Sebrina Posey MSWLCSW a a Manchester VA Medical Center, Manchester, New Hampshire, USA. Available online: 22 Oct 2009

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1 This article was downloaded by: [Florida State University] On: 10 November 2011, At: 12:40 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Smith College Studies in Social Work Publication details, including instructions for authors and subscription information: Veterans and Suicide: A Review of Potential Increased Risk Sebrina Posey MSWLCSW a a Manchester VA Medical Center, Manchester, New Hampshire, USA Available online: 22 Oct 2009 To cite this article: Sebrina Posey MSWLCSW (2009): Veterans and Suicide: A Review of Potential Increased Risk, Smith College Studies in Social Work, 79:3-4, To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 Smith College Studies In Social Work, 79: , 2009 ISSN: print / online DOI: / Veterans and Suicide: A Review of Potential Increased Risk SEBRINA POSEY Manchester VA Medical Center, Manchester, New Hampshire, USA KEYWORDS Veterans, suicide, warning signs, risk factors, PTSD, VA, prevention Veterans are thought to comprise as much as 20% of all suicides (Sundararaman, Panangala, & Lister, 2008, p. 1). Studies have suggested that male Veterans are at twice the risk of suicide than comparable men in the general population (American Psychiatric Association [APA], 2009). Female Veterans are now thought to be at a 3 times higher risk of suicide than the comparable female population (APA, 2009). Furthermore, suicide among non-veteran women has been found to be greatest between the ages of 35 and 64 years. In comparison with military women, which has been found to be much younger, between 18 and 34 years. A review of suicides among Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans was recently conducted. The study identified that 21.9 per 100,000 of the OEF/OIF Veterans who separated from service between 2002 and 2005 committed suicide (Peake, 2008). In 2007, there were 115 suicides in the active duty Army, more than any year since the start of the first Persian Gulf War (Lopez, 2008), although not all of these suicides were by OEF/OIF Veterans. A review of the effects of deployment stress associated with the physical, psychological, and psychosocial outcomes revealed an association between deployment and increased rates of depression and suicidal ideation (Institute of Medicine [IOM], 2007). Suicide was first named as a public health concern by the surgeon general in 1999 and remains one of the leading concerns today. The Institute of Medicine defines suicide as a fatal self-inflicted destructive act with explicit or inferred intent to die (Goldsmith, Pellmar, Kleinman, & Bunney, 2002, p. 27). According to the Center for Disease Control and Prevention This article not subject to US copyright law. Address correspondence to Sebrina Posey, MSW, LCSW, Suicide Prevention Coordinator, Manchester VA Medical Center, 718 Smyth Road, Manchester, NH 03104, USA. Sebrina. posey@va.gov 368

3 Veterans and Suicide 369 (CDC; 2008), suicide is the 11th leading cause of death in the nation with one suicide occurring every 16 minutes. Among the general population, males are 4 times more likely than females to commit suicide. The most common method of committing suicide among men is by firearms whereas poisoning is the most common method used by females (CDC, 2008). Knowledge of the risk factors for suicide, careful assessment, and appropriate interventions are keys to suicide prevention. RISK FACTORS AND WARNING SIGNS FOR SUICIDE Being able to identify the risk factors for suicide is one way the public can assist in preventing suicides. Risk factors can be organized into three categories: biopsychosocial, environmental, and sociocultural. A primary biopsychosocial risk factor is being diagnosed with a mental disorder, particularly depression. Most depressed people are not suicidal, two thirds of those who die by suicide suffer from a depressive illness (CDC, 2009). A second biopsychosocial risk factor is alcohol and substance use disorders. Between 40% and 60% of those who die by suicide are intoxicated at the time of death. An estimated 18% to 66% of those who die by suicide have some alcohol in their blood at the time of death (National Strategy for Suicide Prevention [NSSP], n.d.). Other biopsychocial risk factors include feeling hopeless, having a history of trauma or abuse, being diagnosed with a physical disability, having a family history of suicide, previous suicide attempts, and being impulsive and/or having aggressive tendencies. The biopsychosocial risk factors may be why individuals with traumatic brain injuries (TBI) may be at increased risk for suicide. Research has found that TBI survivors are at increased risk for suicidal ideation (Simpson & Tate, 2002), suicide attempts (Silver et al., 2001) and suicide completions (Teasdale & Engberg, 2001). Of note, TBI is one of the leading injuries faced by the Iraq/Afghanistan soldiers today, thereby placing these veterans at increased risk for suicide. Environmental risk factors for suicide consist of job or financial loss, recent separation or divorce, access to firearms, and being exposed to clusters of suicide that may have a contagious affect. Last, sociocultural factors include lack of social support, barriers to accessing mental health treatment, and cultural and/or religious belief (CDC, 2008; Suicide Prevention Resource Center, 2009). Protective factors against suicide include social support, spirituality, responsibility to family and children, life satisfaction, positive problem solving skills, therapeutic relationship, and positive coping skills (APA, 2009). Risk factors specific for Veterans include gun ownership, debilitating physical injuries, and mental health issues (Sundararaman et al., 2008). Recent deployment also increases the risk for suicide due to complications. Potential complications of deployment can include depression, alcohol/drug addiction and abuse, divorce, job loss, homelessness, poverty, posttraumatic

4 370 S. Posey stress disorder (PTSD), and loss of spirituality. Differences do exist between recently deployed National Guard/Reservists and active duty. Notably, Guard/ Reserve experience multiple deployments rather than one deployment most common in active duty soldiers. Reservists can be pulled individually or in small groups whereas active duty soldiers are deployed in established groups such as a company, regimen, or battalion. The families of Reservists are generally spread over large geographical locations whereas families of active duty soldiers are often on base-like settings that offer increased support. Reservists return to a culture that needs to be reminded of their deployments and experience multiple adjustments upon return (Morris, 2008). A large body of research indicates that there is a correlation between PTSD and suicide (Hudenko, 2007). There is considerable debate about the reason for this increase though. Some studies suggest that suicide risk is higher due to the symptoms of PTSD, others claim that suicide risk is higher in these individuals because of related psychiatric conditions. The studies that find PTSD as the cause of suicide suggest that high levels of intrusive memories can predict the relative risk of suicide (Fontana & Rosenheck, 1995). High levels of arousal symptoms and low levels of avoidance have also been shown to predict suicide risk. On the other hand, researchers have also found that conditions that co-occur with PTSD, such as depression, may be more predictive of suicide (Kotler, Iancu, Efroni, & Armiir, 2001). In addition, some cognitive styles of coping, such as using suppression, repression, or avoidance to deal with stress, may also be predictive of suicide risk in individuals with PTSD. Specific to combat-related trauma, research has found that the most significant predictors of suicide attempts and preoccupation with suicide are combat-related guilt and the intensity of the combat trauma. These factors often render the emotional coping capacities of Veterans ineffective (Hendin & Haas, 1991; Prigerson et al., 1999). In addition to being familiar with risk factors for suicide, it is also important to understand the warning signs of suicide. Most people who are contemplating suicide do in fact give hints or clues. Some warning signs include verbal clues such as I am such a burden on my family or I wish I were dead. Other warning signs include giving away prized possessions, withdrawal from family and friends, writing a will, sudden or impulsive purchase of a firearm, and sleep problems (U.S. Department of Health and Human Services, 2005). It is important to note that all suicide ideations and threats need to be taken seriously. In any health care organization, a suicidal patient s initial contact often will be whoever picks up the phone at the practice. The progress from that individual to a clinician who can assess the level of urgency of the situation is part of a complex chain of events. Whoever comes in contact with the potentially distressed suicidal individual needs to be aware, and

5 Veterans and Suicide 371 comfortable enough to ask the person directly whether they are experiencing suicidal thoughts, or thoughts of harming themselves. (Bonner et al., 2005, p. 2) ASSESSMENT AND TREATMENT OF SUICIDE BEHAVIOR In 2003, the APA (2009) developed Practice Guidelines (PG) specific to the assessment and treatment of suicide behaviors. The PG provides recommendations to clinicians regarding the assessment process, psychiatric management, and specific treatment modalities. For example, the APA suggests that the suicide assessment should include information about the patients past history, current circumstances, and mental state. The assessment should also include direct questioning about suicide intent. APA also provides guidelines relative to treatment options. Recommended somatic therapies include the use of psychotropic medications such as antidepressants and lithium. Other treatment options include psychotherapies such as cognitive behavior therapy and interpersonal psychotherapy. Additionally, the APA provides guidance to clinicians related to psychiatric managements. Psychiatric management includes establishing and maintaining a therapeutic alliance, attending to the patient s safety, determining the best treatment setting, developing a treatment plan, coordinating and collaborating with other clinicians, promoting adherence to the treatment plan, providing education to the patient and family, and reassigning for safety and suicide risk (APA, 2009). A clinician s role should include making oneself available, being aware, and offering hope, not reassurances. A distressed person does not want to hear, everything s going to be ok, and I know exactly how you feel. VETERANS HEALTHCARE ADMINISTRATION The Veterans Administration (VA) is committed to preventing suicide among Veterans and is taking steps to prevent suicides among the U.S. Veterans. The VA currently has two research centers dedicated to suicide prevention: Veterans Integrated Service Network (VISN) 2 Center of Excellence (CoE) in Canandaigua, New York, and VISN 19 Mental Illness Research Education and Clinical Center (MIRECC) in Denver, Colorado. The CoE has been charged with developing and testing clinical and public health interventions related to suicide risk and prevention whereas the VISN 19 MIRECC focuses on research in the clinical and neurobiological sciences with special emphasis on issues related to suicide risk (Peake, 2008). The VA has also hired suicide prevention coordinators (SPCs) at every VA hospital in the nation. The main role of SPCs is to assist in the identification of Veterans who are at high risk

6 372 S. Posey for suicide. SPCs collaborate with treatment teams to ensure that care is enhanced for Veterans who are identified as high risk for suicide. Additionally, the SPCs provide education and training to VA staff and the community about risks for suicide (Peake, 2008; Sundararaman et al., 2008). In July, 2007, the VA National Suicide Hotline became operational. The VA Suicide Prevention Hotline is a collaborative effort between VA and the National Suicide Prevention Lifeline, a program of the Substance Abuse and Mental Health Services Administration (SAMHSA). Those who call Lifelines National Suicide Prevention Hotline, TALK, are asked to press 1 if they are a Veteran, or are calling about a Veteran. Unlike other such hotlines, VA s hotline is staffed solely by mental health professionals 24 hours a day, seven days a week. Hotline staff is trained in both crisis intervention strategies, and in issues relating specifically to Veterans, such as traumatic brain injury and post traumatic stress disorder. In emergencies, the hotline contacts local emergency resources such as police or ambulance services to ensure an immediate response. (Peake, 2008,p.8) There have been approximately 120,000 calls to the hotline directly to the VA call center since its origination. CONCLUSION Suicide is a national problem and a serious issue for Veterans. Suicide prevention is everyone s responsibility. Strategies for preventing suicide include being familiar with the risk factors and warning signs of suicide. Suicide can only be prevented if identified. Additionally, clinicians, especially those working with returning Veterans with known risk factors including PTSD and TBI, should not only become familiar with assessment, management guidelines, and available treatment options but also be prepared to implement them. In reality, when working with any Veteran or any individual in the general population, health care workers should be familiar with warning signs that can assist them with linking the potentially suicidal individual with help, which can include any of the following resources depending on the severity of the situation: for example, national suicide hotline, local community mental health clinic, local emergency room, or 911. Suicide can be prevented if individuals who come into contact with potentially suicidal individuals build their comfort, awareness, and knowledge base. REFERENCES American Psychiatric Association. (2004). Practice guideline for the assessment and treatment of patients with suicidal behaviors. Washington, DC: Author.

7 Veterans and Suicide 373 Bonner, L., Felker, B., Chaney, E., Vollen, K., Berry, K., Revay, B., et al. (2005). Suicide risk response: Enhancing Patient safety through development of effective institutional policies. Agency for Healthcare Research and Quality, 3, Centers for Disease Control and Prevention. (2008). Suicide prevention. Retrieved February 1, 2009, from Centers for Disease Control and Prevention. (2009). Suicide and self-inflicted injury, Faststats. Atlanta, GA: Author. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among Vietnam veterans: A model of etiology in a community sample. American Journal of Psychiatry, 152, Goldsmith, S., Pellmar, T., Kleinman, A., & Bunney, W. (Eds.). (2002). Reducing suicide: A national imperative. Washington, DC: National Academy Press. Retrieved February 1, 2009, from Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry, 148, Hudenko, W. (2007). PTSD and suicide. National Center for PTSD fact sheet. Retrieved June 10, 2009, from fc_suicide.html Institute of Medicine. (2007). Physiologic, psychologic, and psychosocial effects of deployment-related stress. Washington, DC: National Academies Press. Kaplan, M. S., Huguet, N., McFarland, B. H., & Newsom, J. T. (2007). Suicide among male veterans: A prospective population-based study. Journal of Epidemiology and Community Health, 61, Kotler, M., Iancu, I., Efroni, R., & Armiir, M. (2001). Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous & Mental Disease, 189, Lopez, C. T. (2008). NIMH to study factors that cause suicide. Army News. Available at: Macfarland, B. (2009, May). Abstract SCR nd Annual Meeting of the American Psychiatric Association, San Francisco, CA. Morris, J. J. (2008). Adjusting to civilian life after combat duty with the guard or reserve. Military OneSource. National Strategy for Suicide Prevention. (n.d.). Mental illness and suicide facts. Washington, DC: Department of Health and Human Services. Available at: Peake, J. B. (2008, May). Statement of the Honorable James B. Peake, MD, Secretary of Veterans Affairs before the Committee on Veterans Affairs, United States House of Representatives. Available at: hvac/ asp Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F. I., Maciejewsk, P. K., Davidson, J. R., et al. (1999). Consensus criteria for traumatic grief: A preliminary empirical test. British Journal of Psychiatry, 174, Silver, J. M., Kramer, R., Greenwald, S., & Weissman, M. (2001). The association between head injuries and psychiatric disorders: Findings from the New Haven NIMH Epidemiologic Catchment Area Study. Brain Injury, 15,

8 374 S. Posey Simpson, G. K., & Tate, R. L. (2002). Suicidality after traumatic brain injury: Demographic, injury and clinical correlates. Psychological Medicine, 32, Suicide Prevention Resource Center. (2009). Risk and protective factors for suicide. Retrieved February 1, 2009, from Sundararaman, R., Panangala, S., & Lister, S. A. (2008). CRS report for Congress: Suicide prevention among veterans. Salem, OR: Oregon Department of Veterans Affairs, Governor s Task Force on Veterans Services. Available at: Teasdale, T. W., & Engberg, A. W. (2001). Suicide after traumatic brain injury, a population study. Journal of Neurology, Neurosurgery & Psychiatry, 71, U.S. Department of Health and Human Services, Substance Abuse & Mental Health Services Administration. (2005). Suicide warning signs. Retrieved February 1, 2009, from _pdf/nsple.pdf