Use of ICD-9-CM Diagnosis Code V62.89 (Other Psychological or Physical Stress, Not Elsewhere Classified) Following a Suicide Attempt

This cross-sectional, cohort study focused on services provided to veterans at Veterans Health Administration (VHA) medical centers in relation to the ICD-9-CM diagnostic code V62.89— “other psychological or physical stress, not elsewhere classified”—in the month following a suicide attempt. This period is recognized as one of increased risk of reattempts and death by suicide (1). V62.89 covers four chief complaints: borderline intellectual functioning, life circumstance problems, phase-of-life problems, and religious or spiritual problems (2). Diagnostic V codes are used to document symptoms, classify patient-clinician encounters, describe patient status, or identify circumstances or problems that may influence a person’s health (2).

The issue of suicidal behavior among veterans has garnered considerable empirical attention in the past decade. The VHA is the largest integrated health care system in the country. Within the VHA, patients recognized as being at increased risk of suicide are afforded an “enhanced care package” that includes increased follow-up, care monitoring and tracking, and enhanced access to services and availability of treatment (3). In addition, the VHA has implemented a systemwide suicide event reporting system, known as the Suicide Prevention Applications Network (SPAN) (4). The SPAN database includes individual case reports of patients with a history of suicidal behavior (completed suicide, suicide attempts, and serious suicide ideation resulting in preventive action) known to VHA clinical providers and suicide prevention coordinators.

Despite these extensive systemic efforts and research demonstrating the increased incidence of mental disorders among veterans with suicidal behavior (5), little is known about how to support survivors of suicide attempts who may be dealing with other psychological or physical stressors, such as those reflected in V62.89. According to fluid vulnerability theory (FVT), suicide risk is conceptualized as a function of baseline and acute risk factors (6). Among the complaints associated with V62.89, all have been found to be associated in some way with suicidal behavior (7–10) and could be indicative of baseline risk factors (for example, historical and static variables, biological predispositions, and core schemas) (6). According to FVT, the presence of multiple baseline risk factors or few protective factors suggests a degree of vulnerability for suicidal behavior. Consequently, identifying ways to address the complaints associated with V62.89 could potentially serve to mitigate these baseline risk factors, decreasing an individual’s vulnerability.

Moreover, a limited number of clinically focused studies exist to inform the effective integration of clinical services into suicide prevention efforts (3). The delivery of appropriate clinical services is an important part of suicide prevention efforts, especially as related to preventing suicide reattempts among survivors (11). The pairing of SPAN reports with clinical data in a VHA administrative database provides an opportunity to better characterize service use by veterans recognized as being at increased risk of suicide.

Methods

SPAN was used to identify a cohort of veterans with a case report of a nonfatal suicide attempt that occurred between April 1, 2010, and September 30, 2012. Case reports that were not able to be linked to clinical diagnostic data in the VHA’s National Patient Care Database (NPCD) were excluded from the analysis. The analysis was based on the first nonfatal suicide attempt reported in SPAN during the referenced time period.

The NPCD was used to capture patient demographic information (age, sex, and race) and data on health care service use by using inpatient and outpatient encounter records that document any diagnosis codes related to a given service. These records allowed us to identify patients who received services related to V62.89 in the 30 days following a suicide attempt, use of V62.89 as well as other psychiatric diagnostic categories in the encounter record, how many days after the attempt that services were provided, patients who received services in the year preceding their attempt, the clinical setting in which services were provided, and the type of service provider.

This study considered only the first record of a service encounter related to V62.89 for patients who received services on more than one occasion after their attempt. For patients who were found to have received services related to V62.89 in the year preceding their attempt, only the encounter record closest to the attempt was considered.

To better understand the context in which V62.89 was used, this study also examined psychiatric diagnoses in the service encounter record. When documenting a service encounter, providers enter a single primary diagnosis as well as one or more secondary diagnoses into the encounter record. These identify the diagnosis code or codes in relation to which a given service was provided. For this analysis, we examined any mental disorder, substance use disorder, major depression, alcohol use disorder, other substance use disorder, depression, and personality disorder. The specific ICD-9-CM diagnosis codes used for each of these diagnostic categories are available on request from the corresponding author.

Institutional review board approval was granted by the Research and Development Committee at the U.S. Department of Veterans Affairs (VA) Medical Center in Syracuse, New York. Data collection was conducted within the VA Informatics and Computing Infrastructure. Statistical analysis was conducted with SAS Enterprise Guide, version 6.1.

Results

The SPAN database included 22,701 suicide attempt case reports that met inclusion criteria for this study. After linking with the NPCD, 2,173 (10%) veterans were found to have received clinical services related to V62.89 following their suicide attempt. Of this group, 649 (30%) had also received clinical services related to V62.89 in the year preceding their attempt. Chaplains were the most frequent service providers for encounters with V62.89 (N=1,745, 80%), followed by social workers (N=179, 8%). No clear or coherent pattern could be found to describe the remaining types of service providers.

Table 1 presents the primary and secondary diagnoses entered at the time of a V62.89-related service encounter with a chaplain and with other service providers. Chi square tests of independence were performed to identify any differences in the use of V62.89 as well as select categories of psychiatric diagnoses on the encounter record. V62.89 was listed as a primary diagnosis significantly more often in service encounters with chaplains than in encounters with other providers (χ²=598.25, df=1, p<.001). For primary diagnoses, other service providers more often listed any mental disorder (χ²=431.95, df=1, p<.001), a substance use disorder (χ²=50.44, df=1, p<.001), or major depression (χ²=78.08, df=1, p<.001). For secondary diagnoses, other service providers more often listed any mental disorder (χ²=492.53, df=1, p<.001), a substance use disorder (χ²=166.26, df=1, p<.001), major depression (χ²=115.48, df=1, p<.001), an alcohol use disorder (χ²=138.38, df=1, p<.001), another substance use disorder (χ²=73.89, df=1, p<.001), depression (χ²=191.83, df=1, p<.001), or a personality disorder (χ²=40.82, df=1, p<.001).

Table 1 also presents the characteristics of those who received V62.89-related services from chaplains and from other service providers. Compared with users who received services from other providers, a larger proportion of chaplaincy service users had their first V62.89-related service encounter in an inpatient setting (χ²=389.06, df=1, p<.001) and within a week of their index attempt (χ²=90.24, df=4, p<.001), as well as prior service use related to V62.89 (χ²=6.62, df=1, p=.01). Veterans whose first V62.89-related service encounter after a suicide attempt was with a chaplain rather than with another provider were also found to be significantly older, with the largest proportion age 45 to 54 years (χ²=22.93, df=6, p<.001), and a larger proportion were black or African American (χ²=16.87, df=3, p<.001). No significant differences were noted for sex.

Discussion and Conclusions

This cross-sectional cohort study found that approximately 10% of veterans with a nonfatal suicide attempt recorded in SPAN received clinical services related to V62.89 in the 30 days following their attempt. Chaplains were identified as the predominant service provider for this group. Differences were noted between those who did and did not receive services from a chaplain.

A noteworthy finding of this study is the involvement of chaplains in supporting veterans affected by other psychological or physical stress, not elsewhere classified. At-risk veterans, including those with a history of a suicide attempt, are thought to account for approximately 10% of VHA chaplaincy service users (12). Research suggests that veterans at increased risk of suicide look to chaplains for psychosocial support, not just for spiritual and pastoral care (13). To our knowledge, ours is the first report of a specific clinical diagnostic code being associated with chaplaincy services provided to veterans following a suicide attempt.

As a form of spiritual and pastoral care, chaplaincy services are thought to constitute a complementary and alternative medicine (CAM) modality (14). This is of particular interest because the use of CAM modalities immediately following a suicide attempt has not been previously described in the literature. When services related to V62.89 were first provided by a chaplain, this study found that such services were usually provided within one week of the suicide attempt and most often in inpatient settings. Additional work is needed to better understand the different CAM modalities being used by attempt survivors and how such services can potentially be applied to enhance suicide “postvention” efforts.

Compared with other service providers, the overwhelming majority of chaplaincy encounters related to V62.89 had this code listed as the primary diagnosis. This might suggest that chaplaincy services, as opposed to services from other providers, are chiefly used to support those dealing with this diagnostic code. The acting assumption is that chaplains were the referral target for cases identified with V62.89 by a VA clinical service provider. An alternative explanation could be that V62.89 is the diagnosis code frequently used in the context of chaplaincy services. No published data, however, exist to suggest whether this may be the case. To the best of our knowledge, coding practices and procedures among chaplains have never been the subject of empirical inquiry. In VA settings, during the referenced time period, chaplains were not bound by any expectations or regulations related to how their service encounters were coded or documented.

Future research should consider examining how chaplaincy services differ from other supportive options in addressing cases identified with V62.89, including examining any differences in clinical outcomes. In light of these findings, it would also be prudent to consider the overall involvement of chaplains in supporting veteran populations at increased risk of suicide. This could include, for example, examining the prevalence of chaplaincy consultations provided to veteran suicide attempt survivors, irrespective of the associated diagnosis. This could further illuminate the extent to which V62.89 represents a “diagnostic code of convenience” as opposed to a bona fide target area for chaplaincy services. An additional avenue for future research could include examining how and which clinicians initially identify individuals who may be dealing with complaints indicative of V62.89. The capacity to use the ICD-9-CM diagnosis code V62.89 for a patient or client—and subsequently refer the individual to supportive services—is not limited to any specific group of clinical service providers.

Limitations of this analysis include that no ICD-9-CM modifiers are available to precisely state which of the complaints associated with V62.89 applied to a given patient at the time services were provided. Nevertheless, the inclusion of “religious or spiritual problems” as part of this diagnosis is especially noteworthy. Although religion and spirituality issues are generally recognized as being important to understanding suicidal behavior, they have been largely overlooked in the literature (15). Future research examining use of diagnosis code V62.89 should apply chart review methodology to better understand the distribution of these four complaints.

The findings of this study should be interpreted in the context of several additional limitations. Encounter records do not identify the health care professional who, with due license and clinical authority, made the initial determination of V62.89. Records document only that a given service was provided in relation to the indicated diagnosis code or codes. The sample population was limited to veterans enrolled in VHA health care services. The findings should not, therefore, be generalized to the wider veteran population. Also, SPAN is limited only to suicide events known to VHA clinical providers that were subsequently entered into the database. It does not necessarily represent a comprehensive record of all veterans receiving care within the VHA health care system with a history of a suicide event.

Notwithstanding these limitations, this study found that a sizable percentage of veterans received services related to V62.89 in the month after a suicide attempt. This is an important finding as it highlights the need for assessing and addressing other sources of psychological or physical stress that, in addition to any underlying mental disorder, may be adding to the mental and general medical health burden experienced by survivors of a suicide attempt. In the presence of such stressors, health care providers should ensure that veterans have access to appropriate supportive services.