Suicide Prevention: What Providers Should Know about Returning Veterans and Military Personnel

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Suicide Prevention What Providers Should Know
about Returning Veterans and Military Personnel

• David Litts, O.D.
• Director, Policy and Prevention Practice
• Suicide Prevention Resource Center
• June 24, 2008

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Leading Causes of DeathUnited States, 2003
AGE
Source National Center for Health Statistics
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Years of Potential Life Lost Before Age 65 Years
by Cause of DeathUnited States, 2003
Unintentional injury adverse effects
Malignant neoplasm
Heart disease
Perinatal
Suicide
Homicide
Congenital anomalies
HIV
Cerebrovascular disease
Liver disease
Source National Center for Health Statistics
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U.S. Suicides by Age Rates Numbers, 2003
Source National Center for Health Statistics
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Suicide Rates by Age, Race, and Gender United
States, 2003
Source National Center for Health Statistics
Note Non-Hispanic Ethnicity
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Age-adjusted suicide rates among all persons by
state -- United States, 2003
Rates per 100,000 population 0.0 to 9.1 9.2 to
11 11.1 to 13.4 13.5 to 21.1
Source National Center for Health Statistics
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• Social factors and social integration of
  individuals exert a powerful influence over
  suicidal behaviorbroad social forces account for
  the variation in suicide rates. Suicide 1897

Emile Durkheim
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Institute of Medicine Report - 2002
A societys perception of suicide and its
cultural traditions can influence the suicide
rate. (p 204) Completed suicide occurs more
often in those who are socially isolated and lack
supportive family and friendships. ( p 200)
with one study suggesting that perceived
social support may account for about half of the
variance in suicide potential in youth. (p 200)
Source Goldsmith, SK, et al., Reducing Suicide
a national imperative. 2002.
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Socio-Ecological Model
Community
Individual
Society
Relationship
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Suicide Risk Socio-Ecological Model
Mental IllnessPhysical illness/painSubstance
AbuseHx of attemptIdeation, plans, intent
Community
Individual
Society
Relationship
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Ecological Model
Mental IllnessPhysical illness/painSubstance
AbuseHx of attemptIdeation, plans, intent
Community
Individual
Society
Relationship
Hx of abuseLoss eventsshame, humiliation,
despairSocial isolationLegal/disciplinary
problems
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Ecological Model
Mental IllnessPhysical illness/painSubstance
AbuseHx of attemptIdeation, plans, intent
High unemploymentLocal drug tradeLow
cohesivenessSparse treatment resources
Community
Individual
Society
Relationship
Hx of abuseLoss eventsshame, humiliation,
despairSocial isolationLegal/disciplinary
problems
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Ecological Model
Mental IllnessPhysical illness/painSubstance
AbuseHx of attemptIdeation, plans, intent
High unemploymentLocal drug tradeLow
cohesivenessSparse treatment resources
Community
Individual
Society
Relationship
Hx of abuseLoss eventsshame, humiliation,
despairSocial isolationLegal/disciplinary
problems
Social instabilityHigh firearm
accessibilityStigmaMental health financing
policy
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Programs that address risk and protective
factors at multiple levels are likely to be most
effective.
Institute of Medicine Report--2002
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High-risk Approach
Mortality threshold
Identify and treat high-risk
Population
Low High Suicide risk
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High-risk Approach
Mortality threshold
Identify and treat high-risk
Population
Low High Suicide risk
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Roses Theorem

• A large number of people at small risk may give
  rise to more cases of a disease than a small
  number who are at high risk.

Rose, G., The Strategy of Preventive Medicine.
1991 Oxford, Oxford University Press
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Population-based Approach
Mortality threshold
Move population risk
Population
Low High Suicide risk
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Interventions to Consider

• Building public awareness, political will,
  community readiness
• Developing community capacity for suicide
  prevention
• Coalition building
• Developing community protectorsgatekeeper
  training
• Clergy
• Mentors/peer support
• Barbersbartenders.funeral directorsattorneysh
  uman resource managers
• Life skills development
• Financial management
• Job training
• Anger management
• Cultural norms/social marketing
• Psycho-education
• Social support

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Interventions to Consider

• Means restriction
• Media practices
• Surveillance and research
• Crisis Center/lines
• Clinical services
• Education/training
• AAS/SPRC WorkshopAssessing and Managing Suicide
  Risk
• Linkages between social services and health care
• Access to effective treatments
• Geography
• Financing
• Workforce
• Wrap-around services for survivors of a medically
  serious suicide attempt

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Problems are complex and go beyond the capacity,
resources, or jurisdiction for any single person,
program, organization, or sector to change or
control.
Lasker R., Weiss E., Broadening Participation in
Community Problem Solving A Muiltidisciplinary
Model to SupportCollaborative Practice and
Research. Journal of Urban Health Bulletin of
the New York Academy of Medicine. Vol 80,No 1.
March 2003. p.5.
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Military/Vets Are

• Active-Duty Military
• English speaking
• Healthcarefull parity
• Educated
• Mentally able
• Good mental health
• Housed
• Physically able
• Employed
• Strong military community

• Combat Vets
• English speaking
• HealthcareVA
• Educated
• TBI (diagnosed or not)
• Depression/PTSD
• Homeless?
• Disabled?
• Unemploy-ed/-able
• Civilian community cannot understand flashbacks,
  hyper-vigilance, etc

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Vets Risk and Protective Factors
MaleFamiliar with firearmsStigmaFear of losing
clearanceDepressionRelationship break
upPTSDTraumatic Brain InjuryAlcohol
abuse/dependence
Family/unit cohesionResiliency Self
esteemProblem-solving skillsAccess to health
care
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Suicide Among Vets

• 20 of all suicides in the U.S. are by Vets
• 47 Depressed at time of death one-fourth
  receiving MH Tx
• One-fourth had substance use disorder
• One-fourth had problem with intimate partner
• 40 had physical health problem
• 28 experienced an acute crisis w/i prior 2 weeks

Source National Violent Death Reporting
System/CDC
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What can you do for them?Is mental health
treatment effective?
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Trends in Suicidal Behavior1990-1992 vs
2001-2003National Comorbidity Survey and
Replication

• 9708 respondents, face-to-face survey, aged 18-54
• Queried about past 12 months

Kessler, et al., Trends in Suicide Ideation,
Plans, Gestures, and Attempts in the United
States, 1990-1992 to 2001-2003- JAMA May 25,
2005, Vol 293, No 20.
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Trends in Suicidal Behavior1990-1992 vs
2001-2003National Comorbidity Survey and
Replication
No significant changes
Kessler, et al., Trends in Suicide Ideation,
Plans, Gestures, and Attempts in the United
States, 1990-1992 to 2001-2003- JAMA May 25,
2005, Vol 293, No 20.
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Inpatient Suicide

• Most common sentinel event reported to the Joint
  Commission
• Since 1996 415 (14)
• Method
• 71 Hanging
• 14 Jumping
• Factors in Suicide
• 87 Deficiencies in physical environment
• 83 Inadequate assessment
• 60 Insufficient staff orientation or training

Clinical Setting
Sentinel event reporting began in 1996. Source
Reducing the Risk of Suicide. JCAHO, Joint
Commission Resources, Inc. 2005
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Clinician Education
A recognition is needed that effective
prevention of suicide attempts might require
substantially more intensive treatment than is
currently provided to the majority of people in
outpatient treatment for mental disorders.
Kessler et al., Trends in suicide ideation,
plans, gestures, and attempts in the United
States, 1990-1992 to 2001-2003. JAMA. May 25,
2005. 293(20).
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Clinical Training for Mental Health Professionals

• One day workshop
• Developed by 9-person expert task force
• 24 Core competencies
• Skill demonstration through video of David Jobes,
  Ph.D.
• 110 Page Participant Manual with exhaustive
  bibliography
• 6.5 Hrs CEUs
• 50 Authorized faculty across the U.S.

www.sprc.org/traininginstitute/amsr/clincomp.asp
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Aftercare for Attempters

• 10-20 million suicide attempts each year
  world-wide
• A previous suicide attempt is the strongest risk
  factor for further attempts and for suicide
• 40 of those who die by suicide have made a
  previous attempt

Source Beautrais, Annette, Presentation at
the Annual Conference of the American Association
of Suicidology, 2006
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Aftercare for Attempters

• Risk of repeated suicide attempt is high
• One of the major characteristics of suicide
  attempt behavior.
• 16 (12-22) repetition within one year of an
  attempt.
• 21 (12-30) within 1-4 years.
• 23 (11-32) within 4 or more years. (Owens et
  al 2002)

Source Beautrais, Annette, Presentation at
the Annual Conference of the American Association
of Suicidology, 2006
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Aftercare for Attempters

• Risk of suicide is high
• 1.8 (0.8 - 2.6) within 1 yr of an attempt
• 3.0 (2.0 - 4.4) within 1- 4 years
• 3.4 (2.5 - 6.0) within 5-10 years
• 6.7 (5.0 -11.0) within 9 or more years
  
  
• (Owens et al 2002)

Source Beautrais, Annette, Presentation at
the Annual Conference of the American Association
of Suicidology, 2006
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Clinical Pearls

• Assess suicidality for all patients with any
  signs of distress early in the clinical interview
• Ask directly
• Dont take the first no
• When suicidality is uncovered, assessing acute
  suicide risk becomes the primary focus of the
  interview
• Continue to gather suicide assessment information
  at each subsequent session
• Full suicide assessment at transition points and
  concurrent with life stressors
• Suicide Assessment Five-step Evaluation and
  Treatment (SAFE-T) Card http//www.sprc.org/libra
  ry/safe_t_pcktcrd_edc.pdf

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VA Suicide Prevention Lifeline

• Partnered with the National Suicide Prevention
  Hotline
• 1-800-273-TALK Press 1
• Connects to the VAs 24 hour Suicide Prevention
  Hotline
• Electronic access to VA medical record system

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Intervention
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Addressing risk factors across the various
levels of the ecological model may contribute to
decreases in more than one type of violence.
Violence A global public health problem, World
Health Organization, 2002, p. 15.
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Results
Knox, K, et al., Risk of Suicide and related
adverse outcomes after exposure to a suicide
programme in the US Air Forcecohort study.
British Medical Journal, December 13, 2003.
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Summary

• Complex epidemiology of risk and protective
  factors
• Returning veterans carry many risk factors for
  suicide
• Mental health services are part of a
  comprehensive, public health approach
• Mental health services providers frequently do
  not provide assessment and treatment in the
  intensity required
• Additional training is available in the
  assessment and management of suicidal clients
• Comprehensive, population-based suicide
  prevention programs can be effective

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Suicide Prevention Resource Centerwww.sprc.org1-
877-GET-SPRC