Suicide Prevention in the Department of Veterans Affairs Juli McNeil, LCSW Stephen Clark, LCSW Suicide Prevention Program Jack C. Montgomery VA Medical Center and Clinics

Objectives Objectives Initiation of ProgramInitiation of Program Local StaffLocal Staff National and Local Program OverviewNational and Local Program Overview Suicide Facts and StatisticsSuicide Facts and Statistics Suicide Risk and Protective FactorsSuicide Risk and Protective Factors Safety PlanningSafety Planning Aggregate ReviewAggregate Review What to do to help someoneWhat to do to help someone VA Programs and ServicesVA Programs and Services

Initiation of Program 2007 Joshua Omvig Veterans Suicide Prevention Act The Joshua Omvig Suicide Prevention Act (H.R. 327) is designed to help address: The Joshua Omvig Suicide Prevention Act (H.R. 327) is designed to help address: Post Traumatic Stress Disorder (PTSD) among veterans by requiring mental health training for Veterans Affairs staff;Post Traumatic Stress Disorder (PTSD) among veterans by requiring mental health training for Veterans Affairs staff; Suicide Prevention Coordinator (SPC) at each VA medical facility;Suicide Prevention Coordinator (SPC) at each VA medical facility; MH screening and treatment for veterans receiving VA careMH screening and treatment for veterans receiving VA care Supports outreach and education for veterans and their familiesSupports outreach and education for veterans and their families Peer support counselingPeer support counseling Research into suicide preventionResearch into suicide prevention

Suicide Prevention Program Staff Juli McNeil, LCSW, /3699/4144 Juli McNeil, LCSW, /3699/4144 Program Manager-Suicide Prevention Program Manager-Suicide Prevention Stephen J. Clark, LCSW, Tulsa Suicide Prevention Coordinator Tulsa Suicide Prevention Coordinator 4

Suicide Prevention Program Staff Alexa Youngblood, LCSW, /3699/4144 Suicide Prevention Case Manager Wendy Vogt, /3699 Suicide Prevention/ IOP Administrative Assistant 5

Suicide Prevention Program Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention Coordinators began in FY2007 with full implementation in FY08Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention Coordinators began in FY2007 with full implementation in FY08 A 24/7 Suicide Prevention Hotline.A 24/7 Suicide Prevention Hotline. –330,241 callers have called the hotline –200,531 of those callers have identified themselves as Veterans or family members/friends of Veterans –Over 11,329 rescues of actively suicidal Veterans Online Chat ServiceOnline Chat Service –Initiated in July 2009 –Over 9335 chatters; 3761 mentioned suicide VISN 16 Total Calls YTD 2010 –9742 (2 nd highest)VISN 16 Total Calls YTD 2010 –9742 (2 nd highest) –VISN 22: (1 st highest)

Suicide Prevention Program Development of two centers devoted to research, education, and clinical practice in the area of suicide preventionDevelopment of two centers devoted to research, education, and clinical practice in the area of suicide prevention –Center of Excellence in Canandaigua, NY Develops and tests clinical and public health intervention strategies for suicide preventionDevelops and tests clinical and public health intervention strategies for suicide prevention –MIRECC in Denver, CO Focuses on clinical conditions and neurobiological underpinnings that can lead to increased risk as well as the implementation of interventions aimed at decreasing negative outcomes and training future leaders in the areas of VA Suicide Prevention.Focuses on clinical conditions and neurobiological underpinnings that can lead to increased risk as well as the implementation of interventions aimed at decreasing negative outcomes and training future leaders in the areas of VA Suicide Prevention.

Program Outreach VA Participation in Suicide Prevention Awareness MonthVA Participation in Suicide Prevention Awareness Month Sponsoring public service announcements, web sites and display ads designed to inform Veterans and their families of the VA Suicide Prevention Hotline ( TALK/8255)Sponsoring public service announcements, web sites and display ads designed to inform Veterans and their families of the VA Suicide Prevention Hotline ( TALK/8255) VA has been distributing Suicide Prevention materialsVA has been distributing Suicide Prevention materials Suicide Prevention Coordinators are required to do outreach activities in all of their local communitiesSuicide Prevention Coordinators are required to do outreach activities in all of their local communities Family psycho-educational materialsFamily psycho-educational materials

Local Suicide Prevention Program Tracking High Risk PatientsTracking High Risk Patients Ensuring they receive adequate care/case managementEnsuring they receive adequate care/case management Responding to Hotline ReferralsResponding to Hotline Referrals Local Crisis CallsLocal Crisis Calls Mail ProgramMail Program Support to MH providersSupport to MH providers Aggregate ReviewsAggregate Reviews Environment of Care Rounds on Inpatient and EREnvironment of Care Rounds on Inpatient and ER Training VA StaffTraining VA Staff Operation SAVE Training for non clinicians Operation SAVE Training for non clinicians Operation SAVE for all new employees Operation SAVE for all new employees LMS Training for Clinicians LMS Training for Clinicians Completion of Suicide Behavior Reports (SBRs) Completion of Suicide Behavior Reports (SBRs) Suicide Risk Assessments Suicide Risk Assessments Safety Planning Safety Planning High Risk for Suicide High Risk for Suicide On new research and treatment regarding suicide/suicidal patients On new research and treatment regarding suicide/suicidal patients

Local Suicide Prevention Program Community OutreachCommunity Outreach Providing VA Guide training (Operation SAVE) Providing VA Guide training (Operation SAVE) Providing information about VA care and services Providing information about VA care and services Promoting Veteran and community suicide awareness Promoting Veteran and community suicide awareness Closely working with OEF/OIF VA Staff Closely working with OEF/OIF VA Staff Assisting the VA and community agencies in the dissemination of new information about suicide and specific intervention strategiesAssisting the VA and community agencies in the dissemination of new information about suicide and specific intervention strategies Providing local providers and staff with the appropriate resourcesProviding local providers and staff with the appropriate resources

32,000 US deaths from suicide/ year32,000 US deaths from suicide/ year –Centers for Disease Control and Prevention 91 people die from suicide every day/every 16 minutes91 people die from suicide every day/every 16 minutes Suicide is the 11 th leading cause of death in the USSuicide is the 11 th leading cause of death in the US Suicide is the 2 nd leading cause of death among year oldsSuicide is the 2 nd leading cause of death among year olds Suicide is the 3 rd leading cause of death among year oldsSuicide is the 3 rd leading cause of death among year olds Highest suicide rate is among 65 and older. Older white males are at highest risk.Highest suicide rate is among 65 and older. Older white males are at highest risk. 4 times as many men kill themselves compared to women, yet 3 times as many women attempt suicide as compared to men.4 times as many men kill themselves compared to women, yet 3 times as many women attempt suicide as compared to men. Oklahoma is 10 th in the Nation.Oklahoma is 10 th in the Nation. Important Facts about Suicide

Facts about Veteran Suicide 30,000-32,000 US deaths from suicide/ year30,000-32,000 US deaths from suicide/ year –Centers for Disease Control and Prevention About 20% are VeteransAbout 20% are Veterans National Violent Death Reporting System National Violent Death Reporting System About 18 deaths from suicide per day are VeteransAbout 18 deaths from suicide per day are Veterans –National Violent Death Reporting System About 5 deaths from suicide per day among Veterans receiving care in VHA – VA Serious Mental Illness Treatment, Research and Evaluation CenterAbout 5 deaths from suicide per day among Veterans receiving care in VHA – VA Serious Mental Illness Treatment, Research and Evaluation Center Veterans are more likely to use firearms as a means for suicide Veterans are more likely to use firearms as a means for suicide - National Violent Death Reporting System - National Violent Death Reporting System About 950 attempts/month among Veterans receiving care in VHA as reported by VA Suicide Prevention Program StaffAbout 950 attempts/month among Veterans receiving care in VHA as reported by VA Suicide Prevention Program Staff About 33% of recent Veteran suicides have a history of previous attempts- VA National Suicide Prevention Staff reportsAbout 33% of recent Veteran suicides have a history of previous attempts- VA National Suicide Prevention Staff reports Preliminary data since 2006 show decreased suicide rates in Veterans aged who use VA health care relative to Veterans in the same age group who do not. This decrease in rates translates to about 250 lives per year. – National Violent Death Reporting System and VA Serious Mental Illness Treatment, Resource and Evaluation Center.Preliminary data since 2006 show decreased suicide rates in Veterans aged who use VA health care relative to Veterans in the same age group who do not. This decrease in rates translates to about 250 lives per year. – National Violent Death Reporting System and VA Serious Mental Illness Treatment, Resource and Evaluation Center.

General Risk Factors Thoughts about harming self that include plan & methodThoughts about harming self that include plan & method Previous suicide attemptsPrevious suicide attempts Alcohol or substance abuseAlcohol or substance abuse History of mental illnessHistory of mental illness Poor self-controlPoor self-control HopelessnessHopelessness Recent loss (e.g., loved one, job, relationship)Recent loss (e.g., loved one, job, relationship) Family history of suicideFamily history of suicide History of abuseHistory of abuse Serious health problemsSerious health problems Sexual identity concerns: especially among men 16-24Sexual identity concerns: especially among men Recent discharge from hospital, group home etc.Recent discharge from hospital, group home etc. Recent diagnosis of an illnessRecent diagnosis of an illness Demographic factors: White men over 70 years of age are at increased riskDemographic factors: White men over 70 years of age are at increased risk Burdensomeness, IsolationBurdensomeness, Isolation Chronic Pain, PTSD, TBIChronic Pain, PTSD, TBI

Veteran Specific Risks Multiple deployments Multiple deployments Length of deploymentsLength of deployments Deployments to hostile environmentsDeployments to hostile environments Exposure to extreme stress/death/combatExposure to extreme stress/death/combat Physical/sexual assault while in the service (not limited to women)Physical/sexual assault while in the service (not limited to women) Service related injuries (TBI, PTSD, other medical and mental health diagnoses)Service related injuries (TBI, PTSD, other medical and mental health diagnoses) Familiarity with weaponsFamiliarity with weapons

Protective Factors Positive social supportPositive social support History of adaptive coping skillsHistory of adaptive coping skills Participating in treatmentParticipating in treatment Veteran acknowledges hopefulnessVeteran acknowledges hopefulness Religious beliefs that act as a barrierReligious beliefs that act as a barrier Life satisfaction (e.g., rating 1 to 10)Life satisfaction (e.g., rating 1 to 10) Fear of suicide or deathFear of suicide or death Family or friends that act as barrier to self-harmFamily or friends that act as barrier to self-harm (Rudd, 2006)

Warning Signs Give Added Consideration to Warning Signs: Prior suicide attempts/behaviorPrior suicide attempts/behavior Agitatation, AnxietyAgitatation, Anxiety Hopelessness and BurdensomenessHopelessness and Burdensomeness –Trapped in physical/psychological pain Talking or writing about deathTalking or writing about death Withdrawing and isolatingWithdrawing and isolating Seeking means to kill themselvesSeeking means to kill themselves Acting reckless or engaging in risky activities without regard for safety or deathActing reckless or engaging in risky activities without regard for safety or death

SAFETY PLANNING STEP 1: Warning SignsSTEP 1: Warning Signs STEP 2: Internal Coping StrategiesSTEP 2: Internal Coping Strategies STEP 3: Social Contacts Who May Distract from the CrisisSTEP 3: Social Contacts Who May Distract from the Crisis STEP 4: Family or Friends Who May Offer HelpSTEP 4: Family or Friends Who May Offer Help STEP 5: Professionals and Agencies to Contact for HelpSTEP 5: Professionals and Agencies to Contact for Help STEP 6: Making the Environment SafeSTEP 6: Making the Environment Safe

Aggregate Reviews 10/1/2008 to 6/30/ /1/2008 to 6/30/2009 –116 suicide attempts/behaviors (20 events, 18 uniques reviewed for report) –51/116 were “male other” –FOCUS OF REVIEW--20/51 OD on meds, meds & other substances (alc, illegal drugs) –13/20 suicide attempts/behavior via gun –Majority treated for pain, mood disorder and substance abuse –11 with a previous attempt/behavior ACTIONS Increase use in detailed suicide risk assessment Increase use in detailed suicide risk assessment Increase in use of safety plan Increase in use of safety plan Detailed treatment planning Detailed treatment planning

Aggregate Reviews 10/1/2008 to 6/30/ suicide; 2 accidental overdoses (ODs)1 suicide; 2 accidental overdoses (ODs)ACTION Same actions as with attempts/behaviors plus Same actions as with attempts/behaviors plus Revamp Pain Management Board Revamp Pain Management Board Establish a Pain Clinic Establish a Pain Clinic

Aggregate Reviews 7/1/2009 to 3/31/20107/1/2009 to 3/31/2010 –175 attempts/behaviors –FOCUS-32 events, 29 uniques (Veterans that OD and had one or more previous attempts/behaviors) –98/175 “male other” –59/175 method OD –54/175 method Guns –Veterans in focus had mood disorder, substance abuse and chronic pain. ACTIONS Limit number of dispensed meds at one time Limit number of dispensed meds at one time Drug screens/Appropriate drug screens Drug screens/Appropriate drug screens Increase in Case Conferences Increase in Case Conferences Review/update/change policy regarding screens Review/update/change policy regarding screens

Suicide is Preventable Become a partner in Suicide Prevention Ask Directly about Suicide Suicidal ideationSuicidal ideation Suicide plansSuicide plans Access to MeansAccess to Means Suicidal ideation and behavior is often a “process” and habituation occurs to thoughts of death and the act of self –harm.Suicidal ideation and behavior is often a “process” and habituation occurs to thoughts of death and the act of self –harm. Talking about suicide does not cause a person to be suicidal. Asking shows compassion, reduces isolation and stigma.Talking about suicide does not cause a person to be suicidal. Asking shows compassion, reduces isolation and stigma.

VA Programs and Services OEF/OIF COMBAT CARE STAFFOEF/OIF COMBAT CARE STAFF MH (PTSD, Substance Abuse, Military Sexual Trauma, Mental Health Intensive Case Mgmt, Homeless, etc.)MH (PTSD, Substance Abuse, Military Sexual Trauma, Mental Health Intensive Case Mgmt, Homeless, etc.) TBI/Polytrauma, SCITBI/Polytrauma, SCI Pain Education GroupPain Education Group Spiritual SupportSpiritual Support Veteran ReadjustmentVeteran Readjustment Counseling Centers Counseling Centers