Suicide Prevention in the Veteran Population

1. Suicide Prevention in the Veteran Population Laura Watlington, LCSW Suicide Prevention Program Manager Central Arkansas Veterans Healthcare System

2. A little housekeeping before we start: • Suicide is an intense topic for some people. • If you need to take a break, or step out, please do so, with one condition… • Let me know if you are okay, by giving me a “thumbs up.” • If you aren’t okay, give me a discreet “thumbs down” so I can follow up with you. • Resources • National Suicide Prevention Lifeline: 800 273 8255 • Veterans Crisis Line: Press 1

3. Overview • Objectives • Who are Veterans? • About the Department of Veterans Affairs • Facts and myths about suicide • S.A.V.E intervention • Safety Planning • VA and Community Resources

4. Objectives By participating in this training you will: • Have a general understanding of the scope of suicide within the United States • Know how to identify Veteran-specific risks for suicide • Know how to fully assess level of risk for suicide • Understand how to engage clients in the safety planning process • Be knowledgeable of VA and community resources for Suicide Prevention

5. Military Service Branches • Army • Navy • Marine Corp • Air Force • Coast Guard

6. Status • Active Duty • Reserve • National Guard

7. Who are Veterans? • Federal definition: • Any person who served honorably on active duty in the armed forces of the United States

8. Department of Veterans Affairs • What is the Department of Veterans Affairs? • Veterans Health Administration • Veterans Benefits Administration • National Cemetery Administration • How do Veterans know if they are eligible for healthcare through VA? • http://www.va.gov/healthbenefits/apply/veterans.asp • Other VA benefits • http://benefits.va.gov/benefits/ • http://www.cem.va.gov/

9. Suicide in the United States • More than 42,000deaths from suicide per year among the general U.S. population.1,2 • Suicide is the 10th leading cause of death in the U.S.3 • 17,250 U.S. deaths from homicide per year • Less than 1/2 the number of annual suicides

10. Suicide in the United States • It is estimated that close to one million peoplemake a suicide attempt each year, • One attempt every 35 seconds • Gender disparities: Womenattempt suicide3 times more often than men.1 Mendie by suicide 4 times more often than women.1

11. Cultural Diversity and Suicide Risk Gender disparities • Women attempt suicide 3 times more often than men • Men die by suicide almost 4 times more often than women

12. Cultural Diversity and Suicide Risk Gender disparities • Women attempt suicide 3 times more often than men • Men die by suicide almost 4 times more often than women

13. Diversity and Suicide Risk Are Some Ethnic Groups or Races at Higher Risk? Number of men and women who died by suicide per 100,000 by ethnic/racial categories Note: * Indicates highest rates per category

14. Diversity and Suicide Risk Elder Suicide: • Among depressed Veterans, older (>65) and younger Veterans (18-44) were more likely to die by suicide than middle aged Veterans (45-64). • Veterans who die by suicide were more likely than non-Veterans to: • Be older, Caucasian and educated (>12) • Have more activity limitations at baseline • Have used a firearm at the time of death • Be single, divorced or widowed • Be less likely to be discovered and rescued. • Be less likely to recover from an attempt due to physical frailty. • Older adults are less likely to report suicidal ideation and have well-constructed suicide plans. • At a rate of 36 suicides per 100,000 annually, the greatest risk for suicide in the United States is seen in older (>75 years) Caucasian men.

15. Diversity and Suicide Risk Lesbian, Gay, Bisexual and/or Transgender People Like other minority groups, people who are lesbian, gay, bisexual, and/or transgender (LGBT) may experience prejudice and discrimination. Research indicates that mental health problems, misuse of alcohol and other drugs, and suicidal thoughts and behaviors are more common in this group than in the general population. Risk and Protective Factors Risk factors • Depression and other mental health problems; Alcohol or drug use; Stress from prejudice and discrimination (family rejection, harassment, bullying, violence); Feelings of social isolation Protective factors • Family acceptance; Connections to friends and others who care about them; Sense of safety

16. Facts about Veteran suicide • 18%of all deaths by suicide among U.S. adults were Veterans.4 • Veterans are more likely than the general population to use firearms as a means for suicide.4 • On average, there are 764 suicide attempts per month among Veterans receiving recent VA health care services.5 • 25%of Veterans who died by suicide had a history of previous suicide attempts.5 • 22Veterans a day – based on a study of 3 million Veterans in 20 states released in 2010 • 20 Veteran a day – based on a study of 55+ million Veterans in 50 states from 1979-2014. 6 of the 20 were enrolled in VHA services

17. Myths and Realities about Suicide Myth Reality Myth or reality? Asking about suicide may lead to someone to taking his or her life. Reality: Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. Asking about suicide may lead to someone taking his or her life.

18. Myths and Realities about Suicide Myth Reality Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the Veteran permission to talk about his or her thoughts or feelings.

19. Myths and Realities about Suicide Myth Reality Myth or reality? Asking about suicide may lead to someone to taking his or her life. Reality: Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. There are talkers and there are doers.

20. Myths and Realities about Suicide Myth Reality Most people who die by suicide have communicated some intent. Someone who talks about suicide provides others with an opportunity to intervene before suicidal behaviors occur. Almost everyone who dies by suicide or attempts suicide has given some clue or warning. Suicide threats should never be ignored. No matter how casually or jokingly said, statements like, "You'll be sorry when I'm dead," or "I can't see any way out" may indicate serious suicidal feelings.

21. Myths and Realities about Suicide Myth Reality Myth or reality? Asking about suicide may lead to someone to taking his or her life. Reality: Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. If somebody really wants to die by suicide, there is nothing you can do about it.

22. Myths and Realities about Suicide Myth Reality Most suicidal ideas are associated with treatable disorders. Helping someone connect with treatment can save a life. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and overcome the strong intent to die by suicide, you have gone a long way toward promoting a positive outcome.

23. Myths and Realities about Suicide Myth Reality

24. Myths and Realities about Suicide Myth Reality The intent to die can override any rational thinking. Someone experiencing suicidal ideation or intent must be taken seriously and referred to a clinical provider who can further evaluate their condition and provide treatment as appropriate.

25. S.A.V.E. S.A.V.E. will help you act with care and compassion if you encounter a Veteran who is in suicidal crisis. The acronym “S.A.V.E.” helps one remember the important steps involved in suicide prevention: • Signs of suicidal thinking should be recognized • Ask the most important question of all • Validate the Veteran’s experience • Encourage treatment and Expedite getting help

26. Importance of identifying warning signs • There are behaviors that may indicate/reveal that a Veteran needs help. • Veterans in crisis may show behaviors that indicate a risk of harming or killing themselves.

27. Scenarios • You are meeting with Poppy, a colleague whom you supervise. You have been a bit concerned about Poppy lately. Her usual enthusiastic outlook on life has changed over recent weeks. She is behind with her work and you no longer hear her usual friendly laugh. You tell her she has been looking tired lately and she says she has no energy to get out of bed in the morning. She has lost some weight and does not look as well groomed as she usually is. You become increasingly concerned during the course of the discussion about Poppy’s willingness and ability to keep going. • Leila hasn’t been the same since her mom died. It’s been especially tough because she doesn’t get along with her dad. For months, she’s been saying that if it weren’t for her boyfriend, Dillon, she wouldn’t have anyone who cares about her. But Dillon just broke up with her and Leila is devastated. She talks about needing to end her pain and just last night told you where the key to her diary was in case anyone wants to read it “afterward.”

28. Scenarios 1)What would you say to this person to help him/her? 2) What else would you do or say to help this person?

29. Signs of suicidal thinking Learn to recognize these warning signs: • Hopelessness, feeling like there’s no way out • Anxiety, agitation, sleeplessness or mood swings • Feeling like there is no reason to live • Rage or anger • Engaging in risky activities without thinking • Increasing alcohol or drug abuse • Withdrawing from family and friends

30. Veteran-specific risks • Frequent Deployments to hostile environments (though deployment to combat does not necessarily increase risk). • Exposure to extreme stress • Physical/sexual assault while in the service (not limited to women) • Length of deployments • Service-related injury

31. Asking the question • Know how to ask the most important question of all… “Are you thinking about killing yourself?”

32. Asking the question • Are you thinking of suicide? • Have you had thoughts about taking your own life? • Are you thinking about killing yourself?

33. Asking the question • DO ask the question if you’ve identified warning signs or symptoms • DO ask the question in such a way that is natural and flows with the conversation • DON’Task the question as though you are looking for a “no” answer • “You aren’t thinking of killing yourself are you?” • DON’Twait to ask the question when he/she is halfway out the door

34. How to ask about suicide Suggested Clinician Style: Friendly(compassionate, warm, concerned, supportive, client-centered), Frank (direct, candid, unafraid to ask or talk about risks plainly), and Firm (asking in a confident tone and insisting that this discussion is essential, imperative, and necessary). These help establish therapeutic trust, clear expectations, and relational honesty. • Suicidal Ideation (Normalize): When someone feels as upset as you do , they may have thoughts that life isn’t worth living. What thoughts have you had like this? • Suicidal Planning (Means) If you decided to try to end your life, how would you do it? Tell me about the plans you’ve made. • Access to Means You mentioned that if you were to hurt yourself, you’d probably do it by (describe method). How easy would it be for you to do this?7

35. How to ask about suicide • Protective Factors (Normalize): People often have very mixed feelings about harming themselves. What are some reasons that would stop you or prevent you from trying to hurt yourself? What is it that most holds you back from actually doing this? • Past Experiences What have been your past experiences of making attempts to hurt yourself? What other people do you know who have tried to or have ended their own life? • Future Expectations What are some of this things happening in your life or likely to happen in your life right now that would either make you more or less likely to want to hurt yourself? How do you think people who know you would react if you killed yourself? What would they say, think or feel?7

36. Things to consider when talking with a Veteran at risk for suicide • Remain calm • Listen more than you speak • Maintain eye contact • Act with confidence • Do not argue • Use open body language • Limit questions-let the Veteran do the talking • Use supportive, encouraging comments • Be honest-there are no quick solutions but help is available

37. Validate the Veteran’s experience • Talk openly about suicide. Be willing to listen and allow the Veteran to express his or her feelings. • Recognize that the situation is serious • Do not pass judgment • Reassure that help is available

38. Encourage treatment and Expediting getting help • What should I do if I think someone is suicidal? • Don’t keep the Veteran’s suicidal behavior a secret • Do not leave him or her alone • Try to get the person to seek immediate help from his or her doctor or the nearest hospital emergency room, or • Call 911 • Reassure the Veteran that help is available. • Call the Veterans Crisis Line at 1-800-273-8255, Press 1

39. Suicide Risk Assessments Complete a full Suicide Risk Assessment on all Patients: • A positive depression and/or post-traumatic stress disorder (PTSD) clinical reminder (PHQ2; PHQ9; CSSRS) • A primary complaint of emotional or behavior disturbance • Upon initial contact with Mental Health Service • At times of significant changes in mental status • Prior to discharge from an inpatient mental health admission • Report of suicidal ideations/suicidal behaviors

40. Suicide Risk Assessments A full Suicide Risk Assessment MUST INCLUDE: • Ideation • Risk Factors • Protective Factors • Level of Risk Assigning a level of risk protects the clinician.

41. Suicide Risk Assessments SUICIDE INQUIRY: (Specific questioning about thoughts, plans and intent) • IDEATION:Denies ideation or Admits to ideation (if Admits, then complete the PLAN, INTENT, and ACCESS sections. • PLAN: Yes (describe) • INTENT: Yes (describe) • ACCESS TO FIREARMS OR OTHER MEANS: • Firearms? Y/N • Discussed securing and removing firearms from the home by someone other than self. • Other Means: Y/N • Family involvement in safety/means reduction (describe) • Other strategies to reduce access to means (describe)

42. Suicide Risk Assessments • RISK FACTORS: PAST ATTEMPTS: Y/N ---- How many? SOCIAL/DEMOGRAPHIC FACTORS: • Age [Young adult or Elderly] • Ethnicity [Caucasian] • Sex [Male] • Marital Status [Single/Divorced] • Sexual Orientation [Homosexual or Transgendered] • Living Situation [Alone] CURRENT OR PAST PSYCHIATRIC DISORDERS: • Bipolar disorder • Other Mood Disorder/Depression • Alcohol/Substance • Abuse • PTSD • Cluster B Personality Disorder • Conduct Disorder • Psychotic Disorder • TBI • Other:

43. Suicide Risk Assessments • KEY SYMPTOMS: • Anhedonia • Impulsivity • Anxiety/panic • Agitation • Hopelessness • Insomnia • Command hallucinations • Other: • FAMILY HISTORY OF SUICIDE OR SUICIDE ATTEMPTS: Y/N (Describe:)

44. Suicide Risk Assessments • STRESSORS AND INTERPERSONAL DIFFICULTIES: • Triggering events leading to humiliation • Shame or despair • Loss of relationship • Financial • Health status deteriorating/Newly diagnosed problem • Chronic medical illness (especially CNS disorders, pain) • Intoxication • Substance abuse • Family turmoil/chaos • History of physical or sexual abuse • Social isolation • Thwarted belongingness • Perceived burdensomeness • Other:

45. Suicide Risk Assessments • RECENT CHANGES IN TREATMENT: • Medication changes (describe) • Provider or treatment change (describe) • Discharge from psychiatric hospital (describe) • Other:

46. Suicide Risk Assessments PROTECTIVE FACTORS: • Has problem solving/coping skills • Has religiosity/spirituality • Able to tolerate frustration • Has responsibility to children or beloved pets • Is pregnant • Has positive therapeutic relationships • Is motivated in treatment • Has good social/family supports • Has economic security • Has a sense of responsibility for family, • Other:

47. Suicide Risk Assessments ASSESSED LEVEL OF SUICIDE RISK: (Determination of risk level is a clinical judgment based on assessment of risk factors, protective factors, suicide inquiry and overall clinical presentation. The definitions below represent a range of risk levels and not actual determinations. • MINIMAL RISK: No significant risk factors. • LOW RISK: Suicidal ideation of limited frequency, intensity and duration; no identifiable plans, no intent, no behavior, good self-control and strong protective factors. • MODERATE RISK: Suicidal ideation with a plan but without intent or behavior; some risk factors present, and identifiable protective factors, good self-control, limited dysphoria/symptoms. • HIGH RISK: Recent suicide attempt, significant aborted attempt or attempt that was interrupted; Frequent intense, enduring suicidal ideation with specific plans with intent; Frequent, intense, and enduring suicidal ideation, specific plans, and the presence of multiple risk factors such as substance abuse, poor impulse control, a history of aggressive acts, hopelessness, command hallucinations and few protective factors. • IMMINENT RISK: Protective factors not relevant.

48. Suicide Risk Assessments PLAN: • Refer to the treatment plan in the progress note. • Referred to treating psychiatrist. • Admission to inpatient psychiatry • Will place a Suicide Behavior Consult • Safety plan developed and copy provided to Veteran • Provided Veteran and/or family member/significant other with emergency/crisis numbers • Counseled regarding avoiding/minimizing use of alcohol and avoiding illegal substances • Other:

49. Definitions • Suicidal Self-Directed Violence - Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself with evidence, whether implicit or explicit, of suicidal intent. • Suicide - Death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior. • Suicide Attempt - A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior. • Preparatory Behavior - Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away). • Suicidal Intent - There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and inferred in the absence of suicidal behavior. • Suicidal Ideation - Thoughts of engaging in suicide-related behavior. (Various degrees of frequency, intensity, and duration.) • Interrupted By Self or Other - A person takes steps to injure self but is stopped by self or another person prior to fatal injury. The interruption may occur at any point. • Physical Injury - A bodily injury resulting from the physical or toxic effects of a self-directed violent act interacting with the body.

50. What Care is Provided to Those Identified at High Risk? The VA Suicide Prevention Program provides an enhanced level of care for those Veterans identified as high risk. The Enhanced Care protocol includes: • High Risk Flag (90 day period- can be continued) • Missed Appointment follow-up • Weekly contacts from their Mental Health team for the first 30 days and then at least monthly for the next 60 days • Safety Planning