Psychiatr News August 21, 2009
Volume 44, Number 16, page 1
© 2009 American Psychiatric Association
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Professional News
Army, NIMH Search for Causes of Soldier Suicide Crisis
Aaron Levin
The startling increase in the number of suicides by members of the U.S. Army in the last few years prompts a major collaborative study of risk and protective factors.
The National Institute of Mental Health (NIMH) has tapped a consortium of four research universities to investigate risk and protective factors influencing a troubling increase in suicides in the U.S. Army.
The number of suicides by U.S. soldiers has risen steadily in recent years until levels have equaled those among comparable civilians, who historically have had higher rates. Responding to concern from Congress, the public, and Pentagon officials, the Army allotted $50 million to NIMH for the new study, whose goal is to "provide a science base for effective and practical interventions to reduce suicide rates and address associated mental health problems," according to an NIMH statement.
Such large, longitudinal studies that look at risk and protective factors are unusual in military populations, said Robert Heinssen, Ph.D., acting director of the Division of Services and Intervention Research at NIMH. But the study is unlikely to come up with a single cause for military suicides, he told Psychiatric News.
"[The researchers] are really searching for likely, but weakly linked, risk factors that in combination might create different risk states over time," he said.
The new study will draw on soldiers' personnel and health records and will survey several hundred thousand current soldiers and incoming recruits over the next five years.
The Army now investigates every suicide within the service. It began issuing public reports in 2007 and stated that failed marital or other relationships were most strongly associated with suicide (Psychiatric News, September 21, 2007).
Robert Ursano, M.D., director of the Center for Traumatic Stress Studies at the Uniformed Services University of the Health Sciences (USUHS) in Bethesda, Md., where he also chairs the Department of Psychiatry, will direct the project, the largest ever military study of suicide and mental health.
"This is a unique joining of the Department of Defense and the NIMH to address an issue of national security that will also build tools with peacetime implications," Ursano told Psychiatric News.
His principal collaborators will each add a different area of expertise to USUHS's familiarity with military epidemiology. Stephen Heeringa, Ph.D., of the University of Michigan's Institute for Social Research has experience in securely handling large datasets. Ronald Kessler, Ph.D., of Harvard Medical School is a leading psychiatric epidemiologist, while Columbia University's J. John Mann, M.D., has extensively studied the neurobiology of suicide and the use of the psychological autopsy to examine factors leading up to the event.
The study is a collaborative research project grant, NIMH's term for projects in which the government takes a direct interest beyond routine management, said Heinssen in an interview.
"Two NIMH scientific officers—a psychiatric epidemiologist and a mental health services researcher—will participate as investigators, working on ways to integrate data from surveys with the data the Army routinely collects," said Heinssen.
Several researchers with military backgrounds are also involved in the project, including psychiatric epidemiologist Col. Charles Hoge, director of the Division of Psychiatry and Behavioral Sciences at Walter Reed Army Institute of Research in Silver Spring, Md., and Col. Charles Engel, assistant chair of the Department of Psychiatry at USUHS.
Former APA President Paul Appelbaum, M.D., the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law and director of the Division of Psychiatry, Law, and Ethics at the Department of Psychiatry at Columbia University College of Physicians and Surgeons, will chair the project's ethics committee, which faces two primary challenges in a study of military populations: confidentiality of information and voluntariness of consent to protect soldiers from coercion and undue influence.
Four Sources Will Be Tapped
Study data will come from four main sources, beginning with the Army's massive existing records on service personnel. Researchers will also survey 90,000 current service members, including those from the National Guard and Reserves, asking about risk and protective factors, as well as about suicidal ideation and attempts. The 80,000 to 120,000 recruits who join the Army in each of the study's first three years will be asked to complete a similar survey.
Study investigators will also set up a case-control study matching soldiers who attempted or completed suicide in recent years with demographically similar controls.
The project may be analogous to another long-term study of disease-influencing factors.
"The Framingham heart study looked at the roles of lifestyle, behavioral characteristics, and biological functions and came up with a good algorithm for stroke and heart attack," said Heinssen. "With that information, the risk factors in cardiovascular disease became targets for treatment."
Key Results to Get Early Release
The new study will look for and evaluate several personal and community factors that might influence the risk for suicide, including combat exposure, overseas deployments, and unit cohesion. It will also consider intermediate outcomes such as posttraumatic stress disorder, depression, anxiety, divorce, family violence, and substance abuse. An "adaptive survey design" will permit investigators to alter survey questions if necessary to provide more data.
The investigators will not wait to complete the study before passing along any useful results.
"Real-time information can allow the leadership to respond quickly and allocate resources for prevention," said Ursano.
The study will provide unpublished interim reports to the Army every six months over the five-year life of the project. However, researchers may present results through normal peer-reviewed channels in print or at scientific conferences as results reach meaningful levels, said Heinssen.
At least one long-time student of suicide hopes the researchers will look beyond proximate causes.
"I applaud the effort, but they may have to go back earlier in life to find vulnerabilities to suicidal behavior," said Mark Kaplan, Dr.P.H., a professor of community health at Portland State University in Oregon.
Suicide is a rare and complex phenomenon, said Kaplan in an interview. The inevitable access of soldiers to weapons and the desensitization to killing of military training and combat make it simpler for an unhappy soldier to impulsively take his own life, but stoicism and difficulty articulating emotions that are part of American masculine culture are contributing factors too, he said.
Nevertheless, the knowledge gained by the study may be generalizable to broader populations, said another civilian expert.
"I believe it is exciting and a very comprehensive approach to understanding the problems that lead to suicide in the adult population," said psychiatrist Paula Clayton, M.D., medical director of the American Foundation for Suicide Prevention. "I'm grateful to the service for recognizing a problem that needs investigating and for funding this study."
The NIMH press release on the study is posted at
Army, NIMH Search for Causes of Soldier Suicide Crisis
Friday, August 28, 2009
Army, NIMH Search for Causes of Soldier Suicide Crisis
Tuesday, August 25, 2009
New data show depression's stubborn grasp in Minnesota
State clinics reveal their rates of success for treating the mental illness, and the results are sobering.
By MAURA LERNER , Star Tribune
Last update: August 20, 2009 - 9:40 PM
Featured comment
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For the first time, Minnesota clinics are publicly reporting their success rates at treating depression. The bad news: Only about 4 percent of patients are considered "in remission" -- or no longer depressed -- after six months of treatment.
Success rates for 54 participating clinics were reported Wednesday by MN Community Measurement, an industry group that tracks health-care quality, and posted on its website, www.mnhealthscores.org.
The top-rated clinic, HealthPartners'-Regions Maplewood, reported that 11 percent of its patients had recovered; six clinics reported zero.
Some of the scores are artificially low because of the difficulty in tracking down patients for follow-up, said Jim Chase, the group's president.
But Chase said he believes this kind of public report card -- the first of its kind for depression care -- will spur clinics to make needed improvements, as it has for diabetes care.
"We think when we make it public, one of the advantages is people see who's doing well," said Chase. "There is research out there that there's a better way to treat patients. We hope by measuring the results that we can drive that change."
The rates were based on how patients responded to a standardized depression questionnaire.
For many reasons, depression has been difficult to treat; many patients stop taking their medications or never fill their prescriptions. A 2003 study found that only one in five people with major depression received adequate care.
In the past few years, dozens of Minnesota clinics have started using a questionnaire, known as the PHQ-9 test, to track the symptoms of depression. It asks patients how often, in the previous two weeks, they've experienced nine common symptoms: from feelings of hopelessness to trouble sleeping to thoughts of harming themselves.
The questionnaire is not universally used, Chase said, but he hopes the new public report card will change that. "What we're expecting is the use rate is going to go up a lot, and that's an important step," he said.
As part of the new program, clinics are supposed to give the test to patients at diagnosis and again six months later, to see if their symptoms improve.
Dr. Michael Trangle, who heads the behavioral health program at HealthPartners, the state's third-largest health insurer and clinic system, said it can be tough to get depressed patients to take the follow-up test, one reason the success rates have been so low. "The cardinal symptoms are not just sadness but a lack of energy, initiative," he said. "It's the quintessential group that doesn't follow up.
"Our system of care as usual is very passive and reactive," Trangle added. "If somebody doesn't schedule an appointment, that's it. We don't reach out." This program, he said, will challenge clinics to stay in touch with those patients and, if they're not getting better, adjust their treatment.
Chase cautioned against reading too much into the initial results. "I don't think you want to interpret it as, gee, only 4 percent are ever getting better," he said. This is just the first step, he said, in an effort to get clinics to start measuring depression care much as they do diabetes care.
He noted that more than 400 Minnesota clinics participate in his group's diabetes scorecard, which tracks how well patients control five key risk factors, such as blood pressure and cholesterol. The success rates have jumped from 4 percent to 19 percent since the clinics started tracking and sharing their results, he said.
Maura Lerner • 612-673-7384
VA gives 1,200 vets wrong diagnosis in letter
VA gives 1,200 vets wrong diagnosis in letter
By P.J. Dickerscheid - The Associated Press
Posted : Monday Aug 24, 2009 21:44:24 EDT
CHARLESTON, W.Va. — Former Air Force Reservist Gale Reid received a letter from the Veterans Affairs Department that told her she had Lou Gehrig's disease, and she immediately put herself through a battery of painful, expensive tests. Five days later, the VA said its "diagnosis" was a mistake.
The Montgomery, Ala., resident was among at least 1,200 veterans who received a letter about disability benefits for ALS, also known as Lou Gehrig's disease, even though they hadn't been diagnosed with the illness, according to the National Gulf War Resource Center. Veterans were initially suspicious of the letters, but still went through the agony not knowing exactly whether they had the fatal disease, which typically kills people within five years.
At least 2,500 letters informing veterans of disability benefits for ALS were sent out, and of those, some 1,200 were a mistake, according to the National Gulf War Resource Center. The wrongly sent letters were supposed to inform veterans of an undiagnosed neurological disorder, according to the Gulf War veterans group, which provides information, support and referrals about illnesses to veterans.
No one knows for sure exactly how many letters were mailed to veterans treated at VA hospitals and how many were a mistake. VA spokeswoman Katie Roberts didn't return telephone messages or an e-mail Monday.
Former Army Sgt. Samuel Hargrove cried Sunday after opening his letter.
"I can't even describe the intensity of my feelings," said the father of two from Henderson, N.C. "With so many health issues that I already have, I didn't know how to approach my family with the news."
So, at first, he didn't. Hargrove later discovered the mistake after talking with fellow veterans in the resource center and online, and he became angry.
Reid was just as upset.
"I've been through a week of hell, emotionally, physically and financially," she said.
Denise Nichols, vice president of the National Gulf War Resource Center, said her group has received calls and e-mails from panicked veterans in Alabama, Florida, Kansas, North Carolina, West Virginia and Wyoming.
"Our fear was this could push somebody over the edge," said Nichols, who was worried the news could lead already fragile veterans to commit suicide. "We don't want that to happen."
Jim Bunker, president of the veterans group, said he talked to someone at the VA and was told the mistake was caused by a coding error. The VA uses more than 8,000 codes for various diseases and illnesses and veterans with undiagnosed neurological disorders, which can range from mild to severe, were accidentally assigned the code for ALS, he said.
ALS is a rapidly progressive disease that attacks the nerve cells responsible for controlling voluntary muscles.
Nichols said she suspected something was amiss because some of the veterans she knew who received the letters did not exhibit any ALS symptoms. Hargrove said he became suspicious because the letter didn't come from his doctor, and Reid said she sought a second opinion even though she believed the letter wasn't the right way to inform patients of a diagnosis.
The veterans groups notified the VA of the problems late last week, and the agency was in the process of calling every person who mistakenly received a letter, Bunker said.
The VA has taken some heavy criticism already this year. In June, Congress questioned the agency over botched colonoscopies at medical centers in Florida, Georgia and Tennessee that may have exposed 10,000 veterans to HIV and other infections. Last month, the VA Medical Center in Philadelphia disclosed that the number of cancer patients receiving incorrect radiation doses had risen to 98 veterans over a six-year period.
The Gulf War veterans group is urging the VA to reimburse any veteran who scheduled additional tests with civilian doctors. Reid said her tests cost about $3,000, though it may take weeks before she finds out how much her private insurance will cover.
"We are trying to work with the VA because we realize it was an error and they were trying to do something right for the people who were diagnosed with ALS," Nichols said. "Basically this was a good effort that ended badly."
Air Force Times article link
Status of VUFT and VCS Lawsuit aginst the VA in the 9th Circuit Court (PTSD Lawsuit)
VCS - VUFT Lawsuit Update:
Class Action Suit: On 12 August we appeared before the 9th Circuit Court of Appeals. An article from the LA Times on 24
August summarizes the results so far < latimes.com/news/nationworld/nation/healthcare/la-me-veterans-suit24-2009aug24,0,1423297.story>
.Case Progress to Date:
7/23/2007Suit filed w/Federal District Court
9/25/2007 Defendant’s Motion to Dismiss
2/11/2208 Motion for Preliminary Injunction
2/25/2008 Preliminary Injunction Hearing
4/21/2008 Trial
6/25/2008 Judgment based on jurisdiction
7/25/2008 Appeal notice filed w/9th Circuit Court of Appeals
12/10/2008 Appeal brief filed
12/15/2008 Swords to Plowshares and Vietnam Veterans of America
file amicus briefs
12/22/2008 Military Spouses for Change and United Spinal Association
file amicus briefs
3/4/2009 Appeal will not be subject to Mediation
4/6/2009 Requested an extension to reply to the DVA response to our
brief
4/22/09 Extension granted to 1 May 2009
5/1/09 Appellants’ Reply Brief filed
6/11/09 Oral Arguments Scheduled for 12 August 2009
8/12/09 Oral arguments
9/1/09 Reply on mediation
