Full access
Articles
Published Online: 15 February 2018

General Medical, Mental Health, and Demographic Risk Factors Associated With Suicide by Firearm Compared With Other Means

Jennifer M. Boggs, M.S.W. [email protected], Arne Beck, Ph.D., Sam Hubley, Ph.D., Edward L. Peterson, Ph.D., Yong Hu, M.A., L. Keoki Williams, M.D., M.P.H., Deepak Prabhakar, M.D., M.P.H., … Show All … , Rebecca C. Rossom, M.D., M.S.C.R., Frances L. Lynch, Ph.D., Christine Y. Lu, Ph.D., Beth E. Waitzfelder, Ph.D., Ashli A. Owen-Smith, Ph.D., Gregory E. Simon, M.D., M.P.H., and Brian K. Ahmedani, Ph.D., L.M.S.W.Authors Info & Affiliations
Publication: Psychiatric Services
Volume 69, Number 6
https://doi.org/10.1176/appi.ps.201700237
Track CitationsAdd to favorites
PDF/EPUB

Abstract

Objective:

Mitigation of suicide risk by reducing access to lethal means, such as firearms and potentially lethal medications, is a highly recommended practice. To better understand groups of patients at risk of suicide in medical settings, the authors compared demographic and clinical risk factors between patients who died by suicide by using firearms or other means with matched patients who did not die by suicide (control group).

Methods:

In a case-control study in 2016 from eight health care systems within the Mental Health Research Network, 2,674 suicide cases from 2010–2013 were matched to a control group (N=267,400). The association between suicide by firearm or other means and medical record information on demographic characteristics, general medical disorders, and mental disorders was assessed.

Results:

The odds of having a mental disorder were higher among cases of suicide involving a method other than a firearm. Fourteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by firearm, including traumatic brain injury (TBI) (odds ratio [OR]=23.53), epilepsy (OR=3.17), psychogenic pain (OR=2.82), migraine (OR=2.35), and stroke (OR=2.20). Fifteen general medical disorders were associated with statistically significant (p<.001) greater odds of suicide by other means, with particularly high odds for TBI (OR=7.74), epilepsy (OR=3.28), HIV/AIDS (OR=6.03), and migraine (OR=3.17).

Conclusions:

Medical providers should consider targeting suicide risk screening for patients with any mental disorder, TBI, epilepsy, HIV, psychogenic pain, stroke, and migraine. When suicide risk is detected, counseling on reducing access to lethal means should include both firearms and other means for at-risk groups.
Suicide is the 10th leading cause of death among all persons and the third leading cause of death among persons between the ages of 20 and 50 (1). The fatality rate of suicide attempts varies substantially depending on means: 85% of attempts involving firearms result in death, compared with 69% involving suffocation, 2% involving poisoning and overdose, and 2% involving other means (2). Although homicide and accidental shootings receive the most attention in the news media and in policy contexts, 63% of firearm injuries in the United States are self-inflicted (3). Approximately 50% of all suicide deaths occur by firearm, 20% by suffocation or hanging, 20% by medication or chemical poisoning, and 10% by other methods (including jumping, self-injury with a sharp object, and drowning) (2,4).
The health care setting is recognized as an opportune setting for prevention of suicide (4–6), and for that reason—as well as a recent rise in suicide mortality (7)—the Joint Commission recommends that providers in multiple health care settings increase suicide screening and conduct means restriction counseling for at-risk patients (8). Means restriction counseling occurs when a general or behavioral health provider advises a patient, the family of a patient, or both to voluntarily remove access to objects that may be used for suicide, such as firearms, potentially lethal medications, sharp objects, and suffocation instruments (9). When patients are identified in primary care as being at risk of suicide, typically during depression screening, means restriction counseling is a highly recommended risk management practice (10). Patients and family members are usually receptive to means restriction counseling when a suicide risk is identified (11,12).
Despite these recommendations, provider surveys indicate that means restriction counseling delivery rates are low. Only 4% to 14% of emergency department physicians and 22% of psychologists discuss means restriction following a suicide attempt (13,14). That is concerning because 10% of patients who make nonfatal suicide attempts go on to die by suicide, and 25% have a subsequent nonfatal attempt (15,16). It has been suggested that rates of means restriction counseling may be low because providers do not believe in its effectiveness (17), and they focus instead on mitigating intent. Suicidal intent is impulsive or not planned in advance in 82% of attempts (18) and is estimated to last from five minutes to one hour (19,20). Therefore, the opportunity for providers to intervene effectively when suicide intention arises is dependent on patients accessing care during times of crisis. Means restriction counseling is a promising approach to save lives by creating a barrier to the impulsive intent of self-harm, which is independent of the patient’s voluntarily accessing care. Effective and efficient means restriction counseling depends on reliably identifying which patients to screen for suicide to determine those who would benefit.
Identifying patients at risk of suicide in general medical settings is challenging. Recent evidence suggests that relying solely on pre-existing psychiatric diagnoses or an expectation that patients will spontaneously volunteer risk symptoms is problematic (10,21). For example, of people who die by suicide, 57% of veterans (22) and 50% of civilians (4) had no recorded history of a mental disorder at the time of their death. Yet 45% of patients seek medical care within one month prior to suicide death (4,23). These findings highlight a gap in the current implementation of suicide risk detection in general medical settings, which typically occurs only following a positive depression screen.
Identifying general medical disorders that may be significant risk factors for suicide is important to inform suicide risk detection. Using the same data source as this study, our group conducted one of the largest U.S.-based studies examining the association of common general medical disorders with suicide (24). Findings indicated particularly high odds ratios for traumatic brain injury (TBI), sleep disorders, and HIV/AIDs after the analyses controlled for mental and substance use disorders. This study builds on our previous work to examine the association of general medical disorders and mental disorders with specific means of suicide.
The objectives of this study were to identify patients who are most at risk of suicide death by firearm compared with other means by using data that are readily available to health care providers. We compared demographic and clinical variables among patients who died by firearm versus other means of suicide with those of matched patients who did not die by suicide (control group) . Understanding this constellation of risk factors has the potential to inform suicide risk assessment and prevention practices, including means restriction counseling.

Methods

Sample, Settings, and Data

In 2016, we conducted a case-control study of 2,674 adult and adolescent patients who died by suicide and 267,400 patients who did not die by suicide. Patients were members of eight learning health care systems within the Mental Health Research Network (25). The network sites in this study included Henry Ford Health System (Michigan), HealthPartners (Minnesota), Harvard Pilgrim Health Care (Massachusetts), and Kaiser Permanente health systems in Colorado, Georgia, Hawaii, Oregon, and Washington. Each site offers integrated general medical and mental health care services, including individual and group therapy, intensive outpatient programs, and psychiatric medication management. These sites cover a population area of more than three million, with demographic characteristics mirroring the surrounding urban and suburban geographic areas. Detailed population demographic and health plan characteristics stratified by site are available at the Mental Health Research Network Web site (hcsrn.org/mhrn/en/Tools%20&%20Materials/MHRNResources/).
As a control, a random sample of 100 patients were matched to each of the 2,674 suicide cases by site and year of death. The date of suicide death was considered as the index date for cases, and their matched counterparts were assigned the same index date. All participants were continuously enrolled in a health plan for at least 10 months during the year prior to the index date, which allows for a small disenrollment gap during the month of death. Each site received institutional review board approval.
All data were extracted from a Virtual Data Warehouse that includes electronic health record and insurance claims data (26–28). The Virtual Data Warehouse is a set of variables with mutually agreed-upon validated definitions across each site to facilitate multisite research projects across the network. This allows each site to retain its own private patient general medical and mental health record data yet overcome the challenge of data harmonization inherent in multisite research. There are routine data quality verifications to ensure that the standard variables are defined similarly across systems. Death data are verified with mortality records from national, state, and local public health organizations by Social Security Number or through a combination of the patient’s name, birthdate, and demographic profile.
To identify patients who died by suicide and the method of suicide, we used ICD-10 codes to define firearm suicide (X72–X74) and suicide by other means (X60–X71, X75–X84, and Y87.0) (29). Other means included all means other than firearm, with poisoning and hanging or suffocation being the most common. ICD-9 codes were captured from health system encounters (inpatient and outpatient) for all study patients to ascertain diagnoses that were current within the year prior to the date of death (30). Diagnoses were extracted for 13 major mental and substance use disorders and 21 general medical disorders. Demographic information on age and sex were available from the data warehouse, and neighborhood income and education were estimated by using geocoded addresses and census block data.

Statistical Analyses

All statistical analyses were carried out by using SAS, version 9.4. Descriptive statistics summarized demographic variables, mental disorders, and general medical disorders for cases of suicide, grouped by means of suicide death (firearms or other means). To determine the association of mental disorders and general medical disorders with suicide death, we used a series of logistic regressions to calculate odds ratios (ORs) and 95% confidence intervals. Four separate models were analyzed to determine the relative contributions of demographic and clinical variables to the odds of suicide by firearm or other means. Using logistic regression, multivariable models were fit for cases of suicide by firearm versus the control group (model 1) and cases of suicide by other means versus the control group (model 2). Covariates for models 1 and 2 included age, sex, and disorder (for example, diabetes). For models 1 and 2, separate models were run for each of the 35 mental and general medical disorders, and the odds ratios for each model are reported.
To evaluate the difference in association between suicide and individual disorders among cases of suicide by firearm versus other means, model 3 included a gun × disorder interaction term. The interaction p value detects whether there were statistically significant differences between the firearm and other-means groups in the odds for each disorder. Because of large gender differences in the means of suicide, we isolated the impact of gender and comorbidity by using an interaction of comorbidity × gender in a fourth logistic regression model. To determine comorbidity, we defined a variable for comorbidity as the presence of zero, one, or two of the following general medical disorders: asthma, back pain, TBI, cancer, congestive heart failure, chronic obstructive pulmonary disease, diabetes, heart disease, HIV/AIDS, hypertension, epilepsy, migraine, multiple sclerosis, osteoporosis, Parkinson’s disease, psychogenic pain, renal disorders, and stroke. To isolate the effect of comorbidity involving general medical disorders from the effect of having a mental disorder, we defined a binary covariate for presence of any mental disorder, which was included only in model 4. Additionally, we included age, education, and income as covariates in the model. Separate models were run for the firearm and other-means groups. We were primarily interested in the odds ratios associated with various levels of comorbidity (0, 1, and ≥2 general medical disorders) within each gender.

Results

Our sample included 2,674 cases of suicide death, 1,298 (49%) by firearm and 1,376 (51%) by other means (Table 1). Men (77%, N=2,063) accounted for most cases of suicide death, with a higher proportion of men among cases involving a firearm (89%, N=1,155) versus other means (66%, N=908). Most cases (61%, N=1,631) involved at least one mental disorder, with the highest prevalence for alcohol use, anxiety, depression, and sleep disorders, respectively (data not shown). This rate is higher compared with the results of previous studies conducted by the network, which reported that 50% of suicide cases involved a mental disorder, because of the inclusion of dementia and tobacco use in the definition of mental disorder. A substantial portion of cases did not involve having had a psychiatric disorder diagnosed in the year prior to suicide death (45% [N=579] of suicides by firearm and 33% [N=921] of suicides by other means). Compared with the control group, suicide cases involving a firearm were significantly more likely to be associated with being older, being male, having lower education, or having lower incomes (Table 1). Deaths by other means showed similar patterns, although there were no differences in education between cases of suicide and the control group.
TABLE 1. Demographic characteristics associated with cases of suicide and a control group, by means of suicide
 FirearmOther means
 Control group (N=129,800)Cases (N=1,298) Control group (N=137,600)Cases (N=1,376) 
VariableN%N%pN%N%p
Age (M±SD years)39.5±22 53±19.1 .00139.1±21.9 47.1±18.4 .001
Age group          
 ≤2033,90026665 36,1772614911 
 21–3012,820101209 13,7901013510 
 31–4017,2451314611 18,4751318113 
 41–5021,4161623818 22,9891732624 
 51–6021,0051628122 22,2391630322 
 61–7012,6421018214 13,2091013210 
 71–806,990514911 6,9865725 
 >803,78131169 3,7353786 
Sex         .001
 Male61,665471,15889 65,3604791466 
 Female68,1455314011.00172,2405346234 
College education45,4303542833.00148,1603549636.077
Yearly household neighborhood income (M±SD $)68,466±28,743 65,793±27,371 .00170,382±29,457 68,502±29,544 .007
Because age and sex varied significantly between cases and the control groups, we adjusted only for sex and age in our subsequent models for testing the association between specific mental disorders and general medical disorders and suicide by firearms versus other means. Adjustment primarily reduced the odds of firearm suicide among many conditions by correcting for cases being primarily male and older. The clinical differences between college education and income, although statistically significant, were not substantial enough to be considered clinically meaningful and for this reason were not included.
Table 2 shows the odds of having a mental disorder among suicide cases versus the control groups. Compared with the control groups, the odds of having a mental disorder were significantly greater among cases of suicide by firearm and cases of suicide by other means for all mental disorders, except autism. Notably, the odds of having a mental disorder were significantly larger for the other-means group compared with the firearm group across all mental disorders except autism, dementia, and tobacco use. For example, compared with the control group, the odds of having depression were significantly higher among cases involving other means compared with cases involving a firearm (OR=12.28 and 7.29, respectively). This implies that patients with mental disorders are more likely to use other means of suicide besides a firearm.
TABLE 2. Likelihood of mental and general medical disorders among cases of suicide by firearm or other meansa
Disorder and means%OR95% CIpb
Mental disorder    
 Any psychiatric disorder   .001
  Firearm55.395.51*4.92–6.16* 
  Other means66.939.04*8.06–10.15* 
 Alcohol abuse or dependence   .003
  Firearm12.719.15*7.66–10.93* 
  Other means16.7215.19*13.04–17.68* 
 Anxiety disorder   .001
  Firearm21.966.53*5.68–7.50* 
  Other means28.207.74*6.84–8.75* 
 Attention disorder   .017
  Firearm1.621.65*1.06–2.57 
  Other means3.342.60*1.92–3.53* 
 Autism   .913
  Firearm—c   
  Other means.36c2.04.84–4.97 
 Bipolar disorder   .001
  Firearm4.018.04*5.97–10.83* 
  Other means11.7023.32*19.43–27.98* 
 Dementia   .915
  Firearm2.312.20*1.50–3.29* 
  Other means2.252.75*1.89–3.99* 
 Depression   .001
  Firearm35.137.29*6.46–8.23* 
  Other means48.6912.28*10.96–13.74* 
 Drug abuse or dependence   .001
  Firearm6.639.43*7.44–11.95* 
  Other means11.0517.42*14.51–20.92* 
 Other psychosis   .001
  Firearm2.625.49*3.79–7.96* 
  Other means4.8714.39*10.96–18.89* 
 Schizophrenia   .003
  Firearm1.319.82*5.82–16.56* 
  Other means3.2023.74*16.89–33.36* 
 Sleep disorder   .003
  Firearm17.233.09*2.65–3.59* 
  Other means19.624.33*3.76–4.97* 
 Prior suicide attempt (E950–958)   .001
  Firearm8.40271.62*186.59–395.40* 
  Other means13.23323.84*243.38–430.88* 
 Tobacco use   .752
  Firearm22.573.29*2.87–3.78* 
  Other means20.063.61*3.14–4.14* 
Medical disorder    
 Amputation   .533
  Firearm.31c1.00.37–2.72 
  Other means.44c2.13.94–4.83 
 Asthma   .199
  Firearm5.551.23.97–1.56 
  Other means6.831.35*1.09–1.67* 
 Back pain   .300
  Firearm21.801.78*1.10–6.54* 
  Other means23.262.10*1.84–2.39* 
 Traumatic brain injury   .001
  Firearm9.4823.53*18.84–29.39* 
  Other means3.427.74*5.71–10.50* 
 Cancer   .001
  Firearm11.331.86*1.55–2.24* 
  Other means6.181.25.99–1.57 
 CHF   .024
  Firearm5.551.76*1.36–2.27* 
  Other means3.341.60*1.17–2.17* 
 COPD   .062
  Firearm11.401.94*1.62–2.33* 
  Other means8.791.84*1.57–2.23* 
 Diabetes   .002
  Firearm13.561.25*1.06–1.48* 
  Other means9.811.11.92–1.33 
 Epilepsy   .966
  Firearm1.463.17*1.97–5.08* 
  Other means1.383.28*2.07–5.21* 
 Fibromyalgia   .004
  Firearm3.001.68*1.21–2.33* 
  Other means5.232.61*2.04–3.32* 
 Heart disease   .004
  Firearm9.941.15.94–1.39 
  Other means6.691.18.95–1.48 
 HIV/AIDS   .023
  Firearm.39c1.41.58–3.45 
  Other means1.166.03*3.60–10.10* 
 Hypertension   .001
  Firearm30.741.28*1.12–1.47* 
  Other means24.931.22*1.04–1.40* 
 Migraine   .002
  Firearm2.472.35*1.64–3.36* 
  Other means4.513.17*2.44–4.11* 
 Multiple sclerosis   .510
  Firearm.31c1.61.59–4.38 
  Other means.44c2.05.91–4.61 
 Obesity   .946
  Firearm4.85.93.72–1.20 
  Other means4.87.90.70–1.15 
 Osteoporosis   .351
  Firearm1.461.32.83–2.11 
  Other means2.111.20.82–1.75 
 Parkinson’s   .423
  Firearm.69c1.24.63–2.44 
  Other means.872.70*1.50–4.87* 
 Psychogenic pain   .001
  Firearm.82.82*1.53–5.19* 
  Other means1.383.47*2.19–5.51* 
 Renal disorder   .199
  Firearm7.011.34*1.07–1.68 
  Other means5.891.62*1.27–2.05* 
 Stroke   .064
  Firearm4.312.20*1.66–2.93* 
  Other means2.331.62*1.13–2.33* 
a
Based on ICD-9 codes captured from health system encounters (inpatient and outpatient) for all study patients for diagnoses that were current within the year prior to the date of death, as follows: mental health and substance use conditions (290–319), asthma (493), back pain (720.0–724.9), cancer (140–209), congestive heart failure (CHF) (402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, and 428), chronic obstructive pulmonary disease (COPD) (490–492, 494, and 496), diabetes mellitus (250), epilepsy (345), fibromyalgia (729.1), heart disease (410–414), HIV/AIDS (042,043,044, and V08), hypertension (401), migraine (346), multiple sclerosis (340), osteoporosis (733.0–733.09), Parkinson’s disease (332), psychogenic pain (307.8 and 307.89), renal disease (403, 582, 583, 585, 586, 588, 404.02, 404.12, 404.92, and 593.9), sleep disorder (291.82, 307.4, 327, and 780.5), and traumatic brain injury (800, 801, 803, 804, and 850–854). The reference group is a control group of 100 patients who did not die by suicide and who were matched to each of the suicide cases. Percentages are based on 1,298 cases of suicide involving a firearm and 1,376 cases involving other means.
b
For differences between the two groups of suicides (firearm versus other means) in the odds of having each disorder
c
Cell size was less than 10 cases. Results should be interpreted with caution.
*
p<.01
Table 2 also shows the odds of having a general medical disorder among suicide cases versus the control groups. The odds of having most general medical disorders were statistically significantly higher among suicide cases versus controls, but they were substantially lower than the odds of having a mental disorder, with some notable exceptions. The ORs for having a mental or general medical disorder by means of suicide, ranked from lowest to highest for firearms cases, are presented in Figure 1. For suicide by firearm, the odds of having TBI (OR=23.53) and epilepsy (OR=3.17) were particularly high. For cases involving other means of suicide, there were particularly high odds for TBI (OR=7.74), epilepsy (OR=3.28), HIV/AIDS (OR=6.03), migraine (OR=3.17), and psychogenic pain (OR=3.47).
FIGURE 1. Association of general medical and mental disorders with suicide by firearm or other meansa
aThe reference group is a control group of 100 patients who did not die by suicide and who were matched to each of the suicide cases. CHF, congestive heart failure; COPD. chronic obstructive pulmonary disease
*p<.05, for association between disorder and suicide death by other means only (or by firearm only, in the case of diabetes, fibromyalgia, and cancer)
**p<.05, for association between disorder and suicide death by other means and by firearm
In our analysis of the burden of comorbid general medical disorders, we found a significant increase in the odds of firearm suicide among men with two or more general medical disorders versus no general medical disorders (OR=1.94) but not in the odds of suicide by other means (Table 3). For women, we found the opposite pattern, with greater odds of suicide by other means among women with two or more general medical disorders versus no general medical disorders (OR=2.41) but no difference in the odds of death by firearm.
TABLE 3. Odds of suicide by firearm or other means associated with number of chronic general medical conditions, by sexa
N of chronicFirearmOther means
conditionsOR95% CIOR95% CI
Men
0 vs. 11.25*1.06–1.48*1.11.93–1.32
0 vs. ≥21.94*1.64–2.78*1.231.0–1.48
1 vs. ≥21.55*1.32–1.83*1.11.92–1.34
Women
0 vs. 1.99.65–1.501.53*1.19–1.97*
0 vs. ≥2.99.66–1.472.41*1.91–3.04*
1 vs. ≥21.00.64–1.561.58*1.25–1.99*
a
Risk adjusted for sex, age, college education, income, site, and mental disorders. All covariates entered the logistic regression significantly at p<.01 except college education and income for the firearm group. The reference group is a control group of 100 patients who did not die by suicide and who were matched to each of the suicide cases.
*
p<.01

Discussion

We aimed to identify salient risk factors for suicide by firearm compared with other means that are easily identifiable by general medical and mental health providers. Our findings indicate that the odds of having a mental and substance use disorder were substantially less among cases of suicide with a firearm compared with cases of suicide with other means, and this was true for nearly all mental and substance use disorders. In our sample, the most common means of suicide other than a firearm, consistent with national statistics (7), were medication overdose and suffocation or hanging. Assessing for stockpiles of medications and objects used for hanging (such as ropes and belts), which are often easily available in the home, is advisable for patients with mental health and substance use histories who are at risk of suicide (6). Surprisingly, we observed that substance use disorders were associated with higher odds of suicide compared with many other mental disorders. This indicates the need for suicide risk mitigation for all means as a key component of substance use treatment. Training programs in lethal-means restriction counseling are available for mental health and medical providers, and several emphasize motivational methods to engage both patients and family members in safety planning (6,31).Family members are essential to help monitor access to all types of lethal means that may be readily available within the home, particularly means other than firearms that may be easily acquired by persons at risk. Ease of accessing means other than firearms may deter some providers from means assessment because eliminating access may seem impossible. Some means other than firearms, particularly overdose by nonopioid medications, are highly accessible and less lethal, which may deter clinicians from counseling to reduce access (32). However, our results show that persons with mental disorders were more likely to use means other than firearms. A reasonable conclusion would be that our results indicate that counseling to reduce access to the most toxic or lethal substances or medications in overdose (for example, opioids) and materials used for suffocation (for example, ropes) would potentially reduce suicide among the large group of patients with mental disorders dying by means other than a firearm.
The results reported for general medical disorders do not control for co-occurring mental disorders, which affects the interpretation of our results for the association of general medical disorders with suicide. There is an established and well-recognized direct causal relationship between mental disorders and suicide, with 90% of families of suicide decedents reporting that the family member experienced psychiatric symptoms prior to death (33). Our group conducted a prior study that compared the association of general medical disorders and suicide and controlled for the presence of mental disorders (24). For this study, we chose not to control for mental disorders in our analysis of individual general medical disorders because half of patients who die by suicide do not have a mental disorder diagnosis coded in the medical record. Therefore, given that we assume that many patients who die by suicide have undiagnosed mental disorders, our results illuminate which general medical disorders should trigger additional risk screening. We do not assume that our results indicate a direct causal association between general medical disorders and suicide; instead, we suggest that the associations established here between suicide and general medical disorders indicate which of these disorders may co-occur with mental disorders and increase risk of suicide. Interestingly, the general medical disorders with the highest association with suicide in our results are those with high rates of comorbidity with mental disorders or those characterized by organic injury to the brain. Among cases of suicide by firearm, these included TBI, epilepsy, psychogenic pain, migraine, and stroke. Among cases of suicide by other means, we observed substantially increased odds of TBI, epilepsy, HIV/AIDS, migraine, and psychogenic pain. Some prior literature from smaller samples, or large samples from other countries, suggests that each of these conditions may have an association with mental illness comorbidity, suicide ideation, or suicide attempt (34–39).
We chose to control for mental disorders in the analysis of comorbid general medical illnesses because we wanted to try to isolate the impact of comorbidity involving general medical disorders on suicide risk; however, we acknowledge that our estimates are potentially biased because of underdiagnosis of mental disorders. Nonetheless, our results should remind providers to pay attention to suicide risk among patients with comorbid general medical disorders. We observed that the risk of suicide among women with multiple comorbidities was notably higher for suicide by other means, but not for suicide by firearm. It is possible that much of this risk comes from prescription pain medication overdoses among women in middle age, especially white women (40). Among the substances used for overdose, prescription pain medications (for example, opioids) are the most lethal (41). Our results show especially high risk of fibromyalgia, back pain, psychogenic pain, and migraine among cases of suicide by other means; these are chronic pain conditions that are more common among women (42), frequently involve pain medication prescription, and have high mental health comorbidity (43–45). This would indicate that women with comorbidities that involve prescription pain medications are at high risk of suicide. Medical providers may consider screening these women for suicide and if indicated, conduct subsequent assessment for stockpiles of medication as a lethal means for suicide.
For men, the impact of having comorbid general medical disorders increased risk of suicide by firearm, but not by other means. These findings are consistent with national surveillance data showing that men between the ages of 45 and 64 have the highest rate of firearm suicide death (41). Additionally, in the United States, 45% of males own a firearm, compared with 11% of women (46). In light of these data, general medical providers should consider suicide risk screening and subsequent assessment for access to firearms among men with comorbid general medical illnesses. A Florida law known as “Docs vs. Glocks,” which prohibits physicians from asking about or documenting gun ownership in medical records, was recently found to be unconstitutional (47). A federal court determined that the right to free speech includes discussing firearms with patients and that doing so does not impinge upon the Second Amendment right to bear arms.

Conclusions

Our analysis suggests that general medical and mental health providers may wish to consider providing suicide risk assessment and means restriction counseling for several novel groups of patients, in addition to those with a recorded mental disorder. These groups include patients with a TBI, HIV/AIDS, epilepsy, a pain condition, stroke, and migraine. Men with general medical comorbidities should be targeted for suicide risk screening and counseled to reduce access to firearms when risk is detected. Persons with substance use disorders should be screened for suicide and assessed for access to both firearms and other means. Our results suggest a need for an analysis that directly investigates the link between prescription pain medication overdose and suicide mortality among women with pain conditions.

References

1.
Fatal Injury Reports. Atlanta, Centers for Disease Control and Prevention, Injury Prevention and Control Data and Statistics (WISQARS), 2016. https://www.cdc.gov/injury/wisqars/fatal_injury_reports.html. Accessed February 8, 2017
Google Scholar
2.
Vyrostek SB, Annest JL, Ryan GW: Surveillance for fatal and nonfatal injuries—United States, 2001. MMWR Surveillance Summaries 53:1–57, 2004
PubMed
Google Scholar
3.
Kochanek KD, Murphy SL, Xu J, et al: Deaths: final data for 2014. National Vital Statistics Reports 65:1–122, 2016
Google Scholar
4.
Ahmedani BK, Simon GE, Stewart C, et al: Health care contacts in the year before suicide death. Journal of General Internal Medicine 29:870–877, 2014
Crossref
PubMed
Google Scholar
5.
Stone DM, Crosby AE: Suicide prevention. American Journal of Lifestyle Medicine 8:404–420, 2014
Crossref
PubMed
Google Scholar
6.
CALM: Counseling on Access to Lethal Means. Waltham, MA, Suicide Prevention Resource Center, 2017. http://www.sprc.org/resources-programs/calm-counseling-access-lethal-means. Accessed March 1, 2017
Google Scholar
7.
Suicide and Self-Inflicted Injury. Atlanta, Centers for Disease Control and Prevention, National Center for Health Statistics, 2014. https://www.cdc.gov/nchs/fastats/suicide.htm. Accessed Feb 8, 2017
Google Scholar
8.
Detecting and treating suicide ideation in all settings. Sentinel Event Alert, Feb 24, 2016. https://www.jointcommission.org/assets/1/18/SEA_56_Suicide.pdf
Google Scholar
9.
Bryan CJ, Stone SL, Rudd MD: A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology: Research and Practice 42:339, 2011
Crossref
Google Scholar
10.
McDowell AK, Lineberry TW, Bostwick JM: Practical suicide-risk management for the busy primary care physician. Mayo Clinic Proceedings 86:792–800, 2011
Crossref
PubMed
Google Scholar
11.
Kruesi MJ, Grossman J, Pennington JM, et al: Suicide and violence prevention: parent education in the emergency department. Journal of the American Academy of Child and Adolescent Psychiatry 38:250–255, 1999
Crossref
PubMed
Google Scholar
12.
McManus BL, Kruesi MJ, Dontes AE, et al: Child and adolescent suicide attempts: an opportunity for emergency departments to provide injury prevention education. American Journal of Emergency Medicine 15:357–360, 1997
Crossref
PubMed
Google Scholar
13.
Brent DA, Bridge J: Firearms availability and suicide evidence, interventions, and future directions. American Behavioral Scientist 46:1192–1210, 2003
Crossref
Google Scholar
14.
Sullivan GR: Suicide-by-firearm and the clinical assessment of firearm access. Dissertation Abstracts International, 65-04B, 2004. www.worldcat.org/title/suicide-by-firearm-and-the-clinical-assessment-of-firearm-access/oclc/190788310?referer=di&ht=edition
Google Scholar
15.
Bostwick JM, Pabbati C, Geske JR, et al: Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. American Journal of Psychiatry 173:1094–1100, 2016
Crossref
PubMed
Google Scholar
16.
Beghi M, Rosenbaum JF, Cerri C, et al: Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review. Neuropsychiatric Disease and Treatment 9:1725–1736, 2013
PubMed
Google Scholar
17.
Betz ME, Sullivan AF, Manton AP, et al: Knowledge, attitudes, and practices of emergency department providers in the care of suicidal patients. Depression and Anxiety 30:1005–1012, 2013
PubMed
Google Scholar
18.
Lewiecki EM, Miller SA: Suicide, guns, and public policy. American Journal of Public Health 103:27–31, 2013
Crossref
PubMed
Google Scholar
19.
Baca-García E, Diaz-Sastre C, Basurte E, et al: A prospective study of the paradoxical relationship between impulsivity and lethality of suicide attempts. Journal of Clinical Psychiatry 62:560–564, 2001
Crossref
PubMed
Google Scholar
20.
Simon OR, Swann AC, Powell KE, et al: Characteristics of impulsive suicide attempts and attempters. Suicide and Life-Threatening Behavior 32(suppl):49–59, 2001
Crossref
PubMed
Google Scholar
21.
Ilgen MA, Bohnert AS, Ignacio RV, et al: Psychiatric diagnoses and risk of suicide in veterans. Archives of General Psychiatry 67:1152–1158, 2010
Crossref
PubMed
Google Scholar
22.
Basham C, Denneson LM, Millet L, et al: Characteristics and VA health care utilization of US veterans who completed suicide in Oregon between 2000 and 2005. Suicide and Life-Threatening Behavior 41:287–296, 2011
Crossref
PubMed
Google Scholar
23.
Luoma JB, Martin CE, Pearson JL: Contact with mental health and primary care providers before suicide: a review of the evidence. American Journal of Psychiatry 159:909–916, 2002
Crossref
PubMed
Google Scholar
24.
Ahmedani BK, Peterson EL, Hu Y, et al: Major physical health conditions and risk of suicide. American Journal of Preventive Medicine 53:308–315, 2017
Crossref
PubMed
Google Scholar
25.
Rossom RC, Simon GE, Beck A, et al: Facilitating action for suicide prevention by learning health care systems. Psychiatric Services 67:830–832, 2016
Crossref
PubMed
Google Scholar
26.
Wagner EH, Greene SM, Hart G, et al: Building a research consortium of large health systems: the Cancer Research Network. Journal of the National Cancer Institute Monographs 35:3–11, 2005
Crossref
Google Scholar
27.
Hornbrook MC, Hart G, Ellis JL, et al: Building a virtual cancer research organization. Journal of the National Cancer Institute Monographs 35:12–25, 2005
Crossref
PubMed
Google Scholar
28.
Go AS, Magid DJ, Wells B, et al: The Cardiovascular Research Network: a new paradigm for cardiovascular quality and outcomes research. Circulation: Cardiovascular Quality and Outcomes 1:138–147, 2008
Crossref
PubMed
Google Scholar
29.
International Classification of Diseases, 10th Revision. Geneva, World Health Organization, 2012
Google Scholar
30.
International Classification of Diseases, 9th Revision, Clinical Modification. Los Angeles, PMIC, 1995
Google Scholar
31.
Shea SC. The Practical Art of Suicide Assessment: A Guide for Mental Health Professionals and Substance Abuse Counselors. Hoboken, NJ, Wiley, 2002
Google Scholar
32.
Spicer RS, Miller TR: Suicide acts in eight states: incidence and case fatality rates by demographics and method. American Journal of Public Health 90:1885–1891, 2000
Crossref
PubMed
Google Scholar
33.
Cavanagh JT, Carson AJ, Sharpe M, et al: Psychological autopsy studies of suicide: a systematic review. Psychological Medicine 33:395–405, 2003
Crossref
PubMed
Google Scholar
34.
Teasdale TW, Engberg AW: Suicide after traumatic brain injury: a population study. Journal of Neurology, Neurosurgery, and Psychiatry 71:436–440, 2001
Crossref
PubMed
Google Scholar
35.
Mula M, Sander JW: Suicidal ideation in epilepsy and levetiracetam therapy. Epilepsy and Behavior 11:130–132, 2007
Crossref
PubMed
Google Scholar
36.
Ferrer P, Ballarín E, Sabaté M, et al: Antiepileptic drugs and suicide: a systematic review of adverse effects. Neuroepidemiology 42:107–120, 2014
Crossref
PubMed
Google Scholar
37.
Keiser O, Spoerri A, Brinkhof MW, et al: Suicide in HIV-infected individuals and the general population in Switzerland, 1988–2008. American Journal of Psychiatry 167:143–150, 2010
Crossref
PubMed
Google Scholar
38.
Colman I, Kingsbury M, Sareen J, et al: Migraine headache and risk of self-harm and suicide: a population-based study in Ontario, Canada. Headache 56:132–140, 2016
Crossref
PubMed
Google Scholar
39.
Friedman LE, Gelaye B, Bain PA, et al: A systematic review and meta-analysis of migraine and suicidal ideation. Clinical Journal of Pain 33:659–665, 2017
Crossref
PubMed
Google Scholar
40.
Behavioral Health Trends in the United States: Results From the 2014 National Survey on Drug Use and Health. Pub no SMA 15-4927, NSDUH series H-50. Rockville, MD, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2015
Google Scholar
41.
Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999–2010. Morbidity and Mortality Weekly Report 62:537–542, 2013
PubMed
Google Scholar
42.
Munce SE, Stewart DE: Gender differences in depression and chronic pain conditions in a national epidemiologic survey. Psychosomatics 48:394–399, 2007
Crossref
PubMed
Google Scholar
43.
Edlund MJ, Martin BC, Devries A, et al: Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clinical Journal of Pain 26:1–8, 2010
Crossref
PubMed
Google Scholar
44.
Outcalt SD, Kroenke K, Krebs EE, et al: Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. Journal of Behavioral Medicine 38:535–543, 2015
Crossref
PubMed
Google Scholar
45.
Bruffaerts R, Demyttenaere K, Kessler RC, et al: The associations between preexisting mental disorders and subsequent onset of chronic headaches: a worldwide epidemiologic perspective. Journal of Pain 16:42–52, 2015
Crossref
PubMed
Google Scholar
46.
Hepburn L, Miller M, Azrael D, et al: The US gun stock: results from the 2004 National Firearms Survey. Injury Prevention 13:15–19, 2007
Crossref
PubMed
Google Scholar
47.
United States Court of Appeals for the 11th Circuit, DC Docket no 1:11-cv-22026-MGC Sess (2017)
Google Scholar

Information & Authors

Information

Published In

Go to Psychiatric Services
Go to Psychiatric Services

Cover: Sea Grasses and Blue Sea, by Milton Avery, 1958. Oil on canvas. Gift of friends of the artist, Museum of Modern Art, New York. Digital image © The Museum of Modern Art/Licensed by SCALA/Art Resource, New York. © The Milton Avery Trust/Artists Rights Society, New York.

Psychiatric Services
Volume 69 • Number 6 • June 01, 2018
Pages: 677 - 684
PubMed: 29446332

History

Received: 22 May 2017
Revision received: 26 July 2017
Revision received: 9 October 2017
Revision received: 4 December 2017
Accepted: 13 December 2017
Published online: 15 February 2018
Published in print: June 01, 2018

Keywords

  1. Suicide
  2. Lethal Means
  3. Firearms
  4. Physical Health Burden
  5. Traumatic Brain Injury

Authors

Details

Jennifer M. Boggs, M.S.W. [email protected]
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Arne Beck, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Sam Hubley, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Edward L. Peterson, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Yong Hu, M.A.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
L. Keoki Williams, M.D., M.P.H.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Deepak Prabhakar, M.D., M.P.H.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Rebecca C. Rossom, M.D., M.S.C.R.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Frances L. Lynch, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Christine Y. Lu, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Beth E. Waitzfelder, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Ashli A. Owen-Smith, Ph.D.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Gregory E. Simon, M.D., M.P.H.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author
Brian K. Ahmedani, Ph.D., L.M.S.W.
Ms. Boggs and Dr. Beck are with the Institute for Health Research, Kaiser Permanente Colorado, Denver. Dr. Hubley is with the Department of Family Medicine, University of Colorado School of Medicine, Aurora. Dr. Peterson is with the Department of Public Health Sciences, Mr. Hu and Dr. Ahmedani are with the Center for Health Policy and Health Services Research, Dr. Williams is with the Center for Health Policy and Health Services Research and the Department of Internal Medicine, and Dr. Prabhakar is with the Department of Behavioral Health Services, all at the Henry Ford Health System, Detroit. Dr. Rossom is with the HealthPartners Institute, Bloomington, Minnesota. Dr. Lynch is with the Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon. Dr. Lu is with the Department of Population Medicine, Harvard Medical School, and with Harvard Pilgrim Health Care Institute, both in Boston. Dr. Waitzfelder is with the Center for Health Research, Kaiser Permanente Hawaii, Honolulu. Dr. Owen-Smith is with the Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, and the School of Public Health, Georgia State University, Atlanta. Dr. Simon is with the Health Research Institute, Kaiser Permanente Washington, Seattle.
View all articles by this author

Notes

Send correspondence to Ms. Boggs (e-mail: [email protected]).

Competing Interests

Dr. Williams reports receipt of payment for serving as scientific advisor on a project from Merck. The other authors report no financial relationships with commercial interests.

Funding Information

National Institute of Mental Health10.13039/100000025: 1R01MH103539-01A1
The work was supported by a grant from the National Institute of Mental Health (R01MH103539).

Metrics & Citations

Metrics

Citations

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download.

For more information or tips please see 'Downloading to a citation manager' in the Help menu.

Format
Citation style
Style
Copy to clipboard
Tips for downloading citations

View Options

View options

PDF/EPUB

View PDF/EPUB

Login options

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Personal login Institutional Login Open Athens login
Item saved, go to cart
Purchase Options

Purchase this article to access the full text.

PPV Articles - Psychiatric Services

PPV Articles - Psychiatric Services

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Media

Figures

Other

Tables

Share

Share

Share article link

Share

×

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.