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Service Implications of Providing Intensive Monitoring During High-Risk Periods for Suicide Among VA Patients With Depression

Dr. Valenstein, Dr. McCarthy, Ms. Austin, Ms. Ganoczy, Dr. Kim, Dr. Zivin, Dr. Piette, and Dr. Blow are affiliated with Health Services Research and Development, Department of Veterans Affairs Medical Center, 2215 Fuller Rd., Box 130170, Ann Arbor, MI 48113-0170 (e-mail: marciav{at}med.umich.edu). Dr. Kim is also with the Department of Biostatistics and Dr. Eisenberg is with the Department of Health Management and Policy, both at the University of Michigan School of Public Health, Ann Arbor. Dr. Valenstein, Dr. McCarthy, Dr. Zivin, and Dr. Blow are also with the Department of Psychiatry and Dr. Piette is also with the Department of Internal Medicine, all at the University of Michigan School of Medicine, Ann Arbor. Dr. Olfson is with the Department of Psychiatry, Columbia School of Medicine, New York City.

OBJECTIVES: Department of Veterans Affairs (VA) patients in depression treatment have high suicide rates after psychiatric hospitalization, antidepressant starts, and dosage changes. Policy makers have recommended closer monitoring during these periods to reduce suicide. This study assessed the frequency of high-risk periods in clinical settings, the levels of monitoring provided during these periods, and the estimated costs of providing monitoring consistent with the most stringent Food and Drug Administration recommendation for treatment periods after antidepressant change (seven visits in the first 12 weeks). METHODS: Monitoring visits were identified in the 12-week period after antidepressant starts and dosage changes and after discharge from psychiatric hospitalization for 100,000 randomly selected VA patients in depression treatment between April 1, 1999, and September 30, 2004. Incremental costs of providing intensive monitoring were estimated by using VA Health Economics Resource Center average cost data. RESULTS: Patients averaged less than one high-risk period each year. They completed an average of 2.4 monitoring visits during the 12-week period after antidepressant treatment events and 4.9 visits after psychiatric hospitalization. Providing intensive monitoring would cost an additional $408–$537 for each high-risk period after antidepressant treatment events and $313–$341 for each high-risk period after psychiatric hospitalization. During fiscal year 2004 providing intensive monitoring during all high-risk periods would have cost an additional $183–$270 million. Providing intensive monitoring only after psychiatric hospitalizations would have cost an additional $15–$17 million. CONCLUSIONS: Providing intensive monitoring for VA patients in depression treatment during all high-risk periods for suicide would require substantial services reorganization and incremental expenditures. Modest expenditures would support intensive monitoring during the highest-risk period that follows psychiatric hospitalization.

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