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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Method
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BackgroundMethod
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Background
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Method
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“Though a more comprehensive measure of suicide risk may provide a more nuanced perspective, research in a large sample (Louzon et al., 2016; N= 447,245) of Veterans found that a single item measure of SI signi ﬁ cantly predicted suicide mortality ( HR = 1.47), supporting the utility of measuring SI…”
Influential
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Method
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Method
Identifying suicide documentation in clinical notes through zero‐shot learning
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Background
Association Between Patterns of Alcohol Use and Short-Term Risk of Suicide Attempt Among Patients With and Without Reported Suicidal Ideation
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Berman, A. L., & Silverman, M. M. (2020) · Psychiatric Quarterly · doi:10.1007/s11126-020-09856-w · Cited by 11
Ascertainment of Patient Suicides by Veterans Affairs Facilities and Associations With Veteran, Clinical, and Suicide Characteristics
Palframan, K. M., Szymanski, B. R., & McCarthy, J. F. (2021) · American Journal of Public Health · doi:10.2105/ajph.2021.306262 · Cited by 10
Self-citation
Management of Mental Health Disorders, Substance Use Disorders, and Suicide in Adults with Spinal Cord Injury: Clinical Practice Guideline for Health Care Providers
(2021) · The Journal of Spinal Cord Medicine · doi:10.1080/10790268.2021.1863738 · Cited by 9
Veteran Perspectives on Population-Based Suicide Risk Screening in VHA Primary Care: Mixed-Methods Study
Denneson, L. M., Newell, S., Elliott, V. L., Rynerson, A., Niederhausen, M., Salvi, A., Handley, R., Bahraini, N. H., Post, E., Carlson, K., et al. (2023) · Journal of general internal medicine · doi:10.1007/s11606-023-08148-w · Cited by 9
Managing post-sexual assault suicide risk
Gilmore, A. K., Ward‐Ciesielski, E. F., Smalling, A., Limowski, A. R., Hahn, C. K., & Jaffe, A. E. (2020) · Archives of Women s Mental Health · doi:10.1007/s00737-020-01047-7 · Cited by 9
The Narrative Crisis Model of Suicide: A Novel and Empirically Grounded Diathesis-Stress Model of Suicide
Bloch‐Elkouby, S., Yanez, N., Chennapragada, L., Richards, J. A., Cohen, L. J., & GALYNKER, I. I. (2021) · Springer eBooks · doi:10.1007/978-3-030-41319-4_14-1 · Cited by 9
Event-related PTSD symptoms as a high-risk factor for suicide: longitudinal observational study
Chiba, T., Ide, K., Murakami, M., Kobayashi, N., Oka, T., Nakai, F., Yorizawa, R., Miyake, Y., Hamamura, T., Honjo, M., et al. (2023) · Nature Mental Health · doi:10.1038/s44220-023-00157-2 · Cited by 7
“Psychiatric conditions may be more informative for predicting suicide than suicidal ideation given that more than 60–70% of people who have died by suicide reported no suicidal ideation in assessments delivered within 30 days to 1 year of their deaths 31 .”
Background
Effectiveness of cognitive analytic therapy for bipolar affective disorder: A co‐produced single subject cumulative treatment design with extended follow‐up (A 1 /B/A 2 /C‐FU)
Kellett, S., Alhadeff, L., Gaskell, C., & Simmonds‐Buckley, M. (2022) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12390 · Cited by 8
Subjective cognitive difficulties and posttraumatic stress disorder interact to increase suicide risk among middle-aged and older US military veterans
Cations, M., Cook, J. M., Nichter, B., Esterlis, I., & Pietrzak, R. H. (2023) · International Psychogeriatrics · doi:10.1017/s1041610222001053 · Cited by 8
Psychological capital and mental health problems among the unemployed in the post-COVID-19 era: Self- esteem as a moderator
Trung, C. T. T., Nguyen, D., Teh, C. J., & Tee, P. K. (2025) · PLoS ONE · doi:10.1371/journal.pone.0319555 · Cited by 8
“This measure was selected because the item has demonstrated a high degree of reliability in predicting suicidal ideation across different community contexts [39, 40].”
Stability of Suicide Risk Prediction Models During Changes in Health Care Delivery
Simon, G. E., Cruz, M., Shortreed, S. M., Sterling, S., Coleman, K. J., Ahmedani, B. K., Yaseen, Z. S., & Mosholder, A. D. (2023) · Psychiatric Services · doi:10.1176/appi.ps.20230172 · Cited by 8
An Exploratory Analysis of Self-Reported Protective Factors against Self-Harm in an Enrolled Veteran General Mental Health Population
Williamson, A. K., Riendeau, R. P., Stolzmann, K. L., Silverman, A., Kim, B., Miller, C. J., Connolly, S. L., Pitcock, J. A., & Bauer, M. S. (2019) · Military Medicine · doi:10.1093/milmed/usz111 · Cited by 8
The Role of Past Suicidal Behavior on Current Suicidality: A Retrospective Study in the Israeli Military
Shelef, L., Rabbany, J. M., Gutierrez, P. M., Kedem, R., Yehuda, A. B., Mann, J. J., & Yacobi, A. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18020649 · Cited by 9
“Thus, suicidal ideation plays a key role in initiating the suicidal sequence [4,11,12].”
Background
Implementation of a Community-Partnered Research Suicide-Risk Management Protocol: Case Study From Community Partners in Care
Goodsmith, N., Zhang, L., Ong, M. K., Ngo, V. K., Miranda, J. M., Hirsch, S., Jones, F., Wells, K. B., & Chung, B. (2021) · Psychiatric Services · doi:10.1176/appi.ps.202000095 · Cited by 8
“For example, while a positive screen for suicidality on the nine-item Patient Health Questionnaire (PHQ-9) predicts increased relative risk of attempted suicide, absolute risk remains low (14,15).”
Background
Predictors of suicidal ideation among Iranian patients with multiple sclerosis
Asgarian, F. S., Keyhani, A., Moghadasi, A. N., Sahraian, M. A., & Etesam, F. (2021) · Current Journal of Neurology · doi:10.18502/cjn.v19i4.5541 · Cited by 8
Relationship Health and Intimate Partner Violence in Integrated Primary Care: Individual Characteristics and Preferences for Relationship Support across Risk Levels
Crasta, D., Crane, C., Trabold, N., Shepardson, R. L., Possemato, K., & Funderburk, J. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192113984 · Cited by 6
“90) and was used to assess depression (cutoff of ≥10) and recent thoughts of suicide or self-harm (using any positive scores on the ninth item [36]).”
Method
Status loss due to COVID-19, traditional masculinity, and the prediction of suicidal ideation and recent suicide attemptsPreprint
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. (2021) · doi:10.31234/osf.io/h3qy6 · Cited by 8
Suicidal Ideation in Patients With Multiple Sclerosis and Its Association With Clinical and Demographic Characteristics
Bazmi, E., Behnoush, A. H., Eskandarieh, S., Moghadasi, A. N., Navardi, S., Ayoubi, S., Behnoush, B., Forouzesh, M., & Sahraian, M. A. (2025) · Brain and Behavior · doi:10.1002/brb3.70458 · Cited by 7
“The validity of item nine of the PHQ-9 questionnaire has been confirmed as a screening tool to evaluate theriskofsuicidemortalityinadditiontosymptomsofdepression in patients with neurological disorders (Louzon et al. 2016).”
Estimating the per-protocol effect of lithium on suicidality in a randomized trial of individuals with depression or bipolar disorder
Szmulewicz, A., Madenci, A. L., Ferguson, R. E., Liang, M. H., Lew, R., Katz, I. R., & Hernán, M. Á. (2023) · Journal of Psychopharmacology · doi:10.1177/02698811231166460 · Cited by 8
“Second, we modified confounding adjustment by (i) replacing the lagged time-varying covariates by their values measured concurrently with adherence, (ii) replacing change in depression and suicidal ideation scores by the actual scores, (iii) adding intensity of suicidal ideation from the C-SSRS score as a covariate, a…”
MethodSelf-citation
Brief relationship support as a selective suicide prevention intervention: Piloting the Relationship Checkup in veteran couples with relationship and mental health concerns
Crasta, D. J., Funderburk, J. S., Gray, T. D., Córdova, J. V., & Britton, P. C. (2023) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.12983 · Cited by 11
Burnout, moral injury, and suicidal/self-harm ideation among healthcare professionals in Mainland China: Insights from an online survey during the COVID-19 pandemic
Liu, G., Tong, Y., Li, J., Sun, X.-Y., Chen, L., Zheng, X.-W., Zhang, X.-H., Lv, J., Wang, J., Wei, B., et al. (2023) · International Journal of Psychiatry in Medicine · doi:10.1177/00912174231219041 · Cited by 7
A Systematic Review of Suicide Risk in Veterans: Depression is a More Powerful Predictor than Comorbid Psychiatric Disorders
Athey, A. J., & Overholser, J. C. (2018) · Military Behavioral Health · doi:10.1080/21635781.2018.1442757 · Cited by 7
“The confidence intervals of depressive and anxiety disorders overlapped in 3 multivariable models of suicide (Ilgen et al., 2010a; Ilgen et al., 2010b; Louzon et al., 2016.”
Background
Psychiatric and Interpersonal Correlates of Suicide Ideation in Military Sexual Trauma Survivors: The National Health and Resilience in Veterans Study
Monteith, L. L., Smith, N. B., Holliday, R. P., & Pietrzak, R. H. (2018) · Chronic Stress · doi:10.1177/2470547018815901 · Cited by 8
“Despite the brevity of this method, the PHQ-9 suicidal ideation item is associated with suicide attempt and death by suicide.(46,47)”
Method
Evaluating a Recovery-Oriented Intensive Outpatient Program for Veterans at Risk for Suicide
Roush, J. F., O'Brien, K. M., & Ruha, A. L. (2020) · Crisis · doi:10.1027/0227-5910/a000703 · Cited by 7
Contributions of posttraumatic stress disorder (PTSD) and mild TBI (mTBI) history to suicidality in the INTRuST consortium
Fisher, L. B., Bomyea, J. A., Thomas, G. A., Cheung, J. C., He, F., Jain, S., Flashman, L. A., Andaluz, N. O., Coimbra, R. S. M., George, M. S., et al. (2020) · Brain Injury · doi:10.1080/02699052.2020.1807054 · Cited by 7
The acceptability and feasibility of screening, brief intervention, and referral to treatment for pain management among new England veterans with chronic pain: A pilot study
Sellinger, J. J., Martino, S., Lazar, C. M., Mattocks, K. M., Rando, K., Serowik, K. L., Ablondi, K. M., Fenton, B. T., Gilstad‐Hayden, K., Brummett, B. R., et al. (2021) · Pain Practice · doi:10.1111/papr.13023 · Cited by 7
“This is comparable to the rate of positive screens among Veterans treated at VHA facilities.(46) None of these participants required more intensive mental health care following a brief set of follow- up questions.”
Result
Past Levels of Mental Health Intervention and Current Nondisclosure of Suicide Risk Among Men Older Than Age 50
Podlogar, M. C., Gutierrez, P. M., & Joiner, T. E. (2021) · Assessment · doi:10.1177/10731911211023577 · Cited by 7
“Given that suicide risk is not explicitly disclosed before the majority of suicide deaths (Busch et al., 2003; Louzon et al., 2016; G. E. Simon et al., 2013), reliance on selfreport of suicide risk is undeniably a barrier to the effective screening, assessment, management, and prevention of suicide.”
Background
Psychometric Properties of the Self-Injurious Thoughts and Behaviors Interview–Short Form Among U.S. Active Duty Military Service Members and Veterans
Stanley, I. H., Marx, B. P., Fina, B. A., Young‐McCaughan, S., Tyler, H. C., Sloan, D. M., Blankenship, A. E., Dondanville, K. A., Walker, J. L., Boffa, J. W., et al. (2023) · Assessment · doi:10.1177/10731911221143979 · Cited by 7
“, “Thoughts that you would be better off dead or of hurting yourself in some way”) as a single-item indicator of suicide risk (Louzon et al., 2016; Simon et al., 2013).”
Suicidal Ideation Amid COVID-19 Pandemic: A Cross-sectional Study Among Healthcare Workers During the First Wave of COVID-19 in Pakistan
Salman, M., Mallhi, T. H., Khan, Y. H., Mustafa, Z. U., Shehzadi, N., Khan, T. M., & Hussain, K. (2022) · Disaster Medicine and Public Health Preparedness · doi:10.1017/dmp.2022.124 · Cited by 7
The Clinical Utility of PHQ-9 Item 9 for Suicide Prediction
McCusker, P. J. (2016) · Psychiatric Services · doi:10.1176/appi.ps.670904 · Cited by 7
Preliminary Effectiveness of a Therapist-Supported Digital Mental Health Intervention in Reducing Suicidal Ideation
Nelson, B. W., Forman‐Hoffman, V. L., & Peiper, N. C. (2023) · Archives of Suicide Research · doi:10.1080/13811118.2023.2262540 · Cited by 6
“Although the 9th item of the PHQ-9 has been shown to be a robust predictor of suicidal behavior in study populations (Louzon et al., 2016; McCusker, 2016; Rossom et al., 2017; Simon et al., 2016; Yarborough et al., 2021), some research indicates that this item may not be a sufficient screen for SI…”
Predicting suicide attempts among US Army soldiers using information available at the time of periodic health assessments
Naifeh, J. A., Edwards, E. R., Bentley, K. H., Gildea, S. M., Kennedy, C. J., King, A. J., Kleiman, E. M., Luedtke, A. R., Nassif, T. H., Nock, M. K., et al. (2025) · Nature Mental Health · doi:10.1038/s44220-024-00360-9 · Cited by 6
“For example, Louzon and colleagues 9 , in a study of 391,492 US Veterans Health Administration patients who completed the PHQ-9, found that although suicide risk over the next 6 months increased monotonically with increases in responses to item 9, the 87.8% of patients who denied SI accounted for…”
Influential
“They’ll Talk About Everything Else… But Suicidal Ideation”: Clinician Experiences Addressing Non-Disclosure of Suicidal Ideation Among Military-Affiliated Clients
Litschi, M. A., Lancaster, S. L., Linkh, D. J., & Lafferty, M. (2025) · Journal of General Internal Medicine · doi:10.1007/s11606-025-09570-y · Cited by 6
Drop-in suicide prevention group decreases suicidal ideation among Veterans
Simons, G. J., Drewniak, T. A., Jahn, A. L., Gillen, M. J., Larsen, S. E., & Kangas, G. M. (2018) · Military Psychology · doi:10.1080/08995605.2018.1524254 · Cited by 6
Heterogeneous association patterns of depressive subfactors in suicidality: The 2014 and 2016 Korea National Health and Nutrition Examination Surveys
Lee, Y. J., Kim, H. C., Lee, E. M., & Jung, S. J. (2020) · Journal of Affective Disorders · doi:10.1016/j.jad.2020.04.062 · Cited by 7
An 18-month longitudinal study of suicidality in patients diagnosed with schizophrenia
Buchanan, A. W., Sint, K., Stefanovics, E. A., & Rosenheck, R. A. (2020) · Schizophrenia Research · doi:10.1016/j.schres.2020.09.019 · Cited by 7
Improving suicide surveillance systems through the use of the Patient Health Questionnaire-9.
de la Torre, J. A., Ronaldson, A., Vilagut, G., Serrano‐Blanco, A., Molina, A. J., Martín, V., Valderas, J. M., Dutta, R., Dregan, A., & Alonso, J. (2021) · Journal of Affective Disorders · doi:10.1016/j.jad.2021.06.008 · Cited by 7
Associations between sleep complaints, suicidal ideation and depressive symptoms among adolescents and young adults in Greece
Basta, M., Skourti, E., Simos, P. G., Soumaki, E., Li, Y., Gerostergios, G., Samiotakis, G., Dafermos, V., Drakaki, M., Papadakis, N., et al. (2023) · Journal of Sleep Research · doi:10.1111/jsr.13900 · Cited by 6
Predicting risk of suicidal behavior from insurance claims data vs. linked data from insurance claims and electronic health records
Simon, G. E., Shortreed, S. M., Johnson, E., Yaseen, Z. S., Stone, M. B., Mosholder, A. D., Ahmedani, B. K., Coleman, K. J., Coley, R. Y., Penfold, R. B., et al. (2023) · Pharmacoepidemiology and Drug Safety · doi:10.1002/pds.5734 · Cited by 5
“But these results do demonstrate that high-dimensional prediction scores can account for baseline risk of suicidal behavior much more accurately than self-report measures alone 31,34 or predictions based on a small number of risk factors derived from records.”
Result
A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk
Boggs, J. M., Quintana, L. M., Beck, A. L., Clarke, C. L., Richardson, L. A., Conley, A., Buckingham, E. T., Richards, J. A., & Betz, M. E. (2024) · Prevention Science · doi:10.1007/s11121-024-01641-6 · Cited by 7
“Ideally, patients at risk would receive lethal means safety counseling from providers; however, many patients who die or attempt suicide did not previously endorse ideation (Louzon et al., 2016)—precluding them from receiving counseling.”
Social Ties and Suicidal Ideation Among Veterans Referred to a Primary Care–Mental Health Integration Program
Mavandadi, S., Ingram, E. P., Klaus, J. R., & Oslin, D. W. (2019) · Psychiatric Services · doi:10.1176/appi.ps.201800451 · Cited by 6
A machine learning approach to identification of self-harm and suicidal ideation among military and police Veterans
Colic, S., He, J. C., Richardson, J. D., Cyr, K. S., Reilly, J. P., & Hasey, G. (2021) · Journal of Military Veteran and Family Health · doi:10.3138/jmvfh-2021-0035 · Cited by 6
DSM‐5‐TR diagnosis as a guide to suicide risk assessment
Felthous, A. R., Kulkarni, N., & Belean, C. (2023) · Behavioral Sciences & the Law · doi:10.1002/bsl.2617 · Cited by 6
What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports
Schulte, C. E., Sextl-Plötz, T., Baumeister, H., Titzler, I., Sander, L., Sachser, C., Steubl, L., & Zarski, A. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100710 · Cited by 5
“Existing evidence indicates an association between scores on this item and the likelihood of suicide (Louzon et al., 2016; Simon et al., 2013).”
Background
The narrative crisis model of suicide as a framework for suicide prevention
Rogers, M. L., Bloch‐Elkouby, S., Goncearenco, I., Cohen, L. J., Nemeroff, C. B., & GALYNKER, I. I. (2024) · Personalized Medicine in Psychiatry · doi:10.1016/j.pmip.2024.100130 · Cited by 7

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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