Suicide Prevention in the Department of Veterans Affairs

1. Suicide Prevention in the Department of Veterans Affairs Juli McNeil, LCSW Stephen Clark, LCSW Suicide Prevention Program Jack C. Montgomery VA Medical Center and Clinics

2. Objectives Initiation of Program Local Staff National and Local Program Overview Suicide Facts and Statistics Suicide Risk and Protective Factors Safety Planning Aggregate Review What to do to help someone VA Programs and Services

3. Initiation of Program 2007 Joshua Omvig Veterans Suicide Prevention Act The Joshua Omvig Suicide Prevention Act (H.R. 327) is designed to help address: • Post Traumatic Stress Disorder (PTSD) among veterans by requiring mental health training for Veterans Affairs staff; • Suicide Prevention Coordinator (SPC) at each VA medical facility; • MH screening and treatment for veterans receiving VA care • Supports outreach and education for veterans and their families • Peer support counseling • Research into suicide prevention

4. Suicide Prevention Program Staff Juli McNeil, LCSW, 918-577-3087/3699/4144 Program Manager-Suicide Prevention Stephen J. Clark, LCSW, 918-628-2659 Tulsa Suicide Prevention Coordinator

5. Suicide Prevention Program Staff Alexa Youngblood, LCSW, 918-577-3672/3699/4144 Suicide Prevention Case Manager Wendy Vogt, 918-577-4111/3699 Suicide Prevention/ IOP Administrative Assistant

6. Suicide Prevention Program • Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention Coordinators began in FY2007 with full implementation in FY08 • A 24/7 Suicide Prevention Hotline. • 330,241 callers have called the hotline • 200,531 of those callers have identified themselves as Veterans or family members/friends of Veterans • Over 11,329 rescues of actively suicidal Veterans • Online Chat Service • Initiated in July 2009 • Over 9335 chatters; 3761 mentioned suicide • VISN 16 Total Calls YTD 2010 –9742 (2nd highest) • VISN 22: 12365 (1st highest)

7. Suicide Prevention Program • Development of two centers devoted to research, education, and clinical practice in the area of suicide prevention • Center of Excellence in Canandaigua, NY • Develops and tests clinical and public health intervention strategies for suicide prevention • MIRECC in Denver, CO • Focuses on clinical conditions and neurobiological underpinnings that can lead to increased risk as well as the implementation of interventions aimed at decreasing negative outcomes and training future leaders in the areas of VA Suicide Prevention.

8. Program Outreach VA Participation in Suicide Prevention Awareness Month Sponsoring public service announcements, web sites and display ads designed to inform Veterans and their families of the VA Suicide Prevention Hotline (1-800-273-TALK/8255) VA has been distributing Suicide Prevention materials Suicide Prevention Coordinators are required to do outreach activities in all of their local communities Family psycho-educational materials

9. Local Suicide Prevention Program • Tracking High Risk Patients • Ensuring they receive adequate care/case management • Responding to Hotline Referrals • Local Crisis Calls • Mail Program • Support to MH providers • Aggregate Reviews • Environment of Care Rounds on Inpatient and ER • Training VA Staff • Operation SAVE Training for non clinicians • Operation SAVE for all new employees • LMS Training for Clinicians • Completion of Suicide Behavior Reports (SBRs) • Suicide Risk Assessments • Safety Planning • High Risk for Suicide • On new research and treatment regarding suicide/suicidal patients

10. Local Suicide Prevention Program • Community Outreach • Providing VA Guide training (Operation SAVE) • Providing information about VA care and services • Promoting Veteran and community suicide awareness • Closely working with OEF/OIF VA Staff • Assisting the VA and community agencies in the dissemination of new information about suicide and specific intervention strategies • Providing local providers and staff with the appropriate resources

11. Important Facts about Suicide • 32,000 US deaths from suicide/ year • Centers for Disease Control and Prevention • 91 people die from suicide every day/every 16 minutes • Suicide is the 11th leading cause of death in the US • Suicide is the 2nd leading cause of death among 25-34 year olds • Suicide is the 3rd leading cause of death among 15-24 year olds • Highest suicide rate is among 65 and older. Older white males are at highest risk. • 4 times as many men kill themselves compared to women, yet 3 times as many women attempt suicide as compared to men. • Oklahoma is 10th in the Nation.

12. Facts about Veteran Suicide • 30,000-32,000 US deaths from suicide/ year • Centers for Disease Control and Prevention • About 20% are Veterans National Violent Death Reporting System • About 18 deaths from suicide per day are Veterans • National Violent Death Reporting System • About 5 deaths from suicide per day among Veterans receiving care in VHA – VA Serious Mental Illness Treatment, Research and Evaluation Center • Veterans are more likely to use firearms as a means for suicide -National Violent Death Reporting System • About 950 attempts/month among Veterans receiving care in VHA as reported by VA Suicide Prevention Program Staff • About 33% of recent Veteran suicides have a history of previous attempts- VA National Suicide Prevention Staff reports • Preliminary data since 2006 show decreased suicide rates in Veterans aged 18-29 who use VA health care relative to Veterans in the same age group who do not. This decrease in rates translates to about 250 lives per year. – National Violent Death Reporting System and VA Serious Mental Illness Treatment, Resource and Evaluation Center.

13. General Risk Factors • Thoughts about harming self that include plan & method • Previous suicide attempts • Alcohol or substance abuse • History of mental illness • Poor self-control • Hopelessness • Recent loss (e.g., loved one, job, relationship) • Family history of suicide • History of abuse • Serious health problems • Sexual identity concerns: especially among men 16-24 • Recent discharge from hospital, group home etc. • Recent diagnosis of an illness • Demographic factors: White men over 70 years of age are at increased risk • Burdensomeness, Isolation • Chronic Pain , PTSD, TBI

14. Veteran Specific Risks • Multiple deployments • Length of deployments • Deployments to hostile environments • Exposure to extreme stress/death/combat • Physical/sexual assault while in the service (not limited to women) • Service related injuries (TBI, PTSD, other medical and mental health diagnoses) • Familiarity with weapons

15. Protective Factors • Positive social support • History of adaptive coping skills • Participating in treatment • Veteran acknowledges hopefulness • Religious beliefs that act as a barrier • Life satisfaction (e.g., rating 1 to 10) • Fear of suicide or death • Family or friends that act as barrier to self-harm (Rudd, 2006)

16. Warning Signs Give Added Consideration to Warning Signs: • Prior suicide attempts/behavior • Agitatation, Anxiety • Hopelessness and Burdensomeness • Trapped in physical/psychological pain • Talking or writing about death • Withdrawing and isolating • Seeking means to kill themselves • Acting reckless or engaging in risky activities without regard for safety or death

17. SAFETY PLANNING STEP 1: Warning Signs STEP 2: Internal Coping Strategies STEP 3: Social Contacts Who May Distract from the Crisis STEP 4: Family or Friends Who May Offer Help STEP 5: Professionals and Agencies to Contact for Help STEP 6: Making the Environment Safe

18. Aggregate Reviews 10/1/2008 to 6/30/2009 • 116 suicide attempts/behaviors (20 events, 18 uniques reviewed for report) • 51/116 were “male other” • FOCUS OF REVIEW--20/51 OD on meds, meds & other substances (alc, illegal drugs) • 13/20 suicide attempts/behavior via gun • Majority treated for pain, mood disorder and substance abuse • 11 with a previous attempt/behavior ACTIONS • Increase use in detailed suicide risk assessment • Increase in use of safety plan • Detailed treatment planning

19. Aggregate Reviews 10/1/2008 to 6/30/2009 • 1 suicide; 2 accidental overdoses (ODs) ACTION • Same actions as with attempts/behaviors plus • Revamp Pain Management Board • Establish a Pain Clinic

20. Aggregate Reviews • 7/1/2009 to 3/31/2010 • 175 attempts/behaviors • FOCUS-32 events, 29 uniques (Veterans that OD and had one or more previous attempts/behaviors) • 98/175 “male other” • 59/175 method OD • 54/175 method Guns • Veterans in focus had mood disorder, substance abuse and chronic pain. ACTIONS • Limit number of dispensed meds at one time • Drug screens/Appropriate drug screens • Increase in Case Conferences • Review/update/change policy regarding screens

21. Suicide is Preventable Become a partner in Suicide Prevention Ask Directly about Suicide • Suicidal ideation • Suicide plans • Access to Means • Suicidal ideation and behavior is often a “process” and habituation occurs to thoughts of death and the act of self –harm. • Talking about suicide does not cause a person to be suicidal. Asking shows compassion, reduces isolation and stigma.

22. VA Programs and Services • OEF/OIF COMBAT CARE STAFF • MH (PTSD, Substance Abuse, Military Sexual Trauma, Mental Health Intensive Case Mgmt, Homeless, etc.) • TBI/Polytrauma, SCI • Pain Education Group • Spiritual Support • Veteran Readjustment Counseling Centers