Abstract Background Veterans are at elevated risk for suicide compared to non-Veteran U.S. adults. Data sources and analyses to inform prevention efforts, especially for those who do not use Department of Veterans Affairs (VA) healthcare services, are needed. This study aimed to link VA and CDC’s National Violent Death Reporting System (NVDRS) data to create a novel data source to characterize the circumstances precipitating and preceding suicide among Veterans, including among those who did not use VA healthcare. Methods Multi-variable, multi-stage, deterministic linkage of VA-Department of Defense (DoD) Mortality Data Repository (MDR) and NVDRS-Restricted Access Database suicide and undetermined intent mortality records within 189 state-year strata (42 states, 2012–2018). Three linkage stages: (1) exact (matched on: age, sex, death date, underlying cause of death, day of month of birth, first initial of last name); (2) probable (all but one variable matched); (3) possible (all but 2 variables matched). Linkage success and accuracy of NVDRS-documented military history were assessed. Results Across all state-years, 22,019 matches (89.20% of 24,685 MDR Veteran records) were identified (65.47% exact). When high missingness (2 + matching variables in > 10% of records; n = 23) or incomplete reporting (n = 12) state-years were excluded, match rate increased to 94.29% (77.15% exact). NVDRS-documented military history (ever served) was accurate for 87.79% of matched records, with an overall sensitivity of 84.62%. Sensitivity was lower for female (61.01%) and younger (17–39 years; 77.51%) Veterans. Conclusions Accurate linkage of VA-DoD and NVDRS data is feasible and offers potential to improve understanding of circumstances surrounding suicide among Veterans.

Free AccessIntroduction to the Youth HIV Prevention SupplementRegina Benevides, J. Logan and Pragna PatelRegina Benevides1HIV Prevention Branch, Division of Global HIV and Tuberculosis, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.1HIV Prevention Branch, Division of Global HIV and Tuberculosis, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.Address correspondence to Regina Benevides, E-mail: [email protected]Search for more papers by this author, J. Logan1HIV Prevention Branch, Division of Global HIV and Tuberculosis, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.1HIV Prevention Branch, Division of Global HIV and Tuberculosis, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.Search for more papers by this author and Pragna Patel1HIV Prevention Branch, Division of Global HIV and Tuberculosis, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.1HIV Prevention Branch, Division of Global HIV and Tuberculosis, Global Health Center, Centers for Disease Control and Prevention, Atlanta, Georgia.Search for more papers by this authorPublished Online:July 2023https://doi.org/10.1521/aeap.2023.35.suppA.1PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations About Next article FiguresReferencesRelatedDetails Volume 35Issue Supplement AJul 2023 Information© 2023 The Guilford PressPDF download

Black/African American (Black) versus White persons are unequally burdened by human immunodeficiency virus (HIV) in the United States. Structural factors can influence social determinants of health, key components in reducing HIV-related health inequality by race. This analysis examined HIV care outcomes among Black and White persons with diagnosed HIV (PWDH) in relation to three structural factors: racial redlining, Medicaid expansion, and Ryan White HIV/AIDS Program (RWHAP) use. Using National HIV Surveillance System, U.S. Census, and Home Mortgage Disclosure Act data, we examined linkage to HIV care and viral suppression (i.e., viral load < 200 copies/mL) in relation to the structural factors among 12,996 Black and White PWDH with HIV diagnosed in 2017/alive at year-end 2018, aged ≥ 18 years, and residing in 38 U.S. jurisdictions with complete laboratory data, geocoding, and census tract-level redlining indexes. Compared to White PWDH, a lower proportion of Black PWDH were linked to HIV care within 1 month after diagnosis and were virally suppressed in 2018. Redlining was not associated with the HIV care outcomes. A higher prevalence of PWDH residing (v. not residing) in states with Medicaid expansion were linked to HIV care ≤ 1 month after diagnosis. A higher prevalence of those residing (v. not residing) in states with > 50% of PWDH in RWHAP had viral suppression. Direct exposure to redlining was not associated with poor HIV care outcomes. Structural factors that reduce the financial burden of HIV care and improve care access like Medicaid expansion and RWHAP might improve HIV care outcomes of PWDH.

AbstractObjectiveUnintentional drug overdose and suicide have emerged as public health problems. Prescription drug misuse can elevate risk of overdose. Severe suicidal ideation increases risk of suicide. We identified shared correlates of both risk factors to inform cross‐cutting prevention efforts.MethodsWe conducted a cross‐sectional study using the Military Suicide Research Consortium's Common Data Elements survey; 2012–2017 baseline data collected from 10 research sites were analyzed. The sample included 3962 clinical patients at risk of suicide. Factors examined in relation to the outcomes, prescription drug misuse and severe suicidal ideation, included demographic characteristics and symptoms of: hopelessness; anxiety; post‐traumatic stress disorder; alcohol use; other substance use; prior head/neck injury; insomnia; and belongingness. Poisson regression models with robust estimates provided adjusted prevalence ratios (aPRs) and 97.5% confidence intervals (CIs).ResultsMedium and high (vs. low) levels of insomnia were positively associated with prescription drug misuse (aPRs p < 0.025). Medium (vs. low) level of insomnia was positively associated with severe suicidal ideation (aPR: 1.09; CI: 1.01–1.18). Medium and high (vs. low) levels of perceived belongingness were inversely associated with both outcomes (aPRs p < 0.025).ConclusionsResearch should evaluate whether addressing sleep problems and improving belongingness can reduce prescription drug misuse and suicidal ideation simultaneously.

Fatal and nonfatal self-directed and interpersonal violence and unintentional injuries can spread throughout a community just like infectious diseases. What drives people to attempt suicide, harm others, or place themselves in unsafe situations most often results from complex dynamics between themselves and their social environments. Nevertheless, outbreaks of fatal and nonfatal injuries do occur. Similar to how an infectious disease manifests and spreads, outbreaks of self-inflicted, violent injuries, and even unintentional injuries, such as drug overdoses, also can be precipitated by immediate exposures that public health prevention strategies can best address. At some point, a field epidemiologist will face the challenges and the nuances of these epidemics. This chapter provides case stories of injury-related epidemics and the exposures and circumstances that propagated them. It also reviews the types of investigations conducted to address these epidemics, common challenges, and the short- and long-term strategies used to control such dangerous and deadly outbreaks.

OBJECTIVE This study examined trends and correlates of reported post-traumatic stress disorder (PTSD) among young male Veteran suicide decedents, using data from the National Violent Death Reporting System from 2005-2014 on 1,362 male U.S. Veteran suicide decedents aged 18-34 years. METHODS Prevalence of reported PTSD (i.e., diagnosis/symptoms) was determined by mental health diagnostic fields and narratives and examined by year. Demographic, incident, and precipitating circumstance characteristics correlated with reported PTSD were identified. RESULTS One-hundred ninety-eight (15%) decedents had PTSD evidence. A 30-fold increase in reported PTSD prevalence occurred among decedents aged 25-34 years; however, no increase was observed among younger decedents. Reported PTSD was associated with past deployments (odds ratio (OR): 14.5, 95% confidence interval (95% CI): 9.0-23.4); depression (OR: 1.8, 95% CI: 1.2-2.6); and divorce (OR: 1.7, 95% CI: 1.0-2.7). Recent crisis (OR: 0.6, 95% CI: 0.3-0.9) was inversely associated with reported PTSD. CONCLUSIONS Reported PTSD prevalence substantially increased among Veteran suicide decedents aged 25-34 years suggesting it is beginning to play a larger role in suicide for this group. Few correlated suicide risk factors were found, suggesting that if symptoms of PTSD are present, heightened vigilance by providers for suicide risk might be warranted, irrespective of evidence of other risk factors.

Objective Intimate partner (IP) problems are risk factors for suicide among men. However, there is little understanding of why some male suicide decedents who had such problems killed their partners before death (i.e., "IP homicide-suicide"), while most of these decedents did not. To inform prevention efforts, this study identified correlates of IP homicide among male suicide decedents with known IP problems. Methods We examined IP homicide correlates among male suicide decedents aged 18+ years who had known IP problems using 2003-2015 National Violent Death Reporting System data. Prevalence odds ratios and 95% confidence intervals were estimated for demographic, incident, and circumstance variables. IP homicide-suicide narratives were examined to identify additional prevention opportunities. Results An estimated 1,504 (5.0%) of 30,259 male suicide decedents who had IP problems killed their partner. IP homicide-suicide perpetration was positively correlated with suicide by firearm and precipitating civil legal problems but negatively correlated with mental health/substance abuse treatment. An estimated 33.7% of IP homicide-suicides occurred during a breakup; 21.9% of IP homicide-suicide perpetrators had domestic violence histories. Conclusions Connections between the criminal justice and mental health systems as well as stronger enforcement of laws prohibiting firearm possession among domestic violence offenders may prevent IP homicide-suicides.

To gain a better understanding of military suicide, we examined suicide narratives for 135 Soldiers extracted from two large-scale surveillance systems: the Department of Defense Suicide Event Report (DoDSER) and the Centers for Disease Control and Prevention's (CDC) National Violent Death Reporting System (NVDRS). Using coroner/medical examiner and law enforcement narratives captured in the NVDRS and mental health provider narrative data collected across multiple domains from the DoDSER, we examined circumstances surrounding military suicides using a qualitative content analysis approach. We identified five common proximal circumstances: (1) intimate partner relationship problems (63.0%); (2) mental health/substance abuse (51.9%); (3) military job-related (46.7%); (4) financial (17.8%); and (5) criminal/legal activity (16.3%). Evidence of premeditation was present in 37.0% of suicides. Decedents frequently struggled with multiple, high-stress problems and exhibited symptoms of coping and emotion regulation difficulties. Findings demonstrate potential points of intervention for suicide prevention strategies.

Homicide-suicide incidents involving child victims can have a detrimental impact on survivors of the violence, family members and friends of the decedents, and other community members, but the rare occurrence of these acts makes using quantitative data to examine their associated antecedents challenging. Therefore, using qualitative data from the 2003-2011 National Violent Death Reporting System, we examined 175 cases of homicide-suicide involving child victims in an effort to better understand the complex situational factors of these events. Our findings indicate that 98% of homicide-suicides with child victims are perpetrated by adults (mostly parents) and propelled by the perpetrators' intimate partner problems, mental health problems, and criminal/legal problems. These events are often premeditated, and plans for the violence are sometimes disclosed prior to its occurrence. Findings provide support for several theoretical perspectives, and implications for prevention are discussed.

Suicide is the second leading cause of death for youth aged 11 to 15, taking over 5,500 lives from 2003 to 2014. Suicide among this age group is linked to risk factors such as mental health problems, family history of suicidal behavior, biological factors, family problems, and peer victimization and bullying. However, few studies have examined the frequency with which such problems occur among youth suicide decedents or the context in which decedents experience these risk factors and the complex interplay of risk that results in a decedent’s decision to take his/her own life. Data from a random sample of 482 youth (ages 11–15) suicide cases captured in the National Violent Death Reporting System from 2003 to 2014 were analyzed. The sample had fewer girls than boys (31 vs. 69 %) and comprised primarily White youth (79 %), but also African Americans (13 %), Asians (4 %), and youth of other races (4 %). Narrative data from coroner/medical examiner and law enforcement investigative reports were coded and analyzed to identify common behavioral patterns that preceded suicide. Emergent themes were quantified and examined using content and constant comparative analysis. Themes regarding antecedents across multiple levels of the social ecology emerged. Relationship problems, particularly with parents, were the most common suicide antecedent. Also, a pattern demonstrating a consistent progression toward suicidal behavior emerged from the data. Narratives indicated that youth were commonly exposed to one or more problems, often resulting in feelings of loneliness and burdensomeness, which progressed toward thoughts and sometimes plans for or attempts at suicide. Continued exposure to negative experiences and thoughts/plans about suicide, and/or self-injurious acts resulted in an acquired capacity to self-harm, eventually leading to suicide. These findings provide support for theories of suicidal behavior and highlight the importance of multi-level, comprehensive interventions that address individual cognitions and build social connectedness and support, as well as prevention strategies that increase awareness of the warning signs and symptoms of suicide, particularly among family members of at-risk youth.

Medical needs of youth who experience dating violence are not well understood because of limited past research examining the prevalence and predictors of injuries and medical help seeking. To address these gaps, the current study described the prevalence and predictors of injuries from dating violence from grades 8 through 12 in a large sample of youth. Results indicate that one third to one half of youth who experienced any physical and/or sexual dating violence also sustained an injury. Prevalence of injury was highest in the 8th grade and was significantly higher for females than for males across grades 8 through 11. Youth who experienced greater amounts of violent victimization in their relationships (physical, sexual, and psychological) were at the highest risk for injury. Results also suggest that victims at highest risk for injury are girls, White youth, those experiencing multiple types of violence, and those who also engage in perpetration. Given the high prevalence of injury among youth who report dating violence, healthcare professionals may be in a unique position to screen and counsel youth about dating violence. Because the highest prevalence of injury occurred before high school, prevention programs should start early and selected prevention may be used for youth at highest risk for injury.

Manner of death (MOD) classification (i.e., natural, accident, suicide, homicide, or undetermined cause) affects mortality surveillance and public health research, policy, and practice. Determination of MOD in deaths caused by drug intoxication is challenging, with marked variability across states. The Centers for Disease Control and Prevention hosted a multidisciplinary meeting to discuss drug intoxication deaths as they relate to suicide and other MOD. The meeting objectives were to identify individual-level, system-level, and place-based factors affecting MOD classification and identify potential solutions to classification barriers. Suggested strategies included improved standardization in death scene investigation, toxicology, and autopsy practice; greater accountability; and creation of job aids for investigators. Continued collaboration and coordination of activities are needed among stakeholders to affect prevention efforts.

Suicidal Ideation among Afghanistan/Iraq War Veterans remains a health concern. As young Veterans adjust to civilian life, new risk factors might emerge and manifest differently in this group versus those in the general population. We explored these differences. With 2013 National Survey on Drug Use and Health data, we examined differences in risk of past-year suicidal ideation between Veterans of the Afghanistan/Iraq War periods aged 18–34 years (N=328) and age-comparable civilians (N=23,222). We compared groups based on individual and socio-environmental risk factors as well as perceptions of unmet mental healthcare needs. We report adjusted rate ratios (aRRs); interaction terms tested for between-group differences. PY suicidal ideation rates for Veterans and civilians did not differ (52 versus 59 per 1,000, p=0.60) and both groups shared many risk factors. However, drug problems and perceived unmet mental health care needs were vastly stronger risk factors among Veterans versus civilians (interaction terms indicated that the aRRs were 3.8–8.0 times higher for Veterans versus civilians). Other differences were discovered as well. Past-year suicidal ideation rates did not differ by Veteran status among young adults. However, different risk factors per group were detected, which can inform Veteran suicide prevention efforts.

INTRODUCTION:Suicide among military personnel and young Veterans remains a health concern. This study examined stateside distribution of suicides by U.S. county to help focus prevention efforts. METHODS:Using 2005-2012 National Violent Death Reporting System data from 16 states (963 counties, or county-equivalent entities), this study mapped the county-level distribution of suicides among current military and Veteran decedents aged 18-35 years. This study also compared incident circumstances of death between decedents in high-density counties (i.e., counties with the highest proportion of deaths) versus those in medium/low-density counties to better understand the precipitators of suicide in counties most affected. Last, this study identified potential military and Veteran Health Administration intervention sites. All analyses were conducted in 2015. RESULTS:Within the National Violent Death Reporting System participating states, an estimated 262 (33%) current military suicides occurred in just ten (1.0%) counties, and 391 (33%) Veteran suicides occurred in 33 (3.4%) counties. Mental health and intimate partner problems were common precipitating circumstances, and some circumstances differed between cases in high- versus those in medium/low-density counties. Multiple potential intervention sites were identified in high-density counties. CONCLUSIONS:These findings suggest that military and Veteran suicides are concentrated in a small number of counties. Increased efforts at these locales might be beneficial.

BACKGROUNDYouth reporting combined histories of nonfatal violence, suicidal ideation/behavior, and gun-carrying (VSG) are at risk for perpetrating fatal interpersonal violence and self-harm.AIMSWe characterized these youth to inform prevention efforts.METHODWe analyzed 2004 data from 3,931 seventh-, ninth-, and 11-12th-grade youth and compared VSG youth (n = 66) with non-gun carrying youth who either had no histories of violence or suicidal thoughts/behavior (n = 1,839), histories of violence (n = 884), histories of suicidal thoughts/behaviors (n = 552), or both (n = 590). We compared groups based on demographic factors, risk factors (i.e., friends who engage in delinquency, peer-violence victimization, depressive symptoms, illicit substance use), and protective factors (i.e., school connectedness, parental care and supervision). Regression models identified factors associated with VSG youth.RESULTSIllicit substance use and having friends who engage in delinquency were more common among VSG youth in all comparisons; almost all VSG youth had high levels of these factors. Depressive symptoms were positively associated with VSG youth versus youth without either violent or suicide-related histories and youth with violent histories alone. School connectedness and parental supervision were negatively associated with VSG youth in most comparisons.CONCLUSIONFamily-focused and school-based interventions that increase connectedness while reducing delinquency and substance use might prevent these violent tendencies.

Background: High opioid dosage has been associated with overdose, and clinical guidelines have cautioned against escalating dosages above 100 morphine-equivalent mg (MEM) based on the potential harm and the absence of evidence of benefit from high dosages. However, this 100 MEM threshold was chosen somewhat arbitrarily. Objective: To examine the association of prescribed opioid dosage as a continuous measure in relation to risk of unintentional opioid overdose to identify the range of dosages associated with risk of overdose at a detailed level. Methods: In this nested case-control study with risk-set sampling of controls, cases (opioid overdose decedents) and controls were identified from a population of patients of the Veterans Health Administration who were prescribed opioids and who have a chronic pain diagnosis. Unintentional fatal opioid analgesic overdose was measured from National Death Index records and prescribed opioid dosage from pharmacy records. Results: The average prescribed opioid dosage was higher ( P <0.001) for cases (mean=98.1 MEM, SD=112.7; median=60, interquartile range, 30–120), than controls (mean=47.7 MEM, SD=65.2; median=25, interquartile range, 15–45). In a ROC analysis, dosage was a moderately good “predictor” of opioid overdose death, indicating that, on average, overdose cases had a prescribed opioid dosage higher than 71% of controls. Conclusions: A clear cut-point in opioid dosage to distinguish between overdose cases and controls was not found. However, lowering the recommended dosage threshold below the 100 MEM used in many recent guidelines would affect proportionately few patients not at risk for overdose while potentially benefitting many of those at risk for overdose.

Background: Heroin use and overdose deaths have increased significantly in the United States. Assessing trends in heroin use among demographic and particular substance-using groups can inform prevention efforts.Methods: FDA and CDC analyzed data from the National Survey on Drug Use and Health and National Vital Statistics System reported during 2002-2013. Trends in heroin use among demographic and substance using groups were compared for 2002-2004, 2005-2007, 2008-2010, and 2011-2013. A multivariable logistic regression model was used to identify characteristics associated with heroin abuse or dependence.Results: Annual average rates of past-year heroin use increased from 1.6 per 1,000 persons aged >= 12 years in 2002-2004 to 2.6 per 1,000 in 2011-2013. Rates of heroin abuse or dependence were strongly positively correlated with rates of heroin-related overdose deaths over time. For the combined data years 2011-2013, the odds of past-year heroin abuse or dependence were highest among those with past-year cocaine or opioid pain reliever abuse or dependence.Conclusions: Heroin use has increased significantly across most demographic groups. The increase in heroin abuse or dependence parallels the increase in heroin-related overdose deaths. Heroin use is occurring in the context of broader poly-substance use.Implications for Public Health Practice: Further implementation of a comprehensive response that targets the wider range of demographic groups using heroin and addresses the key risk factors for heroin abuse and dependence is needed. Specific response needs include reducing inappropriate prescribing and use of opioids through early identification of persons demonstrating problematic use, stronger prescription drug monitoring programs, and other clinical measures; improving access to, and insurance coverage for, evidence-based substance abuse treatment, including medication-assisted treatment for opioid use disorders; and expanding overdose recognition and response training and access to naloxone to treat opioid pain reliever and heroin overdoses.

BACKGROUND Suicides among men aged 35-64 years increased by 27% between 1999 and 2013, yet little research exists to examine the nature of the suicide risk within this population. Many men do not seek help if they have mental health problems and suicides may occur in reaction to stressful circumstances. AIMS We examined the precipitating circumstances of 600 suicides without known mental health or substance abuse (MH/SA) problems and with a recent crisis. Whether these suicides occurred within the context of an acute crisis only or in the context of chronic circumstances was observed. METHOD Using data from the National Violent Death Reporting System and employing mixed-methods analysis, we examined the circumstances and context of a census of middle-aged male suicides (n = 600) in seven states between 2005 and 2010. RESULTS Precipitating circumstances among this group involved intimate partner problems (IPP; 58.3%), criminal/legal problems (50.7%), job/financial problems (22.5%), and health problems (13.5%). Men with IPP and criminal/legal issues were more likely than men with health and/or job/financial issues to experience suicide in the context of an acute crisis only. CONCLUSION Suicides occurring in reaction to an acute crisis only or in the context of acute and chronic circumstances lend themselves to opportunities for intervention. Further implications are discussed.

To help understand suicide among soldiers, we compared suicide events between active duty U.S. Army versus civilian decedents to identify differences and inform military prevention efforts. We linked 141 Army suicide records from 2005 to 2010 to National Violent Death Reporting System (NVDRS) data. We described the decedents’ military background and compared their precipitators of death captured in NVDRS to those of demographically matched civilian suicide decedents. Both groups commonly had mental health and intimate partner precipitating circumstances, but soldier decedents less commonly disclosed suicide intent.