Cited by 291Suicide and Self-Harm StudiesOpioid Use Disorder TreatmentMental Health Treatment and Access

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Does Suicidal Ideation as Measured by the PHQ-9 Predict Suicide Among VA Patients?

Louzon, Samantha A., Bossarte, Robert, McCarthy, John F., Katz, Ira R.·2016·Psychiatric Services

DOI 10.1176/appi.ps.201500149

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Abstract

OBJECTIVE: Frequency of suicidal ideation in the past two weeks, assessed by item 9 of the nine-item Patient Health Questionnaire (PHQ-9), has been positively associated with suicide mortality among patients in a setting other than the Veterans Health Administration (VHA). To inform suicide prevention activities at the VHA, it is important to evaluate whether item 9 is associated with suicide risk among patients in the VHA system. METHODS: PHQ-9 assessments (N=447,245) conducted by the VHA between October 1, 2009, and September 30, 2010, were collected. National Death Index data were used to ascertain suicide mortality from the date of PHQ-9 assessment through September 30, 2011. Multivariable proportional hazards regressions were used to evaluate associations between responses to item 9 and suicide mortality. RESULTS: After the analyses adjusted for covariates, a response of "several days" for item 9 was associated with a 75% increased risk of suicide (hazard ratio [HR]=1.75, 95% confidence interval [CI]=1.24-2.46), a response of "more than half the days" was associated with a 115% increased risk of suicide (HR=2.15, CI=1.32-3.51), and a response of "nearly every day" was associated with a 185% increased risk of suicide (HR=2.85, CI=1.81-4.47), compared with a response of "not at all." However, 71.6% of suicides during the study period occurred among patients who responded "not at all" to item 9 from their most recent PHQ-9. CONCLUSIONS: Higher levels of suicidal ideation, indicated by item 9 of the PHQ-9, were associated with increased risk of suicide among patients in the VHA system.

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A practical guide to random-effects Bayesian meta-analyses with application to the psychological trauma and suicide literature.
Reis, D. J., Kaizer, A. M., Kinney, A. R., Bahraini, N. H., Holliday, R. P., Forster, J. E., & Brenner, L. A. (2022) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0001316 · Cited by 36
Social cognition and short-term prediction of suicidal ideation in schizophrenia
Depp, C. A., Villa, J., Schembari, B. C., Harvey, P. D., & Pinkham, A. E. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.09.005 · Cited by 36
“the validity of single item ratings of suicidal ideation in predicting attempts, but to our knowledge, these have not specifically been replicated in schizophrenia (Louzon et al., 2016; Simon et al., 2013).”
What health records data are required for accurate prediction of suicidal behavior?
Simon, G. E., Shortreed, S. M., Johnson, E., Rossom, R. C., Lynch, F. L., Ziebell, R. A., & Penfold, A. R. B. (2019) · Journal of the American Medical Informatics Association · doi:10.1093/jamia/ocz136 · Cited by 35
“6 While self-report measures (eg, the Patient Health Questionnaire-9 [PHQ-9] depression questionnaire) can accurately identify people at increased risk, 7,8 those tools have only moderate sensitivity and moderate accuracy for identifying those at highest risk.”
Background
Mental Health Needs of Aging Veterans: Recent Evidence and Clinical Recommendations
Karel, M. J., Wray, L. O., Adler, G., Hannum, A. O. R., Luci, K., Brady, L., & McGuire, M. H. (2020) · Clinical Gerontologist · doi:10.1080/07317115.2020.1716910 · Cited by 35
Posttraumatic stress disorder, depression, and suicidal ideation in veterans: Results from the mind your heart study
Arenson, M. B., Whooley, M. A., Neylan, T. C., Maguen, S., Metzler, T. J., & Cohen, B. E. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.04.046 · Cited by 40
Veterans’ perspectives on discussing moral injury in the context of evidence‐based psychotherapies for PTSD and other VA treatment
Borges, L. M., Bahraini, N. H., Holliman, B. D., Gissen, M., Lawson, W. C., & Barnes, S. M. (2019) · Journal of Clinical Psychology · doi:10.1002/jclp.22887 · Cited by 33
Utility of item 9 of the patient health questionnaire in the prospective identification of adolescents at risk of suicide attempt
Penfold, R. B., Whiteside, U. S., Johnson, E., Stewart, C. C., Oliver, M. M., Shortreed, S. M., Beck, A. L., Coleman, K. J., Rossom, R. C., Lawrence, J. M., et al. (2021) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12751 · Cited by 32
The temporal dynamics of wish to live, wish to die, and their short-term prospective relationships with suicidal desire
Oakey-Frost, N., Moscardini, E. H., Cowan, T., Cohen, A., & Tucker, R. P. (2023) · Behavior Therapy · doi:10.1016/j.beth.2022.12.011 · Cited by 31
Effects of Electroconvulsive Therapy on Short-Term Suicide Mortality in a Risk-Matched Patient Population
Peltzman, T., Shiner, B. R., & Watts, B. V. (2020) · Journal of Ect · doi:10.1097/yct.0000000000000665 · Cited by 31
Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans
Holliday, R. P., Forster, J. E., Desai, A., Miller, C. N., Monteith, L. L., Schneiderman, A., & Hoffmire, C. A. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.11.007 · Cited by 32
Economic precarity, loneliness, and suicidal ideation during the COVID-19 pandemic
Raifman, J., Ettman, C. K., Dean, L. T., Abdalla, S. M., Skinner, A., Barry, C. L., & Galea, S. (2022) · PLoS ONE · doi:10.1371/journal.pone.0275973 · Cited by 32
“Prior research indicates responses to this question were correlated with future suicide attempts and deaths [14,17,18].”
Background
Social support, social network size, and suicidal ideation: A nine-year longitudinal analysis from the Mind Your Heart Study
Arenson, M. B., Bernat, E. M., Reyes, A. D. L., Neylan, T. C., & Cohen, B. E. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.01.017 · Cited by 30
Limitations of Screening for Depression as a Proxy for Suicide Risk in Adult Medical Inpatients
Mournet, A. M., Smith, J. T., Bridge, J. A., Boudreaux, E. D., Snyder, D. J., Claassen, C. A., Jobes, D. A., Pao, M., & Horowitz, L. M. (2021) · Journal of the Academy of Consultation-Liaison Psychiatry · doi:10.1016/j.jaclp.2021.02.002 · Cited by 34
The role of suicide ideation in assessing near-term suicide risk: A machine learning approach
McMullen, L., Parghi, N., Rogers, M. L., Yao, H., Bloch-Elkouby, S., & Galynker, I. (2021) · Psychiatry Research · doi:10.1016/j.psychres.2021.114118 · Cited by 30
Association Between Positive Results on the Primary Care–Posttraumatic Stress Disorder Screen and Suicide Mortality Among US Veterans
Cooper, S. A., Szymanski, B. R., Bohnert, K. M., Sripada, R. K., & McCarthy, J. F. (2020) · JAMA Network Open · doi:10.1001/jamanetworkopen.2020.15707 · Cited by 29
Self-citation
Brief cognitive behavioral therapy reduces suicidal ideation in veterans with chronic illnesses
Ecker, A. H., Johnson, A. L., Sansgiry, S., Fletcher, T. L., Hundt, N. E., Petersen, N. J., Sweeney, A. C., Chaison, A. D., York-Ward, K. M., Kauth, M. R., et al. (2019) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2019.02.002 · Cited by 29
The Association between Recent Cannabis Use and Suicidal Ideation in Adults: A Population-based Analysis of the NHANES from 2005 to 2018
Diep, C., Bhat, V., Wijeysundera, D. N., Clarke, H. A., & Ladha, K. S. (2021) · The Canadian Journal of Psychiatry · doi:10.1177/0706743721996112 · Cited by 29
“Suicidal ideation reported by Item #9 has been shown to be a robust predictor of attempted or completed suicide in the following weeks to months.(22,23) The presence of clinical depression was considered as a secondary outcome.”
Predicting suicide attempts among U.S. Army soldiers after leaving active duty using information available before leaving active duty: results from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS)
Stanley, I. H., Chu, C., Gildea, S. M., Hwang, I. H., King, A. J., Kennedy, C. J., Luedtke, A. R., Marx, B. P., O’Brien, R. W., Petukhova, M. V., et al. (2022) · Molecular Psychiatry · doi:10.1038/s41380-021-01423-4 · Cited by 30
“Although this is consistent with previous research [37], evidence from studies of patients being screened for suicidality during routine outpatient visits who went on to die by suicide shortly thereafter [59, 60], show that the great majority of such patients deny any suicidality.”
Result
Suicidal behaviour in Indigenous compared to non-Indigenous males in urban and regional Australia: Prevalence data suggest disparities increase across age groups
Armstrong, G., Pirkis, J., Arabena, K., Currier, D., Spittal, M. J., & Jorm, A. F. (2017) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/0004867417704059 · Cited by 29
Suicidal Ideation Disparities Among Transgender and Gender Diverse Compared to Cisgender Community Health Patients
Kirakosian, N., Stanton, A. M., McKetchnie, S. M., King, D. S., Dolotina, B., O’Cleirigh, C. M., Grasso, C., Potter, J. E., Mayer, K. H., & Batchelder, A. (2023) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07996-2 · Cited by 33
“For example, although the PHQ-9 is widely used to assess the prevalence of suicidal ideation in research studies, the predictive value of the frequency of thoughts of death or self-harm over the past 2 weeks remains unclear.(66,69,70) Moreover, because the item assesses both passive thoughts about death and desire for…”
Background
Prospective Validity of the Suicide Cognitions Scale Among Acutely Suicidal Military Personnel Seeking Unscheduled Psychiatric Intervention
Bryan, C. J., Rozek, D. C., & Khazem, L. R. (2019) · Crisis · doi:10.1027/0227-5910/a000639 · Cited by 28
Does exposure exacerbate symptoms in veterans with PTSD and alcohol use disorder?
Tripp, J. C., Haller, M. M., Trim, R. S., Straus, E., Bryan, C. J., Davis, B. C., Lyons, R. C., Hamblen, J. L., & Norman, S. B. (2020) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0000634 · Cited by 28
The mediating role of hopelessness in the relationship between self-esteem, social anxiety, and suicidal ideation among Japanese university students who visited a university health care center
Dat, N. T., Mitsui, N., Asakura, S., Watanabe, S., Takanobu, K., Fujii, Y., Toyoshima, K., Kako, Y., & Kusumi, I. (2021) · Journal of Affective Disorders Reports · doi:10.1016/j.jadr.2021.100192 · Cited by 28
Digital Technology for Suicide Prevention
Braciszewski, J. M. (2021) · Advances in Psychiatry and Behavioral Health · doi:10.1016/j.ypsc.2021.05.008 · Cited by 28
Improving Suicide Risk Screening to Identify the Highest Risk Patients: Results From the PRImary Care Screening Methods (PRISM) Study
Bryan, C. J., Allen, M. H., Thomsen, C. J., May, A. M., Baker, J. C., Bryan, A. O., Harris, J. A., Cunningham, C. A., Taylor, K. B., Wine, M. D., et al. (2021) · The Annals of Family Medicine · doi:10.1370/afm.2729 · Cited by 28
Association of sociodemographic, proximal, and distal clinical factors with current suicidal ideation: Findings from a nonclinical sample of young adults
Misiak, B., Samochowiec, J., Gawęda, Ł., & Frydecka, D. (2023) · European Psychiatry · doi:10.1192/j.eurpsy.2023.14 · Cited by 28
“However, there are studies showing the usefulness of this item in stratifying the risk of suicide attempt [2, 112, 113].”
Background
Sexual dysfunction is associated with suicidal ideation in female service members and veterans
Blais, R. K., Monteith, L. L., & Kugler, J. (2017) · Journal of Affective Disorders · doi:10.1016/j.jad.2017.08.079 · Cited by 28
Universal screening may not prevent suicide
Nestadt, P. S., Triplett, P. T., Mojtabai, R., & Berman, A. L. (2018) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2018.06.006 · Cited by 28
Self-Reported Lifetime Depression and Current Mental Distress Among Veterans Across Service Eras
Boakye, E. A., Buchanan, P. M., Wang, J., Stringer, L. M., Geneus, C. J., & Scherrer, J. F. (2017) · Military Medicine · doi:10.7205/milmed-d-16-00119 · Cited by 26
Suicide prevention in medical settings: The case for universal screening
Horowitz, L. M., Roaten, K., Pao, M., & Bridge, J. A. (2018) · General Hospital Psychiatry · doi:10.1016/j.genhosppsych.2018.11.009 · Cited by 27
An implementation evaluation of “Zero Suicide” using normalization process theory to support high-quality care for patients at risk of suicide
Richards, J. A., Simon, G. E., Boggs, J. M., Beidas, R. S., Yarborough, B. J. H., Coleman, K. J., Sterling, S., Beck, A. L., Flores, J. P., Bruschke, C., et al. (2021) · Implementation Research and Practice · doi:10.1177/26334895211011769 · Cited by 25
“depression assessment is a strong predictor of subsequent suicide attempts (Louzon et al., 2016; Simon et al., 2013, 2016), but the link between identification of patients experiencing suicidal thoughts and the ability of health care systems to intervene effectively and help prevent suicide attempts is unclear.”
Background
Depression and PTSD-related anhedonia mediate the association of military sexual trauma and suicidal ideation in female service members/veterans
Blais, R. K., & Geiser, C. (2018) · Psychiatry Research · doi:10.1016/j.psychres.2018.12.148 · Cited by 25
“The PHQ-9 Item 9 has been shown to predict increased risk for suicide in veteran samples (Louzon et al., 2016).”
Background
Dementia-related anxiety and coping styles associated with suicidal ideation
Cui, R., Maxfield, M., & Fiske, A. (2019) · Aging & Mental Health · doi:10.1080/13607863.2019.1636205 · Cited by 24
Is Gratitude Associated With Suicidal Ideation in Veterans With Mental Illness and Student Veterans With PTSD Symptoms?
Umucu, E., Lo, C.-L., Lee, B., Vargas‐Medrano, J., Diaz-Pacheco, V., Misra, K., Martin, S. L., Thompson, P. M., & Gadad, B. S. (2021) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001406 · Cited by 24
“Item 9 of the PHQ-9 was used to measure SI in previous research (Louzon et al., 2016; Rossom et al., 2017).”
BackgroundMethod
Prevalence of psychological distress, depression and suicidal ideation in an indigenous population in Panamá
Walker, R. J., Campbell, J. A., Dawson, A. Z., & Egede, L. E. (2019) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-019-01719-5 · Cited by 27
Resilience and social support as protective factors against suicidal ideation among tertiary students during COVID-19: a cross-sectional study
Selak, Š., Crnkovič, N., Šorgo, A., Gabrovec, B., Cesar, K., & Žmavc, M. (2024) · BMC Public Health · doi:10.1186/s12889-024-19470-1 · Cited by 47
“Previous research [9, 53] suggests suicidal ideation measured by the 9th item of the PHQ-9 may function as a robust predictor of suicide attempts and deaths.”
Method
Changes in suicide and non‐suicidal self‐injury ideation and the moderating role of specific emotions over the course of dialectical behavior therapy
Rizvi, S. L., & Fitzpatrick, S. (2020) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12691 · Cited by 27
Suicidal ideation during COVID-19: The contribution of unique and cumulative stressors
Rudenstine, S., Schulder, T., Bhatt, K. J., McNeal, K., Ettman, C. K., & Galea, S. (2022) · Psychiatry Research · doi:10.1016/j.psychres.2022.114475 · Cited by 23
Well-being of Canadian Veterans during the COVID-19 pandemic: cross-sectional results from the COVID-19 Veteran well-being study
Richardson, J. D., Cyr, K. S., Forchuk, C. A., Liu, J. J. W., Plouffe, R. A., Le, T., Gargala, D., Deda, E., Soares, V., Hosseiny, F., et al. (2022) · European Journal of Psychotraumatology · doi:10.1080/20008198.2021.2012374 · Cited by 23
Status loss due to COVID-19, traditional masculinity, and their association with recent suicide attempts and suicidal ideation.
Walther, A., Grub, J., Tsar, S., Ehlert, U., Heald, A. H., Perrin, R. N., Ogrodniczuk, J. S., Seidler, Z. E., Rice, S., Kealy, D., et al. (2022) · Psychology of Men & Masculinity · doi:10.1037/men0000408 · Cited by 23
Socio-Economic Position and Suicidal Ideation in Men
Pirkis, J., Currier, D., Butterworth, P., Milner, A. J., Kavanagh, A. M., Tibble, H., Robinson, J., & Spittal, M. J. (2017) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph14040365 · Cited by 25
“It is worth noting here that this single PHQ-9 item has been shown to have good specificity and reasonable sensitivity when compared to a structured clinical interview [24], and was recently shown to predict suicide risk in a large-scale register-based study of (predominantly male) Veterans Administration (VA) patient…”
Result
Discrimination experienced by Aboriginal and Torres Strait Islander males in Australia: Associations with suicidal thoughts and depressive symptoms
Haregu, T., Jorm, A. F., Paradies, Y., Leckning, B., Young, J. T., & Armstrong, G. (2021) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674211031168 · Cited by 24
“Endorsement of suicidal ideation on this item has been associated with a 75–185% increase in the risk of suicide in a study of veterans in the United States (Louzon et al., 2016).”
Background
Military suicide prevention: The importance of leadership behaviors as an upstream suicide prevention target
Trachik, B. J., Oakey‐Frost, N., Ganulin, M. L., Adler, A. B., Dretsch, M. N., Cabrera, Ó., & Tucker, R. P. (2021) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12707 · Cited by 27
“Previous research has indicated that this single-item measure predicts subsequent suicidal behavior in veterans (Louzon et al., 2016).”
Self‐rated sleep quality predicts incident suicide ideation in US military veterans: Results from a 7‐year, nationally representative, prospective cohort study
McCarthy, E., DeViva, J. C., Southwick, S. M., & Pietrzak, R. H. (2021) · Journal of Sleep Research · doi:10.1111/jsr.13447 · Cited by 20
A 50-state survey study of thoughts of suicide and social isolation among older adults in the United States
Solomonov, N., Green, J., Quintana, A., Lin, J. A.-J., Ognyanova, K., Santillana, M., Druckman, J. N., Baum, M., Lazer, D. M. J., Gunning, F. M., et al. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.04.038 · Cited by 25
Expanded Roles and Recommendations for Stakeholders to Successfully Reintegrate Modern Warriors and Mitigate Suicide Risk
Geraci, J. C., Mobbs, M. C., Edwards, E. R., Doerries, B., Armstrong, N. J., Porcarelli, R., Duffy, E., Loos, C. M., Kilby, D. J., Juanamarga, J., et al. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.01907 · Cited by 22
Screening for suicide risk among older adults: assessing preliminary psychometric properties of the Brief Geriatric Suicide Ideation Scale (BGSIS) and the GSIS-Screen
Heisel, M. J., & Flett, G. L. (2020) · Aging & Mental Health · doi:10.1080/13607863.2020.1857690 · Cited by 20
Predictors of Suicidal Ideation Among IBD Outpatients
Hashash, J. G., Vachon, A., Rivers, C. R., Regueiro, M. D., Binion, D. G., Altman, L., Williams, C., & Szigethy, E. (2018) · Journal of Clinical Gastroenterology · doi:10.1097/mcg.0000000000001094 · Cited by 20

Authors: Louzon, S. A., Bossarte, R., McCarthy, J. F., & Katz, I. R.
Affiliations: United States Department of Veterans Affairs (US)
ORCID: Bossarte, Robert
Katz, Ira R.
Venue: Psychiatric Services
Publisher: American Psychiatric Association Publishing
Published: 2016-05-01
Volume: 67
Issue: 5
Pages: 517-522
ISSN: 0022-1597 (ISSN-L)
1075-2730
1557-9700
DOI: 10.1176/appi.ps.201500149
OpenAlex: W2239385095
Cited by: 291
References: 18
Citations by year: 2026: 16 · 2025: 33 · 2024: 24 · 2023: 44 · 2022: 32 · 2021: 44 · 2020: 33 · 2019: 28 · 2018: 23 · 2017: 9 · 2016: 5
FWCI: 29.05
Type: journal article
Language: en
Open access: closed
Locations: Psychiatric Services (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Keywords: suicidal ideation, PHQ-9, suicide mortality, suicide risk, veterans, suicide prevention, Patient Health Questionnaire, suicide risk screening, Veterans Health Administration
MeSH terms: Patient Health Questionnaire, Suicide Prevention, Adult, Aged, Aged, 80 and over, Mental Disorders, Female, Hospitals, Veterans, Humans, Male, Mass Screening, Middle Aged, Risk Factors, Suicide, United States, Veterans, Multivariate Analysis, Proportional Hazards Models, Suicidal Ideation

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Does Suicidal Ideation as Measured by the PHQ-9 Predict Suicide Among VA Patients?

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