Original research| Volume 101, ISSUE 7, P1138-1143, July 2020

Risk Factors for Suicide in a National Sample of Veterans With Multiple Sclerosis

Published:April 20, 2020DOI:



      To examine risk factors in the year before suicide in a national sample of United States veterans with multiple sclerosis (MS), as well as means of suicide and receipt of mental health services prior to death.


      Case control study. Individuals in the Veterans Affairs MS National Data Repository were linked to the National Death Index Plus to obtain death records, including specific causes of death. Participants were veterans with MS who died by suicide and randomly selected nonsuicide MS controls (5 per participant) who were alive at the time of the index suicide. Mental health disorders and medical comorbidities were identified in the year before death for suicides and during the identical time period for controls.


      Veterans Health Administration.


      Veterans (N=426) who received treatment for MS in the United States Veterans Health Administration between 1999 and 2011. There were 71 deaths by suicide and 355 randomly selected controls.


      Not applicable.

      Main Outcome Measure



      Results from the adjusted multivariable model suggest that the following factors were associated with an increased risk for suicide: male sex (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.35-9.42), depression (OR, 1.82; 95% CI, 1.03-3.23), and alcohol use disorder (OR, 3.10; 95% CI, 1.38-6.96). Half (50.7%) had a mental health appointment in the year before suicide. The primary means of suicide was by firearm (62.0%).


      Routine assessment of suicide risk in individuals with MS is warranted, particularly for those with recent history of depression or alcohol use disorder.


      List of abbreviations:

      CI (confidence interval), ICD-9 (International Classification of Diseases, Ninth Revision), MS (multiple sclerosis), OR (odds ratio), PTSD (posttraumatic stress disorder), VHA (Veterans Health Administration), VA (Veterans Affairs)
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        • Ragonese P.
        • Aridon P.
        • Salemi G.
        • D'Amelio M.
        • Savettieri G.
        Mortality in multiple sclerosis: a review.
        Eur J Neurol. 2008; 15: 123-127
        • Feinstein A.
        An examination of suicidal intent in patients with multiple sclerosis.
        Neurology. 2002; 59: 674-678
        • Turner A.P.
        • Williams R.M.
        • Bowen J.D.
        • Kivlahan D.R.
        • Haselkorn J.K.
        Suicidal ideation in multiple sclerosis.
        Arch Phys Med Rehabil. 2006; 87: 1073-1078
        • Kalson-Ray S.
        • Edan G.
        • Leray E.
        • Group S.S.
        An excessive risk of suicide may no longer be a reality for multiple sclerosis patients.
        Mult Scler. 2017; 23: 864-871
        • Brenner P.
        • Burkill S.
        • Jokinen J.
        • Hillert J.
        • Bahmanyar S.
        • Montgomery S.
        Multiple sclerosis and risk of attempted and completed suicide - a cohort study.
        Eur J Neurol. 2016; 23: 1329-1336
        • Feinstein A.
        • Pavisian B.
        Multiple sclerosis and suicide.
        Mult Scler. 2017; 23: 923-927
        • Manouchehrinia A.
        • Tanasescu R.
        • Tench C.R.
        • Constantinescu C.S.
        Mortality in multiple sclerosis: meta-analysis of standardised mortality ratios.
        J Neurol Neurosurg Psychiatry. 2016; 87: 324-331
        • McCarthy J.F.
        • Valenstein M.
        • Kim H.M.
        • Ilgen M.
        • Zivin K.
        • Blow F.C.
        Suicide mortality among patients receiving care in the veterans health administration health system.
        Am J Epidemiol. 2009; 169: 1033-1038
        • Capkun G.
        • Dahlke F.
        • Lahoz R.
        • et al.
        Mortality and comorbidities in patients with multiple sclerosis compared with a population without multiple sclerosis: an observational study using the US Department of Defense administrative claims database.
        Mult Scler Relat Disord. 2015; 4: 546-554
        • Gaskill A.
        • Foley F.W.
        • Kolzet J.
        • Picone M.A.
        Suicidal thinking in multiple sclerosis.
        Disabil Rehabil. 2011; 33: 1528-1536
        • Viner R.
        • Patten S.B.
        • Berzins S.
        • Bulloch A.G.
        • Fiest K.M.
        Prevalence and risk factors for suicidal ideation in a multiple sclerosis population.
        J Psychosom Res. 2014; 76: 312-316
        • Fredrikson S.
        • Cheng Q.
        • Jiang G.X.
        • Wasserman D.
        Elevated suicide risk among patients with multiple sclerosis in Sweden.
        Neuroepidemiology. 2003; 22: 146-152
        • Stenager E.N.
        • Stenager E.
        • Koch-Henriksen N.
        • et al.
        Suicide and multiple sclerosis: an epidemiological investigation.
        J Neurol Neurosurg Psychiatry. 1992; 55: 542-545
        • Stenager E.N.
        • Koch-Henriksen N.
        • Stenager E.
        Risk factors for suicide in multiple sclerosis.
        Psychother Psychosom. 1996; 65: 86-90
        • Allgulander C.
        Psychiatric aspects of suicidal behavior: anxiety disorders.
        in: Hawton K. Van Heerigen K. The international handbook of suicide and attempted suicide. John Wiley & Sons, Hoboken2000: 179-192
        • Lonnquist J.K.
        Psychiatric aspects of suicidal behavior: depression.
        in: Hawton K. van Heeringen K. The international handbook of suicide and attempted suicide. John Wiley & Sons, Hoboken2000: 107-120
        • Murphy G.E.
        Psychiatric aspects of suicidal behavior: substance abuse.
        in: Hawton K. Van Heeringen K. The international handbook of suicide and attempted suicide. John Wiley & Sons, Hoboken2000: 135-146
        • Ilgen M.A.
        • Conner K.R.
        • Roeder K.M.
        • Blow F.C.
        • Austin K.
        • Valenstein M.
        Patterns of treatment utilization before suicide among male veterans with substance use disorders.
        Am J Public Health. 2012; 102: S88-S92
        • Magruder K.M.
        • Yeager D.
        • Brawman-Mintzer O.
        The role of pain, functioning, and mental health in suicidality among Veterans Affairs primary care patients.
        Am J Public Health. 2012; 102: S118-S124
        • McCarthy J.F.
        • Blow F.C.
        • Ignacio R.V.
        • Ilgen M.A.
        • Austin K.L.
        • Valenstein M.
        Suicide among patients in the Veterans Affairs health system: rural-urban differences in rates, risks, and methods.
        Am J Public Health. 2012; 102: S111-S117
        • Turner A.P.
        • Alschuler K.N.
        • Hughes A.J.
        • et al.
        Mental health comorbidity in MS: depression, anxiety, and bipolar disorder.
        Curr Neurol Neurosci Rep. 2016; 16: 106
        • Williams R.M.
        • Turner A.P.
        • Hatzakis Jr., M.
        • Bowen J.D.
        • Rodriquez A.A.
        • Haselkorn J.K.
        Prevalence and correlates of depression among veterans with multiple sclerosis.
        Neurology. 2005; 64: 75-80
        • Chalfant A.M.
        • Bryant R.A.
        • Fulcher G.
        Posttraumatic stress disorder following diagnosis of multiple sclerosis.
        J Trauma Stress. 2004; 17: 423-428
        • Ostacoli L.
        • Carletto S.
        • Borghi M.
        • et al.
        Prevalence and significant determinants of post-traumatic stress disorder in a large sample of patients with multiple sclerosis.
        J Clin Psychol Med Settings. 2013; 20: 240-246
        • Turner A.P.
        • Hawkins E.J.
        • Haselkorn J.K.
        • Kivlahan D.R.
        Alcohol misuse and multiple sclerosis.
        Arch Phys Med Rehabil. 2009; 90: 842-848
        • Cho J.
        • Lee W.J.
        • Moon K.T.
        • et al.
        Medical care utilization during 1 year prior to death in suicides motivated by physical illnesses.
        J Prev Med Public Health. 2013; 46: 147-154
        • Luoma J.B.
        • Martin C.E.
        • Pearson J.L.
        Contact with mental health and primary care providers before suicide: a review of the evidence.
        Am J Psychiatry. 2002; 159: 909-916
        • Niederkrotenthaler T.
        • Logan J.E.
        • Karch D.L.
        • Crosby A.
        Characteristics of U.S. suicide decedents in 2005-2010 who had received mental health treatment.
        Psychiatr Serv. 2014; 65: 387-390
        • Culpepper 2nd, W.J.
        • Ehrmantraut M.
        • Wallin M.T.
        • Flannery K.
        • Bradham D.D.
        Veterans Health Administration multiple sclerosis surveillance registry: The problem of case-finding from administrative databases.
        J Rehabil Res Dev. 2006; 43: 17-24
      1. Joint Department of Veterans Affairs (VA) and Department of Defense (DoD) Suicide Data Repository - National Death Index (NDI).
        (Available at:) (Accessed May 11, 2020)
        • Brenner L.A.
        • Ignacio R.V.
        • Blow F.C.
        Suicide and traumatic brain injury among individuals seeking Veterans Health Administration services.
        J Head Trauma Rehabil. 2011; 26: 257-264
      2. VA Office of Health Equity. National Veteran Health Equity Report—FY2013.
        US Department of Veterans Affairs, Washington, DC2016 (Available at: Accessed May 11, 2020)
        • Turner A.P.
        • Chapko M.K.
        • Yanez D.
        • et al.
        Access to multiple sclerosis specialty care.
        PM R. 2013; 5: 1044-1050
        • Deyo R.A.
        • Cherkin D.C.
        • Ciol M.A.
        Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases.
        J Clin Epidemiol. 1992; 45: 613-619
        • Marrie R.A.
        • Fisk J.D.
        • Tremlett H.
        • et al.
        Differences in the burden of psychiatric comorbidity in MS vs the general population.
        Neurology. 2015; 85: 1972-1979
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        J Clin Epidemiol. 2008; 61: 344-349
        • Lyons B.H.
        • Fowler K.A.
        • Jack S.P.
        • Betz C.J.
        • Blair J.M.
        Surveillance for Violent Deaths - National Violent Death Reporting System, 17 States, 2013.
        MMWR Surveill Summ. 2016; 65: 1-42
        • Bronnum-Hansen H.
        • Stenager E.
        • Nylev Stenager E.
        • Koch-Henriksen N.
        Suicide among Danes with multiple sclerosis.
        J Neurol Neurosurg Psychiatry. 2005; 76: 1457-1459
        • Sadovnick A.D.
        • Eisen K.
        • Ebers G.C.
        • Paty D.W.
        Cause of death in patients attending multiple sclerosis clinics.
        Neurology. 1991; 41: 1193-1196
        • Sumelahti M.L.
        • Hakama M.
        • Elovaara I.
        • Pukkala E.
        Causes of death among patients with multiple sclerosis.
        Mult Scler. 2010; 16: 1437-1442