National Suicide Prevention Efforts for Veterans: The Role of the VISN 2 Center of Excellence for Mental Health and

1. National Suicide Prevention Efforts for Veterans: The Role of the VISN 2 Center of Excellence for Mental Health and PTSD at Canandaigua Kerry L. Knox Ph.D. Director VISN 2 Center of Excellence at Canandaigua Associate Professor, University of Rochester Jan Kemp, Ph.D. Associate Director Education and Training VISN 2 Center of Excellence at Canandaigua

2. VISN 2 Center of Excellence for Mental Health and PTSD at Canandaigua Meet the Faculty and Staff

3. VISN 2 CoE by Design The VISN 2 CoE was officially announced August 2007 There are currently 47 projects in process. 41 people involved in projects at present. Responsibilities: We are a National Resource to VA Central Office on establishing new initiatives and guidelines for suicide prevention for veterans We are a partner in many projects in VISN 2�and We live at the Canandaigua VAMC and collaborate closely with the Department of Psychiatry at the University of Rochester, and all CoE have faculty appointments in the Department

4. VISN 2 CoE by Design

5. Epidemiology and Health Services Research Core: Key Research Questions What is the impact of broadly based, universal suicide prevention efforts on rates of attempted suicide, suicide, depression, PTSD, and other relevant outcomes at a population level? Is access to care at a population level improved through novel suicide interventions and strategies? Are there new, emergent veteran populations at risk for suicidal behaviors? What is the epidemiology of veterans outside of VA�s walls?

6. Clinical Interventions Research Core: Key Research Questions Are treatment strategies that target behavioral change in selected and indicated populations effective for veteran populations? What are the most effective means of disseminating new knowledge to the field concerning evidence based/best practices of behavioral interventions? Does the application of CAMS or MI increase the probability of reducing suicidal events following intervention with a behavioral intervention (such as CBT) through improving client compliance?

7. Education and Training Core: Key Programmatic Activities Education and Training Core Ongoing education and training of clinical staff for VA�s 24 hour Suicide Crisis Line Ongoing education and training of VA�s network of Suicide Prevention Coordinators Development of Training Manuals for Enhancing Clinical Management of Suicidal Veterans Dissemination of new knowledge to the field concerning effectiveness of behavioral interventions; provide support in terms of training as needed to the field

8. Epidemiology and Health Services Research Core: Current and Developing Studies Knox KL, Kemp J. Epidemiology of Callers to VA�s 24 hour Mental Health/Suicide Crisis Line Knox KL, Kemp J. Outcomes and Referral Patterns of Callers to VA�s 24 hour Mental Health/Suicide Crisis Line Lavigne J, Crilly J, Homifer B, Kemp J, Knox KL. Effectiveness of VA�s 24 hour Mental Health/Suicide Crisis Line Crilly J, Lavigne J, Homifer B, Kemp J, Caine ED, Knox KL. Treatment trajectories of VA service connected veterans versus non VA service connected veterans who call VA�s 24 hour Mental Health/Suicide Crisis Line

9. Epidemiology and Health Services Research Core: Current or Developing Studies Lavigne J, Berndt E., Saweikas M, Knox KL Post-launch pharmacosurveillance for suicide for smoking cessation and anti-seizure drugs (in collaboration with Fran Cunningham and Marcia Valenstein) Lavigne J, Knox KL. Handgun use and other risky behaviors in veterans during life transitions Conner K, Ilgen M. Development of a uniform suicide related assessment form for VA�s Suicide Prevention Coordinators VonBergen H, Kemp J, King D, Knox KL. Operation S.A.V.E.: Evaluation of suicide prevention guide training for front-line VA staff and communities (Veteran�s Service Organizations and non VA organizations such as NYS OMH, chaplains, social services)

10. Epidemiology and Health Services Research Core: Current or Developing Studies Knox KL, Kemp J., Lavigne J., Crilly J. Validity and reliability of the suicide behavior reporting template by Suicide Prevention Coordinators across all VA networks Knox KL, Chauncey L, Chitaphong K. Identification of veterans outside the walls of VA: Who and where are they?

11. Clinical Interventions Research Core: Current or Developing Studies Pigeon W, Matteson S, Pratt M, Chauncey L. Knox KL. Cognitive behavioral treatment for insomnia in Vietnam veterans Pigeon W, Matteson S, Pratt M, Chauncey L. Knox KL. Cognitive behavioral treatment for insomnia in returning OEF/OIF veterans Conner K, Britton P, Currier G. Proximate risk factors for suicide in veterans with substance use disorders VonBergen H, Kemp J, Knox KL, Caine ED. Implementation of CAMS following training clinical staff in VISN 7. VonBergen H, Kemp J, Knox KL, Caine ED. Implementation of MI following training clinical staff in VISN 2.

12. Clinical Interventions Research Core: Current or Developing Studies Conner K, Britton P, Currier G. Use of motivational interviewing (MI) in treatment of suicidal veterans with SUDs Conwell Y, Richardson T, King D, Duberstein P. Pilot study of identifying elder veterans seeking care through a community ED for a mental health problem or suicidal behaviors

13. Clinical Interventions Research Core: Current or Developing Studies Conner K, Britton P, Currier G. Use of motivational interviewing (MI) in treatment of suicidal veterans with SUDs Conwell Y, Richardson T, King D, Duberstein P. Pilot study of identifying elder veterans seeking care through a community ED for a mental health problem or suicidal behaviors

14. Education and Training Core: Current or Developing Programs Ongoing education and support for VA�s network of Suicide Prevention Coordinators Ongoing education and support for VA�s 24 hour Mental Health/Suicide Crisis Line Dissemination of training for Operation S.A.V.E. Dissemination of training for CAMS and Motivational Interviewing as a demonstration project in VISN 2 and VISN 7

15. Ongoing VA National Initiatives VA�s 24 hour Mental Health/Suicide Crisis Line VA�s Network of Suicide Prevention Coordinators Patient Record Flag Provide information and guidance for VA National Policy

16. Scientific Consensus Conference Development Core Knox KL, Kemp J., Currier G, Conner K, Conwell Y, Caine ED. Developing guidelines for suicide assessment instruments across VA sites and populations: March 5-6th 2008 Currier G, Knox K, Kemp J, Conner K,Caine ED.: Evidence based/best practices for treatment of suicidal individuals (Early Fall 2008) Currier G, Knox K, Kemp J, Conner K,Caine ED.: Evidence based/best practices for treatment of high risk, non suicidal individuals (Late Fall 2008) VonBergen H, Knox K, Chitaphong, Kemp J, King D, Caine ED. Collaborations with community organizations and institutions to identify OEF/OIF veterans not accessing mental health care in the VA (Winter 2009)

17. Specific Activities related to VA�s Initiatives Suicide Prevention requires ready access to high quality Mental Health Services, supplemented by programs that address the risk of suicide directly

18. Enhancing Access to High Quality Care Implementation of the MH Strategic plan with support of the Mental Health Initiative Enhancing mental health services at community based clinics through integrated care models Increased MH coverage in Emergency Departments Facilitating transition to VA for returning veterans Accelerating access for new patients through new initiatives Expansion of recovery/rehabilitation services as keys to hope for patients with serious mental illness Disseminating evidence-based psychotherapies

19. Structure:Specific Activities for Suicide Prevention Centers of Excellence National programs for education and awareness 24 / 7 Hotline Suicide Prevention Coordinators in each medical center

20. Suicide Prevention Coordinators Each VA Medical Center has or is in the process of hiring a Suicide Prevention Coordinator (SPC) Overall responsibility is to support the identification of high-risk patients and to coordinate ongoing monitoring and enhancements in care. Other responsibilities: Promote awareness and community outreach Training � both for provider and Guides �Flagging� patients at high risk Tracking and monitoring high risk patients and their care Participation in patient safety and environmental analysis to develop local suicide prevention strategies

21. Processes: Hubs of expertise in suicide prevention Provide technical expertise to the field Develop training and educational materials and programs for a wide range of providers, staff and community partners Conduct research and quickly disseminate findings to the field for implementation VISN 19 MIRECC: Clinical approaches VISN 2 COE: Public Health approaches

22. Processes:Education and Awareness Collaboration with Employee Education Service for conferences for clinicians, Satellite broadcast programs and web-based education programs Designation of VA National Suicide Prevention Awareness Day VA Guide Training � a program developed to educate all VA staff as well as those in the community who have contact with veterans about risks of suicide, warning signs, and facilitating care. Clinical training programs General clinical training in development Emergency room providers April 24th Suicide Risk Assessment Pocket Cards and Reference Guide CBT demonstration projects

24. Processes:Education and Awareness con�t.

25. Processes:Focus on Patient Safety Environmental scans in closed inpatient units Enhanced staff coverage in residential care facilities

26. Processes:Screening and Triage Patient screening for MH conditions is being followed by evaluation of suicide risk in those who screen positive Pending requirement for evaluation of new patients within 24 hours of a referral/request for MH services, including evaluation of danger to self or others

27. Processes:Tracking and Monitoring Development of a template to guide the identification of patients with suicide behaviors, and to ensure monitoring and follow-up Development of a national patient alert system so that all providers are aware and are cued to address high-risk patients� needs. Monitoring suicide rates to identify national, regional, and local risk factors as well as trends

28. Processes:Facilitating evidence-based treatments Cognitive Based Therapy Planning for dissemination of pharmacological strategies Other site specific projects including Interpersonal Therapy Dialectical Behavioral Therapy Collaborative Assessment and Management of Suicidality Motivational Interviewing

29. Processes:Veteran Suicide Hotline In conjunction with the national suicide prevention hotline number 1-800-273-TALK. VA option will direct Veterans to a VA professional who will immediately address their crisis situation. Hand-off to local Suicide Prevention Coordinators for follow-up and assurance that these veterans in crisis receive on-going care Use of hotline calls to engage veterans in MH care, trigger intensifying care allow program-solving about difficulties in care