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Mp-Hfm-275-22P Suicide and Violence Perpetration Risk Assessments in the Canadian Armed Forces Health Information System: A Population-Based Analysis Robert Hawes & François Thériault Directorate of Force Health Protection Department of National Defence, Ottawa, Canada NATO HFM-275 Riga, Latvia 05 April 2017 Suicide in the Canadian Armed Forces (CAF) • 3rd leading cause of death in active-duty personnel 1983 -2007 (17%) (Tien et al. 2010) • 23.5 deaths per 100,000 person-years (Rolland-Harris et al, 2016) • 4.3% of CAF service members seriously consider suicide (Mann et al, 2005; Rusu et al, 2016) • 9% of CAF personnel with suicidal ideation attempt suicide (Rusu et al, 2016) • 93% of CAF suicide deaths (83% civilian pop.) accessed health care in previous 12 months (Mann, 2005; Rolland-Harris et al, 2016) Alert CFHIS SQL Referral / Diagnostic / Review of Care Discharge Intake Treatment Diagnostic Assessment MH Referral Periodic Case Psychosocial Review * Functioning Discharge Summary * Intake Session Note * External Screening * Provider Psychiatrist Review Progress Note Family Counselling Communication Case Consult Couple and Individual Conference Note Family Session Communication Note CFHIS Mental Health Session Note Clinical Impression Classification (CIC) 7 Clinical Impression Classifications (CIC) Addictions / Compulsive Behaviours • Classification system to Administrative categorize the MH Childhood / Upbringing assessment or narrative Education Family Circumstance • Terms based on ICD-10 Housing / Economic health status (Z-codes) Legal / Disciplinary • 9 groups, 90 CIC codes Personal Occupational 8 Clinical Impression Classifications (CIC) Addictions / Compulsive Behaviours CIC Code English French ADALCO Alcohol Alcool ADDRGILC Drugs illicit Drogues illicites ADDRGRX Drugs prescribed Médicaments ADTOBAC Tobacco Tabac ADEATDIS Eating disorder Désordre alimentaire Jeux de hasard / jeux de hasard en ADGAMBL Gambling / betting/ VLT ligne ADSEXMAL Sexual Comportements sexuels ADVIDEO Video games Jeux vidéo ADWWW Internet / Social Media Internet/médias sociaux ADOTH Other Autre Administrative Childhood / Upbringing Education Family Circumstance Housing / Economic Legal / Disciplinary Personal Occupational 9 CAF Population Health & Injury Surveillance • EMRs are useful clinical repositories, but are not designed for population health research • Pop health research is risk-oriented, integrative and evolving • Requires time-series analysis, data Adapted from McLeroy et al., 1988 cleaning & validation, warehousing Canadian Armed Forces Health, Evaluation and Reporting Outcomes (HERO) System Targeting Health Information 11 Hypertension Addictions Depression Diabetes BMI (kg/m2) Fracture Lyme Disease Blisters Cervical Cancer Gonorrhea Hearing Loss Suicide Berylliosis Rhabdomyolosis Smoking Low Back Pain 3b Release PTSD hy Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Wh Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why WhyN Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why W hy Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Wh Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why W hy Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why(What) Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Why Wh Why Why Why Why Why Why Why Why Why Why Why WhyWhy? 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Age, Sex Violence Risk Assess. CAF Unit, Command Release, Death Psychosocial Factors US VA/DoD Clinical Practice Guideline Suicide Risk Assessment (2013) Risk of Suicide Indicators of Contributing Initial Action Based Attempt Suicide Risk Factors on Level of Risk • Persistent suicidal • Acute state of mental • Maintain direct High Acute Risk ideation or thoughts disorder / psychiatric observational control of • Strong intention to act or symptoms the patient plan • Acute precipitating event • Limit access to lethal • Not able to control • Inadequate protective means impulse OR recent factors • Immediate transfer with suicide attempt or escort to Urgent / preparatory behaviour Emergency Care setting for hospitalization • Current suicidal ideation or • Existence of warning signs • Refer to Behavioural Health Intermediate Acute thoughts or risk factors AND provider for complete Risk • No intention to act • Limited protective factors evaluation and interventions • Able to control impulse • Contact Behavioural Health • No recent attempt or provider to determine acuity preparatory behaviour of referral • Limit access to lethal means • Recent suicidal ideation or • Existence of protective • Consider consultation with Low Acute Risk thoughts factors AND Behavioural Health to • No intention to act or plan • Limited risk factors determine need for referral • Able to control the impulse and treatment • No planning or rehearsing a • Treat presenting problems suicide act • Address safety issues • No previous attempt • Document care and rational for action Results COUNTS 10.0% Overall 9.2% of Males 2016: 10.0% of CAF MH Intake Screening 14.6% of Females RATES Overall: Males: 126.6/1,000py 136.0/1,000py Females: 192.2/1,000py Personal Anxiety, Depressive Symptoms Adjustment to Stress, Anger Other MH Symptoms, PTSD Occupational Discord, Other Family Job Satisfaction Relationship Distress, Separation/Divorce Work Schedule Stressful Event, Death, Parenting Psychosocial Factors: 1. Personal 3. Occupat. Females 2. Family 1.5x Males 2x Females Addiction 2x Legal Suicide Risk Assessment = Moderate / High Adjusting for Age, Sex, CAF Command Incidence Rate Ratios CMP (Support): C Army: (IRR) 3.5x ~3.5x Navy (Ref) Air Force: Special ~2x Forces: ~2x Violence Risk Assessment = Moderate / High Adjusting for Age, Sex, CAF Command Incidence Rate Ratios (IRR) C Army: ~3x CMP (Support): Navy 2x (Ref) Conclusions Conclusions • 9.2% of males; 14.6% females MH Intake (2016) 1. Personal (Depression, Anxiety, PTSD) 2. Family (Sep/Divorce, Parenting) 3. Occupational (Discord, Satisfaction) • Canadian Army, CMP rate of Mod/Hi Suicide & Violence Risk Assessments Conclusions CFHIS • Electronic Health Record (EHRs) improve coverage of mental health surveillance • Data collection tools should capture contextual information to inform clinical care and prevention efforts • Population health databases can provide novel insights and support longitudinal (prospective) analyses Collaborations Epidemiology Mental Health Primary Care Medical Policy Thank You ~ Merci Robert Hawes [email protected] Canadian Forces Health Services Group Directorate Force Health Protection Acknowledgements CF-HERO / CFHIS Team Project Support Dr Diane Lu Col Scott Malcolm François Thériault LCol Steve Cooper Laura Bogaert Mr Brock Heilman Kiyuri Naicker Daniel Cousineau-Short EXTRA SLIDES Limitations • Consistent with previously published reports (McKibben et al., 2013; Thériault et al., 2016) we observed significantly higher rates of mental health service use among CAF Regular Force females at every age group than their male counterparts. Graph 1. Clinical classifications of mental health intake screening among Canadian Armed Forces Regular Force personnel, 2016. Graph 2. Gender-specific clinical classifications of mental health intake screening among Canadian Armed Forces Regular Force personnel, 2016. Tables Table 1. Demographic
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