensive literature (Illgen et al., 2010) based on a large sample of adults with Substance Use Disorder, reported that more extreme types of violence were associated with suicidal behaviors, both ideation and attempts. The significant low odds ratio for African American status in the bivariate analyses is noteworthy in this study and consistent with similar findings of lower base rates of suicidal behavior among African Americans as contrasted with Caucasians in the US general population (Wenzel et al., 2011). Being African–American therefore appears to be a protective factor. A compelling explanation for this potential protective factor cannot be obtained from the present data; future research may address the possibility of there being an as yet unspecified but important cultural factor that may explain this finding.
In summary, in this analysis of interview data from a large population of homeless veterans in a northeastern region of the US we have generated prediction equations for suicidal behavior based upon interview data that include socio-demographic, physical health, psychiatric and subjective report of psychological problems areas with final equations for ideation and attempts based upon all entered variables. The size of the odds ratios for the interview items concerning self reported depression and difficulty controlling violent behavior would appear to have strong implications for treatment and management of suicide risk in homeless veterans. It is noted that 4.16% of the homeless veterans interviewed have attempted suicide within 30 days before the time of the interview and 13.47% experienced suicidal ideation. Taken literally, the odds ratio findings would mean that there may be up to 13 (thoughts) or 15–1 (attempts) odds that an individual who reports presently being seriously depressed or having difficulty inhibiting aggression can reasonably be viewed as having a serious potential for suicidal behaviors.
Acknowledgment This research was supported by the Mental Illness Research, Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, and the Medical Research Service, Department of Veterans Affairs. References Antypa, N., Van der Does, A.J., Penninx, B.W., 2010. Cognitive reactivity: investigation of a potentially treatable marker of suicide risk in depression. Journal of Affective Disorders 122, 46–52. Cohen, C.I., Thompson, K.S., 1992. Homeless mentally ill or mentally ill homeless? American Journal of Psychiatry 149, 816–823. Desai, R.A., Dausey, D.J., Rosenheck, R.A., 2005. Mental health service delivery and suicide risk: the role of individual patient and facility factors. American Journal of Psychiatry 162, 311–318. Desai, R.A., Liu-Mares, W., Dausey, D.J., Rosenheck, R.A., 2003. Suicidal ideation and suicide attempts in a sample of homeless people with mental illness. Journal of Nervous and Mental Disease 191, 365–371. Eynan, R., Langley, J., Tolomiczenko, G., Rhodes, A.E., Links, P., Wasylenki, D., Goering, P. The association between homelessness and suicidal ideation and behaviors: results of a cross-sectional survey. Suicide and Life Threatening Behavior 32, pp. 418–427. Fischer, P.J., Breakey, W.R., 1991. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychologist 46, 1115–1128. Gamache, G., Rosenheck, R., Tessler, R., 2001. The proportion of veterans among homeless men: a decade later. Social Psychiatry and Psychiatric Epidemiology 36, 481–485. Herman, D.B., Susser, E.S., Jandorf, L., Lavelle, J., Bromet, E.J., 1998. Homelessness among individuals with psychotic disorders hospitalized for the first time: findings from the Suffolk county mental health project. American Journal of Psychiatry 155, 109–113. Illgen, M.A., Burnette, M.L., Connor, K.R., Czyz, E., Murray, R., Chermack, S., 2010. The association between violence and lifetime suicidal thoughts and behaviors in individuals treated for substance use disorders. Addictive Behaviors 35, 111–115. Kasprow, W.J., Rosenheck, R.A., 1998. Substance use and psychiatric problems of Native American veterans. Psychiatric Services 49, 345–350. Lim, S., Kasprow, W.J., Rosenheck, R.A., 2006. Psychiatric illness and substance abuse among homeless Asian–American veterans. Psychiatric Services 57, 704–707. Langhinrichsen-Rohling, J., Snarr, J.D., Slep, A.M., Heyman, R.E., Foran, H.M., 2011. United States Air Force Family Advocacy Program, 2011. Risk for suicidal ideation in the US Air Force: An ecological perspective. Journal of Consulting and Clinical Psychology 79, 600–612. Mann, J.J., Waternaux, C., Haas, G.L., Malone, K.M., 1999. Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry 156, 181–189. Mann, J.J., Ellis, S.P., Waternaux, C.M., Liu, X., Oquendo, M.A., Malone, K.M., Brodsky, B.S., Haas, G.L., Currier, D.J., 2008. Classification trees distinguish suicide attempters in major psychiatric disorders: a model of clinical decision making. Journal of Clinical Psychiatry 69, 23–31. McGuire, J.F., Rosenheck, R.A., 2004. Criminal history as a prognostic indicator in the treatment of homeless people with severe mental illness. Psychiatric Services 55, 42–48.
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Olgiati, P., Serretti, A., Colombo, C., 2009. Retrospective analysis of psychomotor agitation, hypomanic symptoms, and suicidal ideation in unipolar depression. Depression and Anxiety 23, 389–397. Prigerson, H.G., Desai, R.A., Liu-Mares, W., Rosenheck, R.A., 2003. Suicidal ideation and suicide attempts in homeless mentally ill persons: age-specific risks of substance abuse. Social Psychiatry and Psychiatric Epidemiology 38, 213–219. Rosenheck, R.A., Dausey, D.J., Frisman, L., Kasprow, W., 2000. Outcomes after initial receipt of social security benefits among homeless veterans with mental illness. Psychiatric Services 51, 1549–1554. Rosenheck, R., Fontana, A.A., 1994. A model of homelessness among male veterans of the Vietnam War generation. American Journal of Psychiatry 151, 421–427.
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Tessler, R., Rosenheck, R., Gamache, G., 2002. Comparison of homeless veterans with other homeless men in a large clinical outreach program. Psychiatric Quarterly 73, 109–119. Wan, J.J., Morabito, D.J., Khaw, L., Knudson, M.M., Dicker, R.A., 2006. Mental illness as an independent risk factor for unintentional injury and injury recidivism. Journal of Trauma 6, 1299–1304. Wenzel, A., Berchick, E.R., Tenhave, T., Halberstadt, S., Brown, G.K., Beck, A.T., 2011. Predictors of suicide attempts and suicide ideation: a 30-year prospective study. Journal of Affective Disorders 132, 375–382. Williams, J.M., Crane, C., Barnhofer, T., Van der Does, A.J., Segal, Z.V., 2006. Recurrence of suicidal ideation across depressive episodes. Journal of Affective Disorders 91, 189–194.
Contents lists available at SciVerse ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Medical, psychiatric and demographic factors associated with suicidal behavior in homeless veterans Gerald Goldstein a,b,n, James Francis Luther a,b, Gretchen Louise Haas a,b a b
Mental Illness Research, Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA University of Pittsburgh, PA, USA
a r t i c l e i n f o
abstract
Article history: Received 28 November 2011 Received in revised form 27 February 2012 Accepted 18 March 2012
This study assessed potential for suicidal behaviors associated with sociodemographic, predisposing physical and mental health factors and self-reported psychological problems among homeless veterans in a large northeastern region. Data were obtained from a demographic and clinical history interview conducted with 3595 homeless veterans. Odds-ratio (OR) statistics were used to assess potential for suicidal behavior. Statistically significant ratios were similar for ideation and attempts. The highest ratios were for self-report of depression and difficulty controlling violence, but statistically significant ratios were found for reporting sleeping in a treatment facility the night before the interview, receiving VA support for a psychiatric condition, and the diagnoses of Alcoholism, Mood Disorder and Post Traumatic Stress Disorder (PTSD). Low but statistically significant odds-ratios were obtained for most of the physical health items. A negative odds-ratio was obtained for African–American ethnicity. Logistic regression results indicated that for ideation and attempts items entered first involved subjective report of trouble controlling violent behavior and experiencing depression. High odds ratios for the interview items concerning experiencing serious depression and having difficulties controlling violence may have strong implications for treatment and management of homeless veterans. There may be up to 14–1 odds that an individual who reports being seriously depressed or having difficulty inhibiting aggression may have a serious potential for suicidal behaviors. Published by Elsevier Ireland Ltd.
Keywords: Suicide Homelessness Logistic regression
1. Introduction Given that psychiatric and medical disorders are common among the homeless (Herman et al., 1998; Wan et al., 2006), it is not surprising that mortality rates, including rates of suicide are elevated in this population. The causal relationship between psychiatric conditions and homelessness is the subject of some debate (e.g., Cohen and Thompson, 1992). However, it is likely that homelessness is associated not only with substantial economic, social and quality of life handicaps, but also the state of homelessness itself introduces substantial physical, social and psychological stressors to individuals who have no stable residence. From several reports, US military veterans are over-represented among the homeless population in the US (Gamache et al., 2001; Tessler et al., 2002). Veterans may be particularly vulnerable to homelessness, perhaps because of disabilities and health problems developed when in military service, and in part, because of the
n Corresponding author at: Mental Illness Research, Educational and Clinical Center, VA Pittsburgh Healthcare System, 7180 Highland Drive (151R), Pittsburgh, PA 15206, USA. E-mail address: [email protected] (G. Goldstein).
0165-1781/$ - see front matter Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.psychres.2012.03.029
many problems of social readjustment typically associated with discharge from the military (Rosenheck and Fontana, 1994). Homelessness is known to be a risk factor for suicidal behaviors (Mann et al., 2008). Findings from interview studies of homeless individuals suggest that the incidence of suicidal ideation and/or attempts may be higher among homeless individuals as compared with the general population. Eynan et al. (2002) reported a 61% prevalence of suicidal ideation and a 34% prevalence of suicide attempts in a large sample of homeless. Likewise, Desai et al. (2003) found a 66.2% lifetime prevalence of suicidal ideation, a 51.3% lifetime prevalence of suicide attempts and 26.9% of the cases reported an attempt resulting in psychiatric hospitalization. Elevated risk for suicidal behavior among the homeless may be attributable to the significant life stress and degraded quality of life typically associated with homelessness. However, it is also likely that the mental and physical health problems so prevalent among homeless populations and associated with elevated risk for suicide in the general population introduce increased risk for suicidal behavior among the homeless. Mann et al. (1999, 2008) have presented a model that links state-related variables, depression and impulsivity, to suicidal behaviors. The information provided by this study may be relevant to that model which integrates psychiatric disorder and subjective state with suicidal behaviors.
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G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
Interestingly, in the same sample of 7224 homeless individuals with severe mental illness recruited for study through the multisite ACCESS outreach program and described by Desai et al. (2003), Prigerson et al. (2003) found that some demographic correlates of suicidal behavior differed from robust demographic correlates reported for the non-homeless population in the US. For example, they observed an increased rate of self-reported suicidal behavior among those between the ages of 30–39 as contrasted with elevated risk among younger and older age groups in the general population; they also reported that among the elderly homeless in the sample, risk for suicidal behavior increased in the presence of drug and alcohol abuse (Fischer and Breakey,1991). Langhinrichsen-Rohling et al. (2011) reported that in individuals on active military duty, significant predictors of suicidal ideation included depressive symptoms, alcohol problems, family matters including relationship satisfaction and intimate partner victimization, hours worked and community level social support. The present study was an effort to find such predictors among homeless veterans. This study aims to assess potential for suicidal ideation and attempt behaviors associated with (1) sociodemographic factors, (2) predisposing health factors (the existence of chronic or acute physical, mental and substance use conditions) and (3) proximal, state-related psychological risk factors (self-reported psychological problems) among homeless veterans in a large northeastern region of the US.
2. Material and methods As part of a nation-wide outreach effort to provide services to the large population of homeless veterans, the Department of Veterans Affairs (DVA) designed and administered an interview-based questionnaire with several sections covering pertinent areas to veterans who were presently or recently homeless. Data from this survey were made available to the authors from a consecutive series of 3595 interviews conducted over a two-year period (October 1, 2001– September 30, 2003) in one VA regional network. 2.1. Participants Data were collected by DVA outreach workers using a demographic and clinical history interview conducted with 3595 homeless veterans from the Veterans Integrated Services Network 4 (VISN 4) which includes all of Pennsylvania, Delaware and parts of West Virginia, New Jersey and Ohio. The sample included all presently or recently homeless veterans identified and contacted in various settings located in both urban and rural areas within VISN 4, including community facilities for the homeless, VA hospitals, outpatient clinics, prisons, and veteran’s centers in the community for the purpose of providing information about DVA-sponsored health services. The majority of participants lived in shelters (n¼ 1665) or with acquaintances on a temporary basis (n¼ 657). The data were collected as a national survey of veterans under conditions that assured privacy and confidentiality. Participants were contacted by the DVA as part of an outreach program and were asked to volunteer to take the interview without penalty for refusal. The present investigators were given access to these data by the DVA Northeast Program Evaluation Center (NEPEC). Written informed consent was obtained from participants prior to interview (as described in the previous published reports of McGuire and Rosenheck (2004) and Rosenheck et al. (2000)). Data were transmitted to the current investigators in de-identified form with review and approval to conduct the analysis by the Institutional Review Board (IRB) at the local site (VA Pittsburgh Healthcare System, Pittsburgh, PA, 15206). 2.2. Interview procedures Interviews were conducted by experienced health workers, mainly social workers and psychiatric nurses, associated with the DVA-sponsored Healthcare for Homeless Veterans (HCHV) program that routinely performs assessments for identifying and tracking veterans in need of services. A personal interview with the homeless veteran was conducted by these workers who were trained in the administration of this semi-structured procedure The interviews included sections on demographic information, characteristics of the contact with the veteran, military history, living situation, medical history, substance abuse, psychiatric status, employment status, and observations made by the interviewer covering the areas of clinical psychiatric disorder and needs for referral and treatment. Several studies have appeared in the literature utilizing data obtained from this survey process that were reported on beginning in 1991 (e.g., Kasprow and Rosenheck, 1998).
With regard to the present study, two interview items concerned suicidal behaviors—one inquires about suicidal ideation and the other about suicidal attempts. (During the past 30 days, have you had a period (that was not the direct result of alcohol or drug use) in which you had serious thoughts of suicide or attempted suicide?). These items were studied in relation to a set of selected items from the interview that appeared to have possible relevance to suicidal behaviors. These included demographic and historical questions, presence or absence ratings of a set of psychological and emotional problems, physical disorders, and inquiries about several psychiatric difficulties. Diagnostic ratings were made by the interviewers based on self-report information provided by the veteran and supplemented by medical chart information, when available. As indicated in the Kasprow and Rosenheck study, these ratings were made on the basis of unstructured assessments and therefore relied upon clinical judgment sometimes supported by record review. While they should not be construed as being formal International Classification of Diseases (ICD) or Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) diagnoses based upon a standard structured interview, or full medical evaluation, in previous large sample studies these clinical ratings have been associated to meaningful clinical and socio-cultural variables in homeless individuals such as ethnicity (Lim et al., 2006) and suicide risk (Desai et al., 2005). In any event, the diagnostic ratings used in the present study were for broad groups of psychiatric disorders including alcohol and drug substance abuse, schizophrenia and other psychoses, mood disorders, PTSD, personality disorder, and adjustment disorder and broad categories of physical problems such as heart or liver disease without further specificity. Specific DSM-IV or ICD were not used as bases for classification. While computer-based medical records were available to the interviewers for determination of presence/absence of medical and mental health disorders, we do not have information concerning how frequently medical records were used. Interviewers were trained clinicians and knowledgeable concerning the disorders coded, and therefore capable of making accurate determinations regarding the presence/absence of the broad diagnostic categories used here based upon self-report during a clinical interview. Kasprow and Rosenheck (1998) pointed out that when large samples are obtained by report from numerous clinicians, as was the case in the present study, the potential impact of interviewer-specific diagnostic biases should be attenuated. In addition to obtaining these diagnoses, the psychiatric status section of the interview included direct questions for respondent self-report regarding current psychological symptoms and problems, including depression, anxiety, hallucinations, concentration and memory problems, violent behavior and recent (30-day) history of suicidal ideation or suicide attempt behaviors. Contacts with the outreach interviewing program were made through DVA-initiated outreach, referrals from shelter staff, and referrals from DVA patient care facilities, through the veteran’s community centers or through special programs for the homeless. The sample for which complete diagnostic data were available contained 3595 participants. The data analysis was based upon 3429 individuals who had a complete data set. They were collated and entered into computer databases by staff from the DVA Northeast Program Evaluation Center (NEPEC).
2.3. Statistical analyses The design of the study was an odds-ratio (OR) analysis in which an attempt was made to elicit associations between information contained in several sections of the interview and self-reported presence or absence of recent (30-days history) suicidal behaviors, both thoughts of committing suicide and actual attempts. The interview was divided into several separate subsections that included a description of the veteran and circumstances of contact for the interview, military history, living situation, medical status, substance abuse, psychiatric status, employment status and a section called interviewer observations that contains subsections on need for care, psychiatric diagnoses, and plans for referral and treatment. The psychiatric subsection covers self-reported symptoms such as anxiety, but diagnoses are also noted in this last section. The items considered here were selected socio-demographic questions contained in the first section, military history, living situation, medical and psychiatric status descriptive and diagnostic items. All individual items listed in this paper are categorical except for age. For simplicity, age was dichotomized using a median split. The study was directed toward evaluating predictive capacity of interview responses for suicidal behavior, both ideation and attempts. Predictor variables were various socio-demographic and clinical interview items taken from various sections of the interview. In an effort to determine which the most powerful predictors were, a stepwise binary logistic regression analysis was performed. A strict tolerance test (po0.001 to enter the regression equation; po0.01 to remove) was used in order to assure that the most robust items entered the prediction equation. Following this procedure, odds-ratios were recomputed for the entered variables providing probability estimates for the entered variables after accounting for the influence of the other variables in the equation. This procedure evaluates the possibility that probability associated with some individual variable such as being homeless for more than one year may be attenuated by another variable in which the odds-ratio indicates a reduced potential, thereby constituting a possible protective factor.
G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
39
Table 1 Odds ratio (OR) and 95% confidence intervals (CI) for demographic and residence measures of homeless veterans with suicidal ideation in the past 30 days (N¼ 482) or attempted suicide in the past 30 days (N ¼149) compared to homeless veterans with neither (N¼ 2947). Measure
In the past 30 days Suicidal ideation
Suicide attempt
N (%)
OR
95% CI
p
Age 448 Yes No
229 (14.0) 253 (14.1)
0.99
(0.81, 1.19)
Sex Male Female
465 (14.0) 17 (15.9)
0.86
(0.51, 1.46)
Race White Black Other
261 (16.8) 215 (11.8) 3 (8.3)
Service period Pre-Vietnam Vietnam Post-Vietnam Persian Gulf
30 (9.3) 248 (15.3) 181 (14.1) 23 (11.6)
Employment status, past three years Employed/service Unemployed/student Retired/disabled
222 (12.6) 114 (15.3) 142 (15.5)
Service connected, psychiatry Yes No
N (%)
OR
95% CI
58 (3.9) 91 (5.6)
0.69
(0.50, 0.97)
138 (4.6) 11 (10.9)
0.40
(0.21, 0.76)
o0.04
0.89
o0.01
0.59
o 0.01 0.66 0.45
(0.54, 0.80) (0.14, 1.48)
o 0.01 0.19
o0.01 85 (6.2) 63 (3.8) 1 (2.9)
0.60 0.46
(0.43, 0.83) (0.06, 3.41)
o 0.03 1.77 1.61 1.29
(1.19, 2.64) (1.07, 2.42) (0.73, 2.29)
o 0.01 o 0.03 0.39
2.61 3.36 6.72
(1.04, 6.56) (1.34, 8.44) (2.48, 18.2)
49 (24.6) 424 (13.2)
2.15
(1.53, 3.02)
Service connected, other Yes No
56 (16.5) 419 (13.6)
1.25
(0.92, 1.69)
Non-service connected pension Yes No
58 (16.9) 421 (13.7)
1.28
(0.95, 1.73)
Non-VA disability (e.g. SSDI) Yes No
92 (17.5) 385 (13.3)
1.38
(1.08, 1.78)
Other public support Yes No
92 (17.1) 385 (13.5)
1.32
(1.03, 1.70)
Marital status Never married Married/remarried Divorced/separated Widowed
163 (13.6) 18 (12.4) 287 (14.5) 14 (13.1)
1.11
(0.66, 1.87)
1.20 1.06
(0.72, 1.99) (0.50, 2.24)
Where slept last night Own place Relative/friend Shelter No residence Institution Prison/jail
19 (14.7) 108 (17.1) 166 (10.4) 83 (15.8) 86 (21.6) 11 (15.9)
0.92 1.09 0.61
(0.53, 1.58) (0.80, 1.49) (0.46, 0.82)
o 0.01 0.76 0.58 o 0.01
1.46 1.01
(1.04, 2.04) (0.51, 2.00)
o 0.03 0.99
Homeless 4one year Yes No
93 (12.2) 384 (14.6)
0.81
(0.64, 1.03)
Received combat zone fire Yes No
103 (16.0) 366 (13.5)
1.22
(0.97, 1.55)
1.45 1.22
(0.97, 2.17) (0.82, 1.81)
13 (8.0) 135 (4.6)
1.79
(0.99, 3.24)
14 (4.7) 134 (4.8)
0.98
(0.56, 1.72)
17 (5.6) 131 (4.7)
1.21
(0.72, 2.03)
31 (6.7) 116 (4.4)
1.55
(1.03, 2.33)
36 (7.5) 111 (4.3)
1.79
(1.22, 2.65)
58 (5.3) 10 (7.3) 77 (4.4) 3 (3.1)
0.71
(0.36, 1.43)
0.58 0.41
(0.29, 1.15) (0.11, 1.53)
6 (5.2) 22 (4.0) 58 (3.9) 23 (5.0) 33 (9.5) 3 (4.9)
1.05 0.80 0.77
(0.42, 2.63) (0.44, 1.46) (0.47, 1.27)
o0.01 0.93 0.48 0.31
2.02 0.99
(1.16, 3.51) (0.29, 3.41)
o0.02 0.99
32 (4.6) 115 (4.9)
0.93
(0.62, 1.39)
37 (6.4) 112 (4.6)
1.44
(0.98, 2.11)
o 0.01
0.06
0.16
0.94
0.11
0.48
o 0.02
o0.04
o 0.03
o0.01
0.82
0.29
0.09
0.73
0.10
3. Results 3.1. Individual odds-ratios The individual odds-ratios and their associated probability levels are presented in Tables 1 and 2. In most cases the statistically significant ratios were about the same for ideation and attempts.
o0.05 o0.01 o0.01 0.19
67 (4.2) 40 (6.0) 41 (5.0)
(0.98, 1.59) (1.01, 1.59)
o0.01 0.45 o0.01
5 (1.7) 61 (4.3) 63 (5.4) 20 (10.3)
0.07 1.25 1.27
p
0.07
For the demographic data the highest ratios (p o0.01) were associated with having a service connected disability, receiving other public support and being a Vietnam veteran. Location where the participant slept the night before the interview, particularly if it was an institutional setting, also produced a highly significant odds ratio. Self-report of psychological problem items, notably depression, difficulty controlling violent behavior,
40
G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
Table 2 Odds ratios (OR) for psychiatric items for suicidal ideation in the past 30 days (N ¼482) or attempted suicide in the past 30 days (N ¼ 149) compared to homeless veterans with neither (N ¼2947). Measure
I Suicidal ideation
Suicide attempt
N (%)
OR
95% CI
p
Hospitalized for psychiatric problem Yes No
307 (23.3) 172 (8.2)
3.41
(2.79, 4.17)
Psychiatric problem Depression Yes No
447 (23.1) 34 (2.3)
12.8
(8.99, 18.3)
Anxiety/tension Yes No
441 (21.9) 41 (2.9)
9.35
(6.73, 13.0)
Hallucinations Yes No
145 (35.5) 336 (11.2)
4.39
(3.48, 5.54)
Cognitive trouble Yes No
360 (27.6) 121 (5.7)
6.31
(5.06, 7.86)
Violent behavior Yes No
152 (43.6) 328 (10.7)
6.46
(5.08, 8.22)
Prescription meds Yes No
292 (27.3) 187 (8.0)
4.35
(3.56, 5.32)
Psychiatric diagnosis Alcohol abuse/dependency Yes No
329 (15.8) 153 (11.4)
1.45
(1.18, 1.78)
Drug abuse/dependency Yes No
271 (16.2) 211 (12.1)
1.41
(1.16, 1.71)
Schizophrenia Yes No
62 (16.4) 420 (13.8)
1.23
(0.92, 1.65)
Other psychotic disorder Yes No
37 (25.0) 445 (13.6)
2.12
(1.45, 3.12)
Mood disorder Yes No
332 (20.9) 150 (8.2)
2.97
(2.41, 3.65)
Personality disorder Yes No
71 (23.9) 411 (13.1)
2.08
(1.56, 2.77)
PTSD from combat Yes No
65 (27.8) 417 (13.1)
2.56
(1.89, 3.47)
Adjustment disorder Yes No
208 (16.4) 274 (12.7)
1.35
(1.11, 1.64)
N (%)
OR
95% CI
119 (10.5) 30 (1.5)
7.58
(5.05, 11.4)
140 (8.6) 9 (0.6)
15.2
(7.71, 29.9)
134 (7.9) 15 (1.1)
7.76
(4.53, 13.3)
48 (15.4) 101 (3.6)
4.83
(3.35, 6.97)
109 (10.4) 39 (1.9)
5.92
(4.08, 8.61)
61 (23.6) 88 (3.1)
9.66
(6.76, 13.8)
111 (12.5) 37 (1.7)
8.36
(5.71, 12.2)
93 (5.0) 56 (4.5)
1.12
(0.80, 1.58)
84 (5.6) 65 (4.0)
1.41
(1.02, 1.97)
21 (6.3) 128 (4.6)
1.37
(0.85, 2.21)
14 (11.2) 135 (4.5)
2.65
(1.48, 4.74)
95 (7.0) 54 (3.1)
2.36
(1.68,3.32)
21 (8.5) 128 (4.5)
1.98
(1.22, 3.20)
17 (9.1) 132 (4.5)
2.12
(1.25, 3.59)
51 (4.6) 98 (4.9)
0.92
(0.65, 1.31)
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
0.51
o0.01
o0.05
0.16
0.20
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
o0.01
and cognitive problems were associated with particularly high odds ratios based on their magnitude (e.g. 12.8 and 15.2 for depression), but highly significant ratios (p o0.01) were found for many of the psychiatric items. Low, but statistically significant, odds-ratios were obtained for most of the physical health measures. A negative odds-ratio was obtained for African–American ethnicity, suggesting that being African–American may be a protective factor. An important limitation of the study ruling out any consideration of a potentially significant influence was that the very small number of female participants precluded any
P
0.66
meaningful consideration of gender differences. Using our sample of 118 women we ran odds-ratios for ideation and attempts. For ideation, the OR was 1.47 (Confidence intervals (CI) ¼0.95–2.28), which was not significant. An OR of 2.48 (CI¼1.30–4.72) was found for attempts, which is significant. In actual values, 9.3% of the female participants made an attempt while 4% of the males did so. Thus, the probability of making an attempt was significantly higher among women than men. This clearly provocative preliminary finding should provide a focus for future study with larger samples of female veterans.
G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
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Table 3 Odds Ratios (OR) for items entered into the stepwise logistic regression analysisa. Variable
OR
95% CI
OR at final step
95% CI
Ideation Controlling violence Depression Concentration Mood disorder Hallucinations Slept treatment facility
7.303 14.488 6.442 2.950 4.601 2.038
5.859–9.102 10.351–20.277 5.273–7.870 2.449–3.554 3.719–5.691 1.614–2573
3.849 6.786 2.442 1.715 1.920 2.303
2.939–5.040 4.610–9.988 1.912–3.119 1.363–2.158 1.468–2.512 1.706–3.110
Attempts Controlling violence Depression Slept treatment facility Concentration Medical problem-Oral
6.114 11.955 2.188 4.547 0.715
4.331–8.630 6.073–23.536 1.464–3.271 3.134–6.597 0.513–0.996
6.678 8.895 2.488 2.255 0.512
4.631–9.629 3.188–14.276 1.585–3.840 1.462–3.478 0.363–0.741
Variable
OR
CI
OR at final step
CI
Ideation eliminating attempters Concentration Depression Violence Slept treatment facility Hallucinations Mood disorder
6.307 12.838 6.46 1.825 4.388 2.968
5.061–7.859 8.992–18.330 5.078–8.217 1.405–2.371 3.478–5.535 2.415–3.647
2.422 6.331 3.258 2.011 1.905 1.721
1.856–3.162 4.190–9.567 2.428–4.372 1.443–2.804 1.428–2.543 1.341–2.208
Items meeting entry criteria. Violence: In the last 30 days have you had trouble controlling violent behavior? Depression: In the last 30 days have you experienced a serious depression? Slept treatment facility: Where did you sleep last night? Institution (hospital or residential treatment facility). Concentration: In the last 30 days have you experienced trouble understanding, concentrating or remembering? Mood disorder: Which of the following psychiatric diagnoses apply to the veteran? Mood disorder. Medical problem-oral: Does the veteran have or has the veteran complained of any of the following medical problems? Oral/Dental problems. Hallucinations: In the last 30 days have you experienced hallucinations? a
Note: All entered items are statistically significant (p o 0.01).
3.2. Logistic regression Results of the stepwise logistic regression analysis of the variables entered are presented for ideation and attempts in Table 3 in order of entry. For both ideation and attempts, the items entered first involved subjective report of trouble controlling violent behavior and experiencing depression. As can be seen in Table 3, the order entered and the variables themselves are somewhat different between ideation and attempts. Odds-ratios are presented for each variable (ideation and attempts) considered separately and for what was obtained at the final step of the analysis in which the influence of all entered variables can alter the odds-ratio obtained when each variable is considered independently. Clearly, the highest odds-ratios are still obtained for the self-report interview items concerning depressed mood and difficulty controlling violence. These odds-ratios are substantially attenuated when they are calculated in combination with the other entered variables. Thus, for example, the estimated risk associated with suicidal ideation is attenuated by presence of a diagnosed Mood Disorder or not sleeping the previous night in a treatment facility. Nevertheless, the odds-ratios for subjective experience of depression and low violence control remain reasonably high. A secondary stepwise analysis was conducted involving participants who just reported ideation without an actual attempt. The results are also presented in Table 3. The same variables entered with some change in their ordering. Difficulty concentrating was entered first and diagnosis of Mood Disorder was entered last but otherwise the order and the magnitude of the odds-ratios remained about the same. These results indicate that the greatest potential for suicidal behavior is clearly in the realm of subjective reports of current
psychological problems, notably depression with an independent odds-ratio of 14.48 for ideation and 11.96 for attempts. Problems with controlling violence produced an odds-ratio of 7.3 for ideation and 6.1 for attempts. Other odds-ratios for the entered variables, while significant, were substantially more modest.
4. Discussion This study of interview-based data analyzed for suicidality potential found that suicidal behaviors including ideation and actual attempts in the past thirty days are most predictable from subjective reports of the individual’s current state, notably depression and difficulty with controlling violent behavior, with significant but substantially lower predictability associated with certain socio-demographic factors and medical or psychiatric diagnostic variables. Importantly, an interviewee’s complaint of feeling depressed within 30 days of the time of the interview was a substantially more powerful predictor than an established diagnosis of a Mood Disorder. These findings are consistent with a literature based upon more extensive assessment and observation indicating that suicidality is more highly associated with impulsivity and acute depression than it is with established psychiatric illness that may or may not be active (Mann et al., 1999, 2008). These reports of subjective states were by far the most powerful predictors of both ideation and attempts. With regard to depression, the odds ratio for an established diagnosis of Mood Disorder was 2.95 for ideation and in the logistic regression did not enter the regression equation for attempts; however, it is notable that self-report of depression within the last 30 days produced exceptionally high odds-ratios.
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G. Goldstein et al. / Psychiatry Research 199 (2012) 37–43
A useful way of conceptualizing these results is to consider the view that state characteristics of an individual at some particular moment is a more powerful predictor than stable, longstanding trait characteristics. Support for this view may also be found in the relatively high odds ratios (2.04 for ideation and 2.17 for attempts) for the interview item indicating that the subject spent the night before the interview in a hospital or other institutional setting. This situation may reflect the severe stress that is associated with suicidal behaviors. Odds ratios associated with spending the night before the interview in prison (OR¼ 0.88 for thoughts; 1.0 for attempts) were not statistically significant whereas ‘spent night before in an institutional setting’ was included in the regression equation. Similarly, being homeless for a year or more was not associated with statistically significant odds ratios. In fact, ideation was negatively associated with being homeless for more than a year. Older age and ethnicity appeared to be protective factors. As can be seen in Table 1, relative risk is at its lowest in the older age group (OR¼0.99 for thoughts and 0.69 for attempts). 7.6% of the participants who spent the previous night in an institutional setting reported making an actual suicidal attempt as compared with 4.2% of those who spent the previous night outdoors or in prison. The impact of medical illness on suicidality was modest, but often statistically significant. The substance abuse variables produced minimally significant odds ratios, but failed the tolerance test for entry into the logistic regression equation. These results are consistent with the model proposed by Mann et al. (1999, 2008) that links state-related variables, depression and impulsivity, to suicidal behaviors. The finding in this study of exceptionally high odds ratios for subjective reports of current depression and difficulty controlling violent behavior, in contrast to the lower ratios for objective diagnostic indices of depression and psychosis suggest that these self-reported state-related variables represent proximal risk factors that weigh more heavily than indicators that meet diagnostic threshold for a mood disorder. Also important, substance abuse or dependence may be a contributing factor but the high prevalence of those conditions in the sample would suggest that it is not a specific predictor since there were many individuals who had substance abuse problems but did not engage in suicidal behaviors. As indicated in the Mann et al. model, substance abuse and other disinhibiting disorders may induce impulsivity leading to aggressive or suicidal behaviors. The findings are also consistent with an extensive literature on the relation between depression and violence and suicidality. For example, Williams et al. (2006) reported finding s significant association between severity ratings of symptoms of recurrent depression and suicidality. Antypa et al. (2010) found that during a depressive episode suicidality was associated with increased cognitive reactivity to sad mood during periods of remission. Olgiati et al. (2009) found that in non-psychotic Major Depressive Disorder, symptoms of excessive self reproach, diurnal changes, poor appetite and hypomanic symptoms were associated with suicidal thoughts. With regard to violence, as an example of an extensive literature (Illgen et al., 2010) based on a large sample of adults with Substance Use Disorder, reported that more extreme types of violence were associated with suicidal behaviors, both ideation and attempts. The significant low odds ratio for African American status in the bivariate analyses is noteworthy in this study and consistent with similar findings of lower base rates of suicidal behavior among African Americans as contrasted with Caucasians in the US general population (Wenzel et al., 2011). Being African–American therefore appears to be a protective factor. A compelling explanation for this potential protective factor cannot be obtained from the present data; future research may address the possibility of there being an as yet unspecified but important cultural factor that may explain this finding.
In summary, in this analysis of interview data from a large population of homeless veterans in a northeastern region of the US we have generated prediction equations for suicidal behavior based upon interview data that include socio-demographic, physical health, psychiatric and subjective report of psychological problems areas with final equations for ideation and attempts based upon all entered variables. The size of the odds ratios for the interview items concerning self reported depression and difficulty controlling violent behavior would appear to have strong implications for treatment and management of suicide risk in homeless veterans. It is noted that 4.16% of the homeless veterans interviewed have attempted suicide within 30 days before the time of the interview and 13.47% experienced suicidal ideation. Taken literally, the odds ratio findings would mean that there may be up to 13 (thoughts) or 15–1 (attempts) odds that an individual who reports presently being seriously depressed or having difficulty inhibiting aggression can reasonably be viewed as having a serious potential for suicidal behaviors.
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