Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans

Denise M Hynes; Meike Niederhausen; Jason I Chen; Troy A Shahoumian; Mazhgan Rowneki; Alex Hickok; Megan Shepherd-Banigan; Eric J Hawkins; Jennifer Naylor; Alan Teo; Diana J Govier; Kristin Berry; Holly McCready; Thomas F Osborne; Edwin Wong; Paul L Hebert; Valerie A Smith; C Barrett Bowling; Edward J Boyko; George N Ioannou; Theodore J Iwashyna; Matthew L Maciejewski; Ann M O'Hare; Elizabeth M Viglianti; Amy S-B Bohnert

doi:10.1007/s11606-023-08440-9

Risk of Suicide-Related Outcomes After SARS-COV-2 Infection: Results from a Nationwide Observational Matched Cohort of US Veterans

J Gen Intern Med. 2024 Mar;39(4):626-635. doi: 10.1007/s11606-023-08440-9. Epub 2023 Oct 26.

Authors

Denise M Hynes^{1

2

3}, Meike Niederhausen^{4

5}, Jason I Chen^{4

6}, Troy A Shahoumian⁷, Mazhgan Rowneki⁴, Alex Hickok⁴, Megan Shepherd-Banigan^{8

9}, Eric J Hawkins^{10

11

12}, Jennifer Naylor^{13

14

15}, Alan Teo^{4

6}, Diana J Govier^{4

5}, Kristin Berry¹⁰, Holly McCready^{4

6}, Thomas F Osborne^{16

17}, Edwin Wong¹⁰, Paul L Hebert¹⁰, Valerie A Smith^{8

9

18}, C Barrett Bowling^{8

18

19}, Edward J Boyko²⁰, George N Ioannou^{10

21}, Theodore J Iwashyna^{22

23}, Matthew L Maciejewski^{8

9}, Ann M O'Hare^{10

24

25}, Elizabeth M Viglianti^{23

26}, Amy S-B Bohnert^{23

27}

Affiliations

¹ Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA. Denise.Hynes@va.gov.
² College of Health, and Center for Quantitative Life Sciences, Oregon State University, Corvallis, OR, USA. Denise.Hynes@va.gov.
³ School of Nursing, Oregon Health & Science University (OHSU), Portland, OR, USA. Denise.Hynes@va.gov.
⁴ Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System (HCS), Portland, OR, USA.
⁵ OHSU-Portland State University School of Public Health, OHSU, Portland, OR, USA.
⁶ Department of Psychiatry, OHSU, Portland, OR, USA.
⁷ VHA, Patient Care Services: Health Solutions, Washington, DC, USA.
⁸ Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA HCS, Durham, NC, USA.
⁹ Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.
¹⁰ Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound HCS, Seattle, WA, USA.
¹¹ Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound HCS, Seattle, WA, USA.
¹² Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
¹³ School of Medicine, Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.
¹⁴ Education and Clinical Center, VISN 6 Mental Illness Research, Durham, NC, USA.
¹⁵ Durham VA HCS, Durham, NC, USA.
¹⁶ VA Palo Alto HCS, Palo Alto, CA, USA.
¹⁷ Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
¹⁸ Department of Medicine, Duke University, Durham, NC, USA.
¹⁹ Durham VA Geriatric Research Education and Clinical Center, Durham VA HCS, Durham, NC, USA.
²⁰ Seattle Epidemiologic Research Information Center, VA Puget Sound HCS, Seattle, WA, USA.
²¹ Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, WA, USA.
²² Departments of Medicine and Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA.
²³ Center for Clinical Management Research, VA Ann Arbor HCS, Ann Arbor, MI, USA.
²⁴ Hospital and Specialty Medicine Service, VA Puget Sound HCS, Seattle, WA, USA.
²⁵ University of Washington, Seattle, WA, USA.
²⁶ Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
²⁷ Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI, USA.

PMID: 37884839
PMCID: PMC10973286 (available on 2025-03-01)
DOI: 10.1007/s11606-023-08440-9

Abstract

Background: Negative mental health-related effects of SARS-COV-2 infection are increasingly evident. However, the impact on suicide-related outcomes is poorly understood, especially among populations at elevated risk.

Objective: To determine risk of suicide attempts and other self-directed violence (SDV) after SARS-COV-2 infection in a high-risk population.

Design: We employed an observational design supported by comprehensive electronic health records from the Veterans Health Administration (VHA) to examine the association of SARS-COV-2 infection with suicide attempts and other SDV within one year of infection. Veterans with SARS-COV-2 infections were matched 1:5 with non-infected comparators each month. Three periods after index were evaluated: days 1-30, days 31-365, and days 1-365.

Participants: VHA patients infected with SARS-COV-2 between March 1, 2020 and March 31, 2021 and matched non-infected Veteran comparators.

Main measures: Suicide attempt and other SDV events for the COVID-19 and non-infected comparator groups were analyzed using incidence rates per 100,000 person years and hazard ratios from Cox regressions modeling time from matched index date to first event. Subgroups were also examined.

Key results: 198,938 veterans with SARS-COV-2 (COVID-19 group) and 992,036 comparators were included. Unadjusted one-year incidence per 100,000 for suicide attempt and other SDV was higher among the COVID-19 group: 355 vs 250 and 327 vs 235, respectively. The COVID-19 group had higher risk than comparators for suicide attempts: days 1-30 hazard ratio (HR) = 2.54 (CI:2.05, 3.15), days 31-365 HR = 1.30 (CI:1.19, 1.43) and days 1-365 HR = 1.41 (CI:1.30, 1.54), and for other SDV: days 1-30 HR = 1.94 (CI:1.51, 2.49), days 31-365 HR = 1.32 (CI:1.20, 1.45) and days 1-365 HR = 1.38 (CI:1.26, 1.51).

Conclusions: COVID-19 patients had higher risks of both suicide attempts and other forms of SDV compared to uninfected comparators, which persisted for at least one year after infection. Results support suicide risk screening of those infected with SARS-COV-2 to identify opportunities to prevent self-harm.

Keywords: COVID-19; mental health; self-directed violence; suicide attempt; veterans.

MeSH terms

COVID-19*
Electronic Health Records
Humans
SARS-CoV-2
Suicide, Attempted
Veterans*

Abstract

MeSH terms

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