Suicide Prevention: What Providers Should Know about Returning Veterans and Military Personnel David Litts, O.D. Director, Policy and Prevention Practice

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 DeathLeading Causes of DeathUnited States, 2003United States, 2003

10-14 15-24 25-34 35-44 45-54 55-64

1 UnintentionalInjury

UnintentionalInjury

UnintentionalInjury

UnintentionalInjury

Malignant Neoplasms

Malignant Neoplasms

2 Malignant Neoplasms

Homicide Suicide Malignant Neoplasms

Heart Disease Heart Disease

3 Suicide Suicide Homicide Heart Disease Unintentional Injury

Chronic Low. Respiratory

Disease

4 Congenital Anomalies

Malignant Neoplasms

Malignant Neoplasms

Suicide Liver Disease Diabetes Mellitus

5 Homicide Heart Disease Heart Disease HIV Suicide Cerebro-vascular

6 Heart Disease Congenital Anomalies

HIV Homicide Cerebro-vascular

Unintentional Injury

7 Chronic Low. Respiratory

Disease

Influenza & Pneumonia

Diabetes Mellitus

Liver Disease Diabetes Mellitus

Liver Disease

8 Influenza & Pneumonia

Cerebrovascular Cerebrovascular Cerebrovascular HIV Suicide

Source: National Center for Health Statistics

AGE

Years of Potential Life Lost Before Years of Potential Life Lost Before Age 65 Years by Cause of DeathAge 65 Years by Cause of Death

United States, 2003United States, 2003

0 250000 500000 750000 1000000 1250000 1500000 1750000 2000000

Cau

se o

f D

eath

Years of Life Lost

Unintentional injury & adverse effects

Malignant neoplasm

Heart disease

Perinatal

Suicide

Homicide

Congenital anomalies

HIV

Cerebrovascular disease

Liver disease


U.S. Suicides by Age – Rates & Numbers, 2003U.S. Suicides by Age – Rates & Numbers, 2003


0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Age Group (years)

Nu

mb

er

of

Su

icid

es

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

Ra

te o

f S

uic

ide

/10

0,0

00

Number of Suicides Rate of Suicide/100,000

Suicide Rates by Age, Race, and Gender Suicide Rates by Age, Race, and Gender United States, 2003United States, 2003


Note: Non-Hispanic Ethnicity

0

10

20

30

40

50

60

Age Group (Years)

Ra

te/1

00

,00

0

White Male AI Male Black Male

White Female AI Female Black Female

Age-adjusted suicide rates among all Age-adjusted suicide rates among all persons by state -- United States, 2003persons 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 21.1Source: National Center for Health Statistics

•Social factors and social integration of individuals exert a powerful influence over suicidal behavior…broad social forces account for the variation in suicide rates. Suicide 1897

Emile Durkheim

Institute of Medicine Report - 2002Institute 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.

Socio-Ecological ModelSocio-Ecological Model

SocietyCommunity Individual

Relationship

Suicide Risk: Suicide Risk: Socio-Ecological ModelSocio-Ecological Model


Relationship

Mental IllnessPhysical illness/painSubstance AbuseHx of attemptIdeation, plans, intent

Ecological ModelEcological Model


Relationship


Hx of abuseLoss events—shame, humiliation, despairSocial isolationLegal/disciplinary problems



Relationship


High unemploymentLocal drug tradeLow cohesivenessSparse treatment resources




Relationship


High unemploymentLocal drug tradeLow cohesivenessSparse treatment resources

Social instabilityHigh firearm accessibilityStigmaMental health financing policy


“Programs that address risk and protective factors at multiple levels are likely to be most effective.”*

*Institute of Medicine Report--2002

High-risk ApproachHigh-risk Approach

Low HighSuicide risk

Mortality threshold

Pop

ulat

ion

Identify and treat high-risk

High-risk ApproachHigh-risk Approach


Mortality threshold

Pop

ulat

ion

Identify and treat high-risk

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

Population-based ApproachPopulation-based Approach


Mortality threshold

Pop

ulat

ion

Move population risk

Interventions to ConsiderInterventions 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

Interventions to ConsiderInterventions 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

“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.

Military/Vets Are:Military/Vets Are:

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

Family/unit cohesionResiliency Self esteem

Problem-solving skillsAccess to health care

MaleFamiliar with firearms

StigmaFear of losing clearance

DepressionRelationship break up

PTSDTraumatic Brain Injury

Alcohol abuse/dependence

Vets: Risk and Protective Factors

Suicide Among Vets*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

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

Trends in Suicidal BehaviorTrends in Suicidal Behavior1990-1992 vs 2001-20031990-1992 vs 2001-2003

National Comorbidity Survey and ReplicationNational Comorbidity Survey and Replication

1990-1992 2001-2002 P

Ideators with plans 19.6% 28.6% p=.04

Planners with gestures

21.4% 6.4% p=.003

Tx among ideators with gestures

40.3% 92.8%

Tx among ideators with attempts

49.6% 79.0%

*Kessler, et al., Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003- JAMAMay 25, 2005, Vol 293, No 20.

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

Trends in Suicidal BehaviorTrends in Suicidal Behavior1990-1992 vs 2001-20031990-1992 vs 2001-2003

National Comorbidity Survey and Replication*National Comorbidity Survey and Replication*

Suicide

1990-1992

14.8/100k

2001-2003

13.9/100k

Ideation 2.8% 3.3%

Plan .7% 1.0%

Gesture .3% .2%

Attempt .4% .6%

No significant changes

*Kessler, et al., Trends in Suicide Ideation, Plans, Gestures, and Attempts in the United States, 1990-1992 to 2001-2003- JAMAMay 25, 2005, Vol 293, No 20.

Inpatient SuicideInpatient 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

Psych Hosp, 43

Psych Ward, 23

Med/Surg, 15

ED, 3

Res Care, 12

Long-term, 3

*Sentinel event reporting began in 1996. Source: Reducing the Risk of Suicide. JCAHO, Joint Commission Resources, Inc. 2005

Clinical Setting

Clinician EducationClinician 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).

Clinical Training for Clinical Training for Mental Health ProfessionalsMental 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

Aftercare for Attempters*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


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)



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)


Clinical PearlsClinical 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

VA Suicide Prevention LifelineVA 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

Suicide Rate -- US Air Force Members 1990-2002

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Rat

e/10

0,00

0 12

-Mo

Rol

ling

Avg

Suicide Rate -- US Air Force Members 1990-2002

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

Rat

e/10

0,00

0 12

-Mo

Rol

ling

Avg

Intervention

IndividualPeer/FamilySociety

Community

“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.

Comparison of the effects of risk for suicide and related adverse outcomes in the USAF population prior to implementation of the program (1990-1996) and after implementation (1996-2002).

OutcomeRelative Risk (RR) and

95% CI Risk Reduction (1-RR) Excess Risk (RR-1)

Suicide .67 [.5702, .8017] 33% --

Homicide .48 [.3260, .7357] 51%

Accidental Death .82 [.7328, .9311] 18% --

Severe Family Violence .46 [.4335, .5090] 54% --

Moderate Family Violence .70 [.6900, .7272] 30% --

Mild Family Violence 1.18 [1.1636, 1.2040] -- 18%

ResultsResults

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.

SummarySummary

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

Suicide Prevention Resource Centerwww.sprc.org

1-877-GET-SPRC

Documents

Suicide Prevention: What Providers Should Know about Returning Veterans and Military Personnel David Litts, O.D. Director, Policy and Prevention Practice