PITTSBURGH—It’s long been understood that social stress factors such as violence, homelessness, unemployment, relationship problems and other factors can all contribute to veterans’ suicidal ideation and suicide attempts. For the first time, that link can be identified and tracked using only the data available in the VA electronic health record.
The leader of the study, John Blosnich, PhD, has spent his career trying to better understand how these social factors can harm the health and lives of at-risk veterans. A research health scientist with the Center for Health Equity Research and Promotion at the VA Pittsburgh Healthcare System, Blosnich believes the study’s results, published online recently by the Journal of General Internal Medicine, provide hope that VA can use its existing data to better understand the lives of its patients and intervene earlier with those who are at risk for suicide.1
“As a health equity researcher, I’ve always looked at the social factors that are involved in health,” Blosnich said. “Mental health treatment, whether that be psychotherapy or pharmacotherapy, are critical building blocks for suicide prevention. But with suicide being such a dynamic problem, I gravitated toward those social kind of public health factors that might be involved. I’d joined up with VA at a time when it was mobilizing and building this massive infrastructure around suicide prevention. I see a lot of potential in the system to really be a model for how healthcare systems are wrestling with this very insidious problem of suicide. It’s so unlike any cause of death. It’s not like heart disease or cancer. It’s not as simple as checking someone’s A1C or blood pressure. With suicide prevention, we are still struggling how to identify people at risk.”
That the recent study found social stress to be factors in suicide risk was hardly surprising, especially to Blosnich. What was notable was that this risk could be identified using the EHR.
“We’ve known for a long time that adverse life events are highly associated with suicide risk. It’s come up in survey data and psychological autopsies,” Blosnich explained. “But we’re using health data and seeing the same pattern. This isn’t a self-report—this is data inputted by health professionals. We’re still picking up this common pattern.”
Blosnich and his colleagues looked at VISN 4 data from October 2015 through September 2016, which encompassed approximately 260,000 veterans’ records spread across more than 50 facilities. Because health professionals aren’t trained to collect information about social stressors from patients, the researchers didn’t know what they’d find, or whether there would be enough information for a pattern to emerge. Only two social stressors are regularly picked up on VA’s clinical screening questions: housing instability and military sexual trauma. However, Blosnich and his team were able to identify other social stressors, such as violence, by picking out the relevant diagnostic codes.
The pattern was clear: Increasing the number of social stressors in a patient’s life resulted in a corresponding increase in the odds of that veteran having suicidal ideation or attempting suicide.
As VA makes preventing suicide its No. 1 clinical priority, Blosnich hopes the results of this study will inspire providers department-wide to think more broadly about what suicide prevention looks like.
“These social factors can help us get a signal for when a veteran might be in need of help. Then we can start deploying services and deploying people to get those wraparound services so things don’t get worse,” Blosnich said. “Often it’s never just one thing. And it’s very easy to picture how one thing can cascade into another. Is it a recent divorce? A relationship failure? A legal problem? Did they just lose their job? Are they worrying about paying their bills? For some folks, life can be really fragile. These elements help us get that dimension.”
One way VA and other healthcare systems can better identify at-risk individuals is to collect more information, Blosnich said. While VA has universal clinical screening reminders for homelessness and sexual trauma, other social stressors are not regularly identified. Also, clinical codes that could point toward those stressors can be vague and confusing, and physicians might not always know what the codes mean. The average VA clinician might go their entire career without seeing the code for adult maltreatment or understand exactly what it could refer to. However, VA social workers, who have contact with the most at-risk veterans dealing with multiple social stressors, use such codes every day.
“We’re looking more at how to incorporate elements of what VA already does around social work and the role of the social worker in healthcare,” Blosnich said. “What we’re finding is clearly in the wheelhouse of what social workers are trained to do. They meet with people where they are. They sit with them. They understand how to help that person.”
- Blosnich JR, Montgomery AE, Dichter ME, Gordon AJ, Kavalieratos D, Taylor L, Ketterer B, Bossarte RM. Social Determinants and Military Veterans’ Suicide Ideation and Attempt: a Cross-Sectional Analysis of Electronic Health Record Data. J Gen Intern Med. 2019 Nov 19. doi: 10.1007/s11606-019-05447-z. [Epub ahead of print] PubMed PMID: 31745856.