Suicide Prevention Monireh Moghadam, LCSW & Dimitri Ntatsos, LCSW OHSU Psychiatry Grand Rounds June 20, 2017

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1 VA Portland Health Care System Suicide Prevention Monireh Moghadam, LCSW & Dimitri Ntatsos, LCSW OHSU Psychiatry Grand Rounds June 20, 2017

2 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 a Veteran that may be at risk for suicide Know what to do when you identify a Veteran at risk Understand a framework for why people due by suicide Learn a clinical intervention to use with anyone at risk for suicide: Suicide Prevention Safety Plan Know how to discuss reducing access to lethal means 2

3 What do we know about suicide? It s a big public health problem More than 42,000 U.S. deaths from suicide per year among the general population Suicide is the 10 th leading cause of death in the U.S. 3 Every 12.3 minutes someone dies by suicide It is estimated that close to one million people make a suicide attempt each year - one attempt every 35 seconds Oregon is the 8 th highest in the nation for suicide rates 7 Lowest in the country for suicides are: D.C., NY, NJ, MA, MD Highest are: MT, AK, NM, WY, CO Suicide was the leading cause of death for Veterans in Oregon under the age of 45 (2012) 7 Gender disparities: Women attempt suicide 3 times more often than men, men die by suicide almost 4 times more often than women 1 3

4 Suicide in the United States 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 2 Ethnicity/Racial Category Male Female White, non-hispanic * * 7.47 American Indian/Alaskan Native * * 5.50 White, Hispanic Black, non-hispanic Black, Hispanics Asian and Pacific Islander Note: * Indicates highest rates per category 4

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6 Veteran Specific Statistics VETERANS HEALTH ADMINISTRATION 6

7 U.S. Veterans today 7 Sli v_6.14 de

8 VA s largest analysis of suicide data informs prevention strategies for high-risk Veterans Between , the age-adjusted rate of suicide has increased. 8

9 Veteran suicide rates were much smaller among those who used VA services 9

10 What We Know About Veteran suicide 2016 Suicide Data Report VHA Office of Suicide Prevention Veteran Suicide Statistics, 2014 Veterans are more likely to die by suicide than the general population In 2014, an average of 20 Veterans died from suicide each day. 6 of the 20 were users of VA services 14 of 20 are not receiving care at the time of their death Approximately 66% of all Veteran deaths from suicide were the result of firearm injuries. Approximately 65% of all Veterans who died from suicide were aged 50 years or older. After adjusting for differences in age, risk for suicide was 18% higher among male Veterans when compared to U.S. civilian adult males. (2014) After adjusting for differences in age, risk for suicide was 2.4 times higher among female Veterans when compared to U.S. civilian adult females. (2014) 10

11 VA s integrated approach to Suicide Prevention 11

12 Veterans Crisis Line: 9 years of saving lives 12

13 Standard Approach to Suicide Risk What is a Suicide Risk Assessment? Suicide risk assessment is a process in which a healthcare provider gathers clinical information in order to determine the client s risk for suicide. When to Conduct a Suicide Risk Assessment? Any person suspected to be at possible risk for suicide should be formally assessed. What are the key components of a suicide risk assessment? A suicide risk assessment should first evaluate the three domains: suicidal thoughts, intent, and behavior including warning signs that may increase the client s acuity. The suicide risk assessment should then include consideration of risk and protective factors that may increase or decrease the client s risk of suicide. What are warnings signs? Many suicidal individuals may reveal warning signs or signals of their intention to engage in suicidal behavior. Warning signs are those observations that signal an increase in the probability that a person intends to engage in suicidal behavior in the immediate future (i.e., minutes and days). 13

14 Standard Approach to Suicide Risk Differentiate between chronic (unlikely to change over time) and Acute Risk Factors Hopelessness/ desperation/ sense of no way out Current depression Recent discharge from a inpatient/residential psychiatry unit Current substance abuse or impulsive overuse Anxiety, panic, insomnia Pain and physical discomfort (nausea) Extreme humiliation/disgrace; narcissistic mortification Newly diagnosed co-morbid health problem or worsening symptoms Break-down in communication/loss of contact with significant other (including therapist) 14

15 Veteran-specific risks Frequent deployments Deployments to hostile environments Exposure to extreme stress Physical/sexual assault while in the service (not limited to women) Length of deployments Service-related injury 15

16 Protective (Mitigating) Factors Responsibility to children, elder parents, beloved pets Religious Faith Connections to family and community support Social Role Purpose and meaning in life Problem Solving ability Resilience Persistence Positive Coping Skills Attitudes towards Suicide Psychic Toughness Positive professional relationship 16

17 VA Suicide Risk Assessment Guide SUICIDE RISK ASSESSMENT GUIDE You can save a life. It s your call. LOOK for the warning signs ASSESS for risk and protective factors ASK the questions RESPOND in the appropriate way 4 steps to assessing suicide risk among Veterans. All patients who present with positive depression screens, history of mental health diagnosis, or any of the warning signs listed should be further assessed for suicide risk. 17

18 Dr. Thomas Joiner s Theory 18

19 What s a framework that can help us understand Veteran suicide to try and make a difference? Military Training = Stay in Reasonable Mind, Act in Emotion Mind Dr. Marsha Linehan 19

20 Suicide Prevention Safety Plan Therapeutic Intervention Using Collaboration Provides a prioritized list of coping strategies that are pre-planned Bolsters Wise Mind during times we may be stuck in Emotion Mind or Reasonable Mind. 6 steps that are easy to follow, collaborative, Veteran s own words Can be kept on a cell phone app or written in purse, wallet, home, car Not a worksheet - completed by clinician, Veteran/client answers questions Remember to give a copy & suggest a smartphone app! 20

21 No Contracts! Suicide Contracts don t work (research evidence) Contracting for safety may actually increase your liability No research supports the use of no suicide contracts Language implies more concern for medico-legal May be seen as an attempt to free the clinician from blame if a bad outcome No-Suicide contracts may provide a false sense of assurance to the clinician No-Suicide contract asks the patient to promise to stay alive without telling them how to stay alive Do not have the Veteran sign the safety plan 21

22 Safety Planning Suicide Prevention Safety Plan Bolsters Wise Mind, Highlights Positive Coping & STEP 1: RECOGNIZING WARNING SIGNS -Thinking that I am worthless. Increases Connectedness STEP 2: USING INTERNAL COPING STRATEGIES -Listen to music. STEP 3: SOCIAL CONTACTS WHO MAY DISTRACT FROM THE CRISIS -Talking to people at the gym. 22

23 Safety Planning Suicide Prevention Safety Plan: Use the Veteran s Own Words STEP 4: FAMILY OR FRIENDS WHO MAY OFFER HELP These are people that I would be willing to talk to about my thoughts of suicide in order to help me stay safe: -My Pastor Rex Smith: AA/NA Sponsor: STEP 5: PROFESSIONALS AND AGENCIES TO CONTACT FOR HELP -Veterans Crisis Line TALK(8255) press #1, or chat veteranscrisisline.net -Call 911 or come to the Emergency Department -Primary Care Doctor: -Therapist: STEP 6: MAKING THE ENVIRONMENT SAFE - Discuss means restriction - What can you do when you get home today to make your environment safer? 23

24 Guns, Guns, Pills & Guns Guns, Guns, Pills and Guns Provide gun locks and limit access to pills, discuss means restriction as a routine practice with clients. Because Gun deaths: Firearms were one of the top five leading causes of injury-related deaths nationwide in Veterans and guns: Data collected between 2003 and 2006 show that Veterans use firearms more frequently than the general population in acts of suicide. Veterans are, respectively, 1.3 and 1.6 times more likely to use firearms compared with non-veterans. Guns in homes: Research conducted in 2012 showed that firearms could be found in roughly 34 percent of homes nationwide. Weekly dispensing of medications, securing excess medication, getting rid of old ones. Using a pill box that has the Veterans Crisis Line, adding crisis line information to pill bottle caps 24

25 Means Restriction for Overdose by Pills Add Crisis Line to all prescription pill bottles Short prescriptions versus 90 day refills Weekly dispense Discuss the risks of alcohol and other substances mixing with prescriptions Encourage treatment for substance abuse Using family and friends to help manage medication Lock medications in a secure box Safely disposing of excess medications not needed at home 25

26 Suicide by Hanging Most suicides by hanging occur in the person s home Suicide attempt survivors have noted that they thought it would be quick, clean and an easier way to die Access to means is readily available along with multiple anchor points Assessing for whether someone has a history of preparatory suicidal behavior Annually there are between inpatient suicides annually per The Joint Commission About 75% are by hanging Minimizing anchor points in medical centers and in particular psychiatric unit has been a key area of focus for means restriction ASK: -Does you have access to rope? -Have you ever done anything to prepare for hanging yourself? 26

27 Portland Vista Bridge Barrier Summer 2013 barrier was placed on Vista Bridge "Before the barriers were up, we did not hear of instances of people being talked down from jumping, because people just went and jumped," Novick tells WW. "People have to work to a place where they can jump, and it gives them time to think about it. When they stop and they think about it, the police get out there to talk to them. Commissioner Steve Novick Estimated 174 suicides since 1924 off the Vista Bridge 27

28 The Veterans Crisis Line Gun Safety Video Videos Veterans Crisis Line Gun Safety Video Gun safety matters For someone in crisis, a locked firearm can mean the difference between a tragic outcome and a life saved. Though many Veterans are well-versed in gun safety, all Veterans and their families should understand how to properly handle and store firearms in the home. 28

29 How you can connect with VA VHA provides specialty inpatient and outpatient mental health services at its medical centers and community-based outpatient clinics. Crisis support for Veterans, their friends & families. Phone: , Press 1 Text: Live Chat: VA community based centers that provide a range of counseling, outreach and referral services. Phone: WAR-VETS ( ) A free, confidential coaching service provided by VA that helps Veterans family and friends to recognize when their Veteran needs support and connect them with local resources. Phone:

30 Coping and Symptom Management Apps Problem solving skills for stress Manage physical & emotional stress Safety plan & support during crisis Monitor & manage PTSD symptoms Tools for coping, relaxation, distraction & positive thinking Enhance sleep quality & duration 30

31 Additional Resources VA s center of excellence for research and education on the prevention, understanding and treatment of PTSD. Phone: Information on VA services and resources, understanding military culture and experience, and tools for working with a variety of mental health conditions. One-on-one consultation at no charge for VA Providers with general or specific questions about Suicide Risk Management. Phone:

32 References 1 Suicide facts. (2016). Retrieved August 1, 2016, from SAVE Suicide Awareness Voices of Education, F1EC-3F FCB4E6 2 United States Suicide Injury Deaths and Rates per 100,000 in Retrieved August 2, 2016, from Centers for Disease Control and Prevention WISQARS, 3 Suicide Facts at a Glance. (2015). Retrieved August 1, 2016, from Centers for Disease Control and Prevention, 4 CDC. (2016, July 6). Assault or Homicide. Retrieved August 1, 2016, from National Center for Health Statistics, 5 U.S. Department of Veterans Affairs (2016). Suicide among Veterans and other Americans Washington, DC: Office of Suicide Prevention. 6 Based on suicide/ suicide attempts reported within the VA Suicide Prevention Application Network (SPAN) during calendar year Shen X, Millet Suicide Among veterans in Oregon, Oregon Health Authority, Portland, Oregon References 32

33 VA Portland Health Care System Suicide Prevention Team Monireh Moghadam, LCSW Evelyn Unkefer, LCSW Joe Bertagnolli, LCSW Team Line Dimitri Ntatsos, LCSW Margaret Kuehn, LCSW Aimee Johnson, LCSW Questions? Comments? To All Our Veterans, Service Members and Their Families: Thank You for Your Service! 33