Journal Article Annotations
2025, 2nd Quarter

Emergency Psychiatry

Annotations by Clayton Barnes Martinez, MD
July, 2025

Character of Discharge From the US Military and Suicide Mortality.
Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use.

PUBLICATION #1 — Emergency Psychiatry

Character of Discharge From the US Military and Suicide Mortality.

Mark A Reger, Chandru Ravindran, Sybil W Morley, Andrew Devendorf, Kristen J Vescera, Brady M Stephens.

Abstract: JAMA Netw Open. 2025 May 1;8(5):e2512081. doi: 10.1001/jamanetworkopen.2025.12081.

Importance:
Suicide risk may be elevated among individuals who separate from military service with a character of discharge or service that was not honorable (ie, dishonorable, bad conduct, other than honorable, general, or uncharacterized), but a comprehensive evaluation of this possibility has not been previously published.

Objective:
To examine suicide mortality by character of discharge compared with individuals who received an honorable discharge and the full veteran population recently separated from service.

Design, setting, and participants: This retrospective cohort study included all individuals who separated from the active component of the US military between January 1, 2002, and December 31, 2021. Data were obtained from the US Department of Veterans Affairs/Department of Defense Mortality Data Repository. Suicide rates for each character of discharge were compared with those among individuals receiving an honorable discharge and the full veteran population recently separated from service. Analyses were conducted between December 21, 2023, and June 1, 2024.

Exposure:
Character of discharge assigned at separation from the active component of military service.

Main outcomes and measures: Crude suicide rates up to 5 years after separation were examined. Age-standardized rate ratios were used for comparisons within the cohort between strata. Age-standardized mortality ratios (SMRs) were used to compare suicide mortality by character of discharge with the full separation cohort and within specific military service branches.

Results:
Among 3 627 653 individuals (mean [SD] age at separation, 28.4 [8.6] years; 83% men), 5599 deaths by suicide occurred during the study period. All character of discharge groups had significantly higher suicide rates than the honorable group, with standardized rate ratios ranging from 1.91 (95% CI, 1.69-2.17) for uncharacterized to 2.77 (95% CI, 2.52-3.05) for general. Veterans who received an honorable discharge were less likely to die by suicide than the overall cohort population (SMR, 0.82 [95% CI, 0.79-0.85]), while veterans with all other characters of discharge were more likely to die by suicide, with SMRs ranging from 1.23 (95% CI, 1.15-1.31) for uncharacterized to 1.84 (95% CI, 1.72-1.97) for general. Common demographic risk factors for suicide (eg, age, race) were replicated within character groups in most cases.

Conclusions and relevance:
In this cohort study, individuals who did not receive an honorable character of discharge were at significantly higher risk of suicide compared with veterans who received an honorable discharge and the veteran population recently separated from service. These findings suggest that character of discharge may be a helpful risk factor to consider for ongoing suicide prevention efforts.

Annotation

The finding:
While military service is often considered to be a risk factor for suicide, this retrospective cohort study refines that understanding by stratifying risk as it relates to military discharge type. In general, veteran benefits are withheld (or limited) for those receiving a less-than-honorable discharge, making the transition to civilian life substantially more difficult. This study confirms that those with less favorable military discharges are at substantially higher risk of subsequent suicide completion.

Strength and weaknesses:
The study included over 3 million subjects and 5,599 deaths by suicide, facilitating appropriate power to provide meaningful results. The follow up period lasted only five years and excluded reservists, so the study only ventures to describe risk among those with a recent, active-duty military separation. Interestingly, the authors point out that “the character of discharge an individual receives is an indication of documented behavior and may not reflect actual behavior conducted during their service”, alluding to an interesting question of causation: does the behavior resulting in less-than-honorable discharge later coalesce to suicidal behavior, or does the discharge determination itself – regardless of a service member’s true behavior – contribute to risk?

Relevance:
This study reminds the civilian psychiatrist that a military history is of practical importance in a comprehensive risk assessment, and that the type of military discharge may be suggestive of protective or risk factors. As discussed in the study, individuals with an other than honorable or punitive discharge are also more likely to be single, have less social support, and have a history of incarceration. Additionally, less-than-honorable discharges may be caused by behaviors representative of a personality or substance use disorder and indicative of a longstanding, entrenched pattern of behaviors. Thus, this single demographic detail may unveil a host of risk factors for the astute clinician.

PUBLICATION #2 — Emergency Psychiatry

Impact of Emergency Department Safety Planning on 30-Day Mental Health Service Use.

Sara Wiesel Cullen, Mark Olfson, Ming Xie, Steven C Marcus.

Abstract: Psychiatr Serv. 2024 Jun 1;75(6):528-533. doi: 10.1176/appi.ps.20230187. Epub 2024 Mar 27.

Objective:
The aim of this study was to examine the association between emergency department (ED) safety planning and subsequent use of mental health care among individuals treated in the ED for suicidal behavior and to determine whether subsequent use differed by patients’ receipt of recent mental health care.

Methods:
Data from 130 hospitals, derived from a 2017-2018 national hospital survey, were paired with national health insurance data from 2,328 patients with suicidal behavior treated in the EDs of these hospitals. Rates of ED readmission, inpatient admission, and outpatient mental health follow-up care in the 30 days after discharge from the index ED visit were examined.

Results:
During the 30 days after discharge from the index visit, readmissions to the ED (18% vs. 22%) and inpatient admissions (12% vs. 15%) for suicidal behavior or other mental health issues were significantly lower among patients treated in the EDs that routinely implemented safety planning, compared with those that did not, respectively. Among patients who had not received mental health care within 30 days before the index visit, those treated in an ED implementing routine safety planning were about half as likely (adjusted risk ratio=0.60) as those treated in an ED without such planning to have an ED readmission.

Conclusions:
Safety planning was associated with fewer subsequent ED and inpatient admissions among patients treated in the ED for suicidal behavior. The authors recommend that safety planning be universally implemented in EDs and included in routine outpatient care.

Annotation

The finding:
Patients treated at emergency departments that routinely implemented safety planning during visits for suicidal behavior had significantly fewer psychiatric readmissions within 30 days. ED readmission rates were reduced from 22% to 18%, and inpatient psychiatric hospitalization rates declined from 15% to 12%. For patients without recent outpatient mental health care, the benefits were even more striking, with a 40% lower risk of ED readmission. These findings suggest that safety planning has a meaningful protective effect following suicidal crises.

Strength and weaknesses:
The observational design and reliance on teaching institutions limits the generalizability of the results. Further, the study did not examine specific safety planning sub-components, which would be an important subject for future study. Finally, data was self-reported by ED nurse managers, who likely have a vested interest in believing their staff are above average performers.

Relevance:
Routine safety planning is a low-cost, high-impact intervention in emergency psychiatric care, and is particularly valuable for populations lacking regular access to mental health treatment. These study results have direct implications for ED policies, procedures, and resource allocation, supporting broader implementation of standardized safety planning protocols as part of a comprehensive suicide prevention strategy.