PREVENTING VETERAN SUICIDE:

Transcription

1 PREVENTING VETERAN SUICIDE: Targeting Primary Care and ED Providers Presented by Gayle Cole, DHSc, RN, MSN

2 Suicide Suicide is the 10 th leading cause of death o In sub-populations by age, it is even higher o 2 nd leading cause of death for year olds (after unintentional injury) o 20% of U.S. high school students admit to suicidal ideation and 8.6% report an attempt within the previous year o In million adolescents attempted suicide and 300,000 required medical treatment o Bullying and lack of a sense of belonging are key factors in adolescents (Centers for Disease Control and Prevention, 2015) 2

3 Suicide 123 people die daily from suicide That is 45,000 Americans annually Twice as many people die by suicide than homicide annually in the US There are 1 million suicide attempts each year About half of all suicides are firearm-related o Followed by suffocation (including hanging) and poisoning Men are 4 times more likely than women to complete a suicide attempt o Primarily due to method of attempt o White males account for 7 of 10 suicides in the US Suicide costs $50-70 billion annually 3

4 PTSD & Depression in Veterans 1.9 million Veterans have been deployed since the gulf war began in 1990 Mental health diagnoses have spiked since the start of the war in Iraq o More than half of those Veterans seeking care through the Veterans Affairs (VA) have at least one mental health diagnosis 405,000 gulf war Veterans have sought care for Post Traumatic Stress Disorder (PTSD) through the VA o PTSD is an established risk factor for suicide, as is traumatic brain injury (TBI) (U.S. Department of Veterans Affairs, 2011). 4

5 Veteran Suicide The rate of suicide among Veterans is significantly higher than the U.S. average Table 1. Suicide Rates based on Gender, General Population and Veteran Population Gender General Population #/100,000 Veteran Population #/100,000 Male Female to 29 yr old Veterans are at the highest risk 83.3/100,000 Veteran males compared to /100,000 Veteran females compared to 3.4 Risk is highest in the first 3 years after discharge (Hoffmire, Kemp, & Bossarte, 2015). 5

6 Veteran Suicide 22 Veterans and 1 active duty soldier commit suicide every day 1 every 65 minutes (U.S. Department of Veterans Affairs, 2012) 6

7 Suicide and Primary Care A recent survey demonstrated that at least 50% of post-9/11 Veterans have contemplated suicide 75% of patients who completed suicide were seen in an outpatient setting, usually primary care, within 30 days of their death o Only half of our Veterans are seen by the VA o Non-VA providers must be aware of suicide risk Only a small percentage of Veterans seen prior to their suicides were screened for depression or suicidal ideation (U.S. Department of Veterans Affairs, 2015). 7

8 Between 2001 and 2010 male Veteran suicide has increased 15% and female Veteran suicide by 35%. (Villatte et al., 2015) Figure 1. American Psychological Association. (2013) A Veteran s Worst Wounds may be the ones you can t see. Retrieved from: 8

9 Studies show that communal and familial support has a protective effect. Yellow ribbon effect BUT only 50% of Gulf War, OEF/OIF/OND Veterans are utilizing VA care as of 2013 (US Department of Veterans Affairs, 2015). Table 2. Increased Awareness of Veteran Suicide & Mortality Ratio Katz, I. (2012). Lessons learned from mental health enhancement and suicide prevention activities in the veterans health administration. American Journal of Public Health 102 (S1), S14-S16. 9

10 Veteran Suicide and PCPs 45% of Veterans who committed suicide had contact with a PCP within 1 month of the act (Dobscha et al., 2014). Current literature is lacking in characteristics of Veteran suicide victims Veterans have unique characteristics even among different war eras Figure 2. Pham, S. (2013) Vets wait longer and longer for VA care. Retrieved from: 10

11 Veterans and Mental Health 55% of OIF/OEF/OND Veterans have been diagnosed with a mental health or behavioral disorder. o SUD, PTSD, TBI, depression, suicide (US Department of Veterans Affairs, 2015) Physical and environmental considerations o chronic pain, amputations, homelessness, civilian reintegration, hazardous exposures Figure 3. Mental Health First Aid USA. (2015) Sobering Metal Health Statistics for Veterans. Retrieved from: 11

12 Veterans Choice More Veterans will be receiving non-va medical care than ever before

13 Veterans Choice Program (VCP) Purpose of VCP o Improve Veterans access to health care o Allow Veterans to use approved providers o Provides a Call Center to assist with appointments and eligibility Established criteria Accessible via Internet, phone line, and VA medical facilities 13

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15 Which ones are Vets? 15

16 Determine Military History Have you ever served? When? What did you do in the military? Did you experience combat or witness casualties? Were you wounded or hospitalized? Did you have any hazardous exposures? o Noise, chemicals, gases, pesticides, demolition, open-air burn pits, depleted uranium, infectious diseases like malaria, typhoid, hepatitis, TB 16

17 Determine VA involvement Are you seen by the VA? o If not: Is there a reason why? o If so: When was your last appointment? Do you have a service-related disability or condition? Do you have a VA primary care provider? Do you feel your needs are being met? o If no, what do you sense is the problem? 17

18 Screening for Depression Using a depression screening tool Asking about mood, stress, sleep patterns, interest in activities, concentration levels Asking Have you thought about hurting yourself? o We can t dance around the question If the answer is yes o How often are you thinking about that? o Have you thought about how you would do that? o Do you already have a plan? o Do you have the means to do it? 18

19 Depression/Suicide Tools PHQ /f/201412/PHQ-9_English.pdf Ask Suicide Screening Questions Toolkit 19

20 Assessing for PTSD Do you experience trauma-related thoughts or fears? Do you relive the event? Do you have nightmares? How often? Do you ever feel anxious or jittery? Do you ever feel a sense of panic? Do you have trouble sleeping or concentrating? o Have you ever been tested for sleep apnea? 20

21 Pre-Trauma Risks for PTSD Life stress Lack of social support Young age at time of trauma Pre-existing psych disorders or substance misuse Hx of traumatic events Hx of PTSD Others: female gender, low socioeconomic status, low level of education, race, childhood abuse, family hx of psych disturbance 21

22 Trauma-Related Factors Severe trauma Physical injury to self or others Type of trauma High perceived threat to life of self or others Mass trauma Interpersonal trauma 22

23 Post-Traumatic Factors for Ongoing life stress PTSD Lack of positive social support Bereavement or traumatic grief Major loss of resources NEGATIVE social support (shaming or blaming) Poor coping skills Others: distressed spouse, children at home, substance misuse/abuse 23

24 PTSD: Treatment Patient awareness of help/treatment options o Normalization/Psychological first aid Multidimensional approach o Psychotherapy o Cognitive Behavioral Therapy o Prolonged Exposure Therapy o Eye Movement Desensitization and Reprocessing Psychopharmacology o Sertraline and paroxetine FDA approved for PTSD o Venlafaxine has strongest support if choosing SNRI o Prazosin (for sleep/nightmares) o Benzodiazepines are NOT recommended Maximize social support 24

25 PTSD: Risk of Harm All patients with PTSD should be assessed for safety and dangerousness including current risk to self or others, as well as historical patterns of risk: o Suicidal or homicidal ideation, intent (plan), means (e.g., weapon, excess medications) o History (e.g., violence or suicide attempts), behaviors (e.g., aggression, impulsivity), co-morbidities (substance abuse, medical conditions) o Family and social environment including risks to the family o Ongoing health risks or risk-taking behavior Medical and/or psychiatric co-morbidities or unstable medical conditions 25

26 PTSD: Comorbid Conditions PTSD rarely exists in isolation Pts should all be screened for substance misuse/abuse, depression, and other psychiatric disorders Pain (acute or chronic) should be assessed o AND treated! Screening for sleep disorders Pts should be screened for high-risk behaviors: unsafe weapons storage, dangerous driving, HIV and Hepatitis risks 26

27 PTSD: Treat or Refer? Factors to consider when determining the optimal setting for treatment include: o Severity of the PTSD or co-occurring disorders o Local availability of service options (specialized PTSD programs, evidence-based treatments, behavioral health specialty care, primary care, integrated care for co-occurring disorders, Vet Centers, other) o Level of provider comfort and experience in treating psychiatric co-morbidities o Patient preferences o The need to maintain a coordinated continuum of care for chronic co-morbidities o Availability of resources and time to offer treatment 27

28 PTSD: Follow-up Visits We must assess response to treatment. At a minimum, providers should perform a brief PTSD symptom assessment at each treatment visit o PTSD Checklist Comprehensive reevaluation of treatment progress and screen for depression should be completed every 90 days Assessment of functional impairment: do their symptoms make it difficult to participate at work, with family, or in other roles? 28

29 Military Sexual Trauma Defined: sexual assault or repeated, threatening sexual harassment that occurred while the Veteran was in the military Includes any unwanted sexual activity, whether due to threats, harassment, intoxication, coercion. Victim response varies based on type, severity, and duration of the trauma, as well as any history of previous abuse and the responses victim received at the time of the MST 29

30 Assessing for Military Sexual Trauma During your service did you receive uninvited or unwanted sexual attention or remarks? o 1 in 4 women and 1 in 100 men answered YES when screened for MST o Frequently results in subsequent dx of PTSD, depression, substance abuse, chronic pain Did anyone ever use force or the threat of force to have sexual contact with you against your will? Did you report the events to authorities? o If so, was anything done? 30

31 Military Sexual Trauma A female soldier is far more likely to be raped by a fellow service member than killed in combat Approximately 25% of victims did not report being raped because the person to report to WAS the rapist! 62% of women who reported incidents experienced retaliation (social, professional, adverse admin, punishment) Since 2006 more than 100,000 service members have admitted to MST, DOD estimates that there are 19,000 sexual assaults per year The military prosecutes less than 15% of these cases and less than a third of those result in imprisonment 31

32 MST: Victim Statements 32

33 Assessing for TBI During your service, did you experience... heavy artillery fire, vehicular or aircraft accidents, explosions (improvised explosive devices, rocketpropelled grenades, land mines, grenades), or fragment or bullet wounds above the shoulders? Did you lose consciousness? Lose memory? Receive a diagnosis of concussion or head injury? TBI often happens in conjunction with other, severe injuries 33

34 TBI: Lasting Effects Physical complaints: HAs, dizziness, fatigue, irritability, memory problems, inattention, changes in behavior Many TBI patients look completely normal, making it harder for those around them to understand the changes May profoundly affect interpersonal relations, anger management, tendency toward depression 34

35 TBI: What next? What brings the pt in now? What was the severity of the initial injury? o Were there other injuries as well? o 60% of patients seen at Walter Reed for blast related injuries had a TBI as well o Estimated that mild TBI affects 15% of all combat o Do they have a dx of PTSD? How has the recovery process gone so far? What services/interventions have been used? How is this affecting their life? 35

36 Suicide Warning Signs Shame, humiliation or guilt related to service Agitation, anxiety, irritability, insomnia Social withdrawal, paranoia, diminished self-care Feeling like nobody understands, that nobody cares, that nobody is trying to help Feeling trapped or like there is no way out Feeling that life is not worth living Losing interest in family, activities, hobbies Poor work/school performance Getting rid of treasured possessions 36

37 So you are concerned: Do you believe your patient is actively contemplating suicide? Do they have a plan? The means to complete the act? Mobile Crisis-Maryland: Maryland law allows involuntary admission to a hospital when a person: has a mental disorder and needs inpatient care or treatment and presents a danger to the life or safety of the person or others and is unable or unwilling to be admitted voluntarily and there is no available less restrictive form of intervention that is consistent with their welfare and safety. 37

38 Vet Hotline Resources & Mobile App There are a multitude of Veteran resources: Hotline resources & crisis intervention services o Anonymous & non-anonymous phone counseling o o Text a message to o Chat online at Online resources o Stopsoldiersuicide.org o Nvf.org or call For Providers: Suicide Prevention Mobile App (SAMHSA) Training tool for providers Patient and provider educational materials Treatment locator Conversation starters 38

39 Maryland-Specific Maryland Crisis Hotline: Maryland Crisis Connect: Dial 211, then press 1 Online chat 4pm to 9pm M-F at help4mdyouth.org 39

40 General Statistics Military Statistics What are some causes? How can we help? Quick Quiz 40

41 References American Academy of Nursing. (n.d.). Have you ever served in the military? Retrieved from American Foundation for Suicide Prevention. (2015). afsp.org/president-obama-signs-clay-hunt-suicideprevention-american-veterans-act Centers for Disease Control and Prevention. (2015). Suicide and self-inflictedinjury. Retrieved from Dobscha, S., Denneson, L., Kovacs, A., Teo, A., Forsberg, C., Kaplan, M., & McFarland, B. (2014). Correlates of suicide among veterans treated in primary care: Case-control study of a nationally representative sample. Journal of General Internal Medicine, 29(Suppl 4), S htp://dx.doi.org/ /s Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., & Bunney, W. E. (Eds.). (2002). Reducing suicide. Washington, DC: The National Academies Press. Healey, B. J., & Zimmerman, R. S. (2010). The new world of health promotion: New program development, implementation, and evaluation. Sudbury, MA: Jones and Bartlett Publishers. Health Resources and Services Administration. (2016). Shortage areas, health professional shortage area (HPSA) - basic mental health care. Retrieved from Hinojosa, R., Hinojosa, M., Nelson, K., & Nelson, D. (2010). Veteran family reintegration, primary care needs, and the benefit of the patient-centered medical home model. Journal of the American Board of Family Medicine, 23(6),

42 References (continued) Hoffmire, C. A., Kemp, J. E. & Bossarte, R. M. (2015). Changes in suicide mortality for veterans and nonveterans by gender and history of VHA service use Psychiatric Services 66(9), Retrieved from er1.0.pdf Katz, I. (2012). Lessons learned from mental health enhancement and suicide prevention activities in the veterans health administration. American Journal of Public Health,102 (S1), S14-S16. Kimerling, R., Makin-Byrd, K., Louzon, S., Ignacio, R.V., & McCarthy, J.F. (2015). Military sexual trauma and suicide mortality. American Journal of Preventive Medicine. Olenick, M., Flowers, M., & Diaz, V. (2015). US veterans and their unique issues: enhancing health care professional awareness. Advances in Medical Education and Practice, 2015(6), Pietrzak, R., Goldstein, M., Malley, J., Rivers, A. Johnson, D., & Southwick, S. (2010). Risk and protective factors associated with suicidal ideation in veterans of Operation Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123(2010), Pompili, M., Sher, L., Serafini, G., Forte, A., Innamorati, M., Dominici, G., Lester, D., Amore, M. & Girardi, P. (2013). Posttraumatic stress disorder and suicide risk among veterans. Journal of Nervous and Mental Disease, 201(9), Retrieved from h disorder_and_suicide_risk_among_veterans_a_literature_review/links/ fa81b0b pdf

43 References (continued) Seal, K. H., Metzler, T. J., Gima, K. S., Bertenthal, D., Maguen, S. & Marmar, C. R. (2009). Trends and risk factors for mental health disorders among Iraq and Afghanistan veterans using Department of Veterans Affairs health care, American Journal of Public Health 99(9), Substance Abuse and Mental Health Services Administration. (n.d.). Suicide prevention mobile app for health care providers. Retrieved from ww.store.samhsa.gov/apps/suicidesafe/ U.S. Department of Veterans Affairs. (n.d.). Veterans choice program: 101 for veterans. [PDF]. Retrieved from U.S. Department of Veterans Affairs. (2011). Gulf War era veterans report: Pre-9/11. Retrieved from U.S. Department of Veterans Affairs. (2012). Suicide data report, Retrieved from U.S. Department of Veterans Affairs. (2013). Health care use by Gulf War & OEF/OIF/OND veterans. Retrieved from U.S. Department of Veterans Affairs. (2015). PTSD: National Center for PTSD. Retrieved from U.S. Department of Veterans Affairs. (2015). Suicide risk and risk of death among recent veterans. Retrieved from Villatte, J., O Connor, S., Leitner, R., Kerbrat, A., Johnson, L., & Gutierrez, P. (2015). Suicide attempt characteristics among veterans and active-duty service members receiving mental health services: A pooled data analysis. Military Behavioral Health, 3(4)