The Role of Medications in Predicting Suicide-Related Outcomes and Unintended Death in Older Veterans

关于药物在预测自杀相关结局和意外死亡方面的作用，人们知之甚少 年长的退伍军人。50岁及以上的退伍军人自杀死亡人数最多，构成了 大多数(70%)退伍军人，他们极有可能经历各种情况(例如，慢性疼痛， 睡眠障碍、肌肉骨骼)与作为潜在标志物的常用处方药相关 自杀风险(以下简称“高风险”药物类别，包括苯二氮卓类、镇静剂- 催眠药、阿片类药物、抗抑郁药和抗癫痫药)。这些药物在与糖尿病风险的关系中的作用 老年退伍军人的自杀和意外死亡可能很复杂，但信息量极大。简单 获得“高风险”药物，就像获得枪支一样，可能会增加风险。此外，药物可能会 与中枢神经系统作用的药物增加尝试风险的易感性之间存在因果关系 自杀。此外，药物使用的类型和数量可以作为存在的一个有价值的标记 精神症状和相关情绪和精神痛苦的严重程度，以诊断的方式 仅靠代码是无法捕获的。多家药房也可能是一种复杂的 会增加自杀风险的合并症。总而言之，药物治疗有多种潜在途径 可能与自杀风险密切相关，但其他预测因素没有完全捕捉到这一点。因此，信息 药物使用可以大大提高我们识别有高自杀风险的老年退伍军人的能力， 除了已知的风险因素之外，如精神疾病诊断的存在。这可能会提供 通过为我们提供工具来更好地识别高危退伍军人，从而使他们成为攻击目标，从而获得极其有价值的产品 加强筛查和早期干预，以防止自杀。随着对以下问题的日益关注 错误地将自杀归类为药物过量导致的意外死亡，更好地理解 意外伤害致死的药物对预防自杀的努力也很重要。 此外，根据年龄、性别、种族/民族、无家可归者等因素检查相关性，越南 退伍军人状况、与服务相关的残疾、创伤后应激障碍和创伤性脑损伤支持 退伍军人事务部的使命是满足这些弱势群体的需求。为此， 我们研究的主要目标是确定药物作为预后因素的作用，超过其他因素 预测老年退伍军人自杀和意外死亡风险的因素。我们在本报告中提议 申请在现有CSR&D优异奖项目中添加有关药物处方和使用的新问题 (CX001119；PI：Byers)，这已经形成了一个独特的晚年自杀研究队列。这一群体包括所有 2012财年，使用退伍军人管理局医疗保健服务的退伍军人(约500万人)最初年龄在50岁及以上- 2013年，并跟随到现在。这一队列包括关于所有精神病学和医学诊断的信息和 自杀、意外伤害和自杀未遂致死。我们建议将多个国家药房联系起来 数据库(即，退伍军人事务部和联邦医疗保险)到这个队列--研究药物作为预测预后的因素 与自杀相关的后果和意外死亡。在这样做的过程中，我们将描述“高风险”的用法 老年退伍军人自杀相关结局和意外死亡前的药物和多药联用 (目标1)，确定“高风险”药物的使用和某些使用模式(目标2)和 多药联用(目标3)提供了比其他预测因素更高的预后价值，并评估 按弱势群体划分的联系差异(目标4)。如果这一假设是真的，那么某些药物和 使用模式可以识别自杀和意外死亡风险增加的老年退伍军人，它具有重要的意义 对临床护理的影响。可以利用药物的使用和启动来进行针对性的风险评估 以及针对高危老年退伍军人的预防计划。这是退伍军人管理局唯一能够做到的事情。

Little is known about the role of medications in predicting suicide-related outcomes and unintended death in older Veterans. Veterans 50 years and older have the highest number of lives lost to suicide, make up the majority (> 70%) of the Veteran population, and are highly likely to experience conditions (e.g., chronic pain, sleep disorders, musculoskeletal) associated with commonly prescribed medications that are potential markers for suicide risk (hereafter referred to as “high-risk” drug categories, including benzodiazepines, sedative- hypnotics, opioids, antidepressants, and antiepileptics). The role of these medications in relationship to risk of suicide and unintended death in older Veterans is likely complex and, yet, extremely informative. Simply access to “high-risk” medications, similar to access to firearms, may increase risk. Moreover, medications may be causally linked where central nervous system-acting medications increase vulnerability to risk of attempting suicide. In addition, the type and amount of medication use can serve as a valuable marker of the presence and severity of psychiatric symptoms and associated emotional and mental distress, in ways that diagnostic codes alone are unable to capture. It is also likely that polypharmacy is an important indicator of a complex of comorbidities that increases risk of suicide. All-in-all there are multiple potential pathways where medications may be strongly associated with suicide risk in ways not fully captured by other predictors. Thus, information on medication use could substantially enhance our ability to identify older Veterans at high risk of suicide, above and beyond known risk factors such as the presence of psychiatric diagnoses. This could provide extremely valuable products by giving us tools to better identify high-risk Veterans, who could then be targeted for enhanced screening and early intervention to prevent suicide. With mounting concern regarding misclassification of suicides as accidental deaths by drug overdose, better understanding the impact of medications on death by unintentional injury is also important to informing suicide prevention efforts. Furthermore, examining associations by such factors as age, gender, race/ethnicity, homelessness, Vietnam Veteran status, service connected disability, posttraumatic stress disorder, and traumatic brain injury supports the Department of Veterans Affairs' mission to meet the needs of these vulnerable groups. To this end, the primary goal of our study is to determine the role of medications as prognostic factors, above and beyond other factors, in predicting risk of suicide and unintended death in older Veterans. We propose in this current application to add new questions on medication prescribing and use to an existing CSR&D Merit Award project (CX001119; PI: Byers), which has formed a unique cohort for late-life suicide research. This cohort includes all Veterans (~5,000,000) who used VA health care services, were initially 50 years and older in fiscal year 2012- 2013, and followed to present. This cohort includes information on all psychiatric and medical diagnoses and death by suicide and unintentional injury and suicide attempt. We propose linking multiple National Pharmacy databases (i.e., VA and Medicare) to this cohort – to study medications as a prognostic factor in predicting suicide-related outcomes and unintended death. In doing this, we will characterize the use of “high-risk” medications and polypharmacy prior to suicide-related outcomes and unintended death among older Veterans (Aim 1), determine whether use, and certain patterns of use, of “high-risk” medications (Aim 2) and polypharmacy (Aim 3) provide additional prognostic value above and beyond other predictors, and assess differences of associations by vulnerable groups (Aim 4). If this hypothesis is true that certain medications and patterns of use can identify older Veterans at increased risk of suicide and unintended death, it has important implications for clinical care. The use and initiation of medications could be utilized to target risk assessments and prevention programs for older Veterans at high risk. This is something the VA is uniquely positioned to do.