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

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. Leading Causes of Death United States, 2003. AGE.

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

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  1. 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

  2. Leading Causes of DeathUnited States, 2003 AGE Source: National Center for Health Statistics

  3. 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

  4. U.S. Suicides by Age – Rates & Numbers, 2003 Source: National Center for Health Statistics

  5. Suicide Rates by Age, Race, and Gender United States, 2003 Source: National Center for Health Statistics Note: Non-Hispanic Ethnicity

  6. 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

  7. Social factors and social integration of individuals exert a powerful influence over suicidal behavior…broad social forces account for the variation in suicide rates. Suicide1897 EmileDurkheim

  8. Institute of Medicine Report - 2002 “A society’s 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.

  9. Socio-Ecological Model Community Individual Society Relationship

  10. Suicide Risk: Socio-Ecological Model Mental IllnessPhysical illness/painSubstance AbuseHx of attemptIdeation, plans, intent Community Individual Society Relationship

  11. Ecological Model Mental IllnessPhysical illness/painSubstance AbuseHx of attemptIdeation, plans, intent Community Individual Society Relationship Hx of abuseLoss events—shame, humiliation, despairSocial isolationLegal/disciplinary problems

  12. Ecological Model High unemploymentLocal drug tradeLow cohesivenessSparse treatment resources Mental IllnessPhysical illness/painSubstance AbuseHx of attemptIdeation, plans, intent Community Individual Society Relationship Hx of abuseLoss events—shame, humiliation, despairSocial isolationLegal/disciplinary problems

  13. Ecological Model High unemploymentLocal drug tradeLow cohesivenessSparse treatment resources Mental IllnessPhysical illness/painSubstance AbuseHx of attemptIdeation, plans, intent Community Individual Society Relationship Hx of abuseLoss events—shame, humiliation, despairSocial isolationLegal/disciplinary problems Social instabilityHigh firearm accessibilityStigmaMental health financing policy

  14. “Programs that address risk and protective factors at multiple levels are likely to be most effective.”* *Institute of Medicine Report--2002

  15. High-risk Approach Mortality threshold Identify and treat high-risk Population Low High Suicide risk

  16. High-risk Approach Mortality threshold Identify and treat high-risk Population Low High Suicide risk

  17. Rose’s 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

  18. Population-based Approach Mortality threshold Move population risk Population Low High Suicide risk

  19. Interventions to Consider • Building public awareness, political will, community readiness • Developing community capacity for suicide prevention • Coalition building • Developing community protectors—gatekeeper training • Clergy • Mentors/peer support • Barbers……bartenders….funeral directors…attorneys…human resource managers… • Life skills development • Financial management • Job training • Anger management • Cultural norms/social marketing • Psycho-education • Social support

  20. Interventions to Consider • Means restriction • Media practices • Surveillance and research • Crisis Center/lines • Clinical services • Education/training • AAS/SPRC Workshop—Assessing 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

  21. “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.

  22. Active-Duty Military English speaking Healthcare—full parity Educated Mentally able Good mental health Housed Physically able Employed Strong military community Combat Vets English speaking Healthcare—VA Educated TBI (diagnosed or not) Depression/PTSD Homeless? Disabled? Unemploy-ed/-able Civilian community; cannot understand flashbacks, hyper-vigilance, etc Military/Vets Are:

  23. 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

  24. 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

  25. What can you do for them?Is mental health treatment effective?

  26. 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.

  27. 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.

  28. 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

  29. 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).

  30. 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

  31. 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

  32. 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

  33. 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

  34. Clinical Pearls • Assess suicidality for all patients with any signs of distress early in the clinical interview • Ask directly • Don’t 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/library/safe_t_pcktcrd_edc.pdf

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

  36. Intervention

  37. Community Individual Peer/Family Society “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.

  38. Results Knox, K, et al., Risk of Suicide and related adverse outcomes after exposure to a suicide programme in the US Air Force:cohort study. British Medical Journal, December 13, 2003.

  39. 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

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

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