1. RECOGNIZING THE POTENTIAL: THE NURSE’S ROLE IN SUICIDE PREVENTION Janell Christenson, APRN-BC, LAC, CT, CHPN Suicide Prevention Coordinator, Sioux Falls VA Health Care System

2. Disclaimer The views and opinions expressed in my presentation today, including any examples or assumptions, are mine personally, and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or any agency of the U.S. Government.

3. Disclaimer The views and opinions expressed in my presentation today, including any examples or assumptions, are mine personally, and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or any agency of the U. S. Government.

4. Recognizing the Potential… Suicide is the 10 th leading cause of death in America and substantially outnumbers homicides. It is the 2 nd leading cause of death in teens. (2013 official data) There are approximately 39,000 suicides a year in America compared to 24,000 murders (CDC data). There is a suicide every 2.8 minutes Over 80% of suicides are in white men. Middle aged men have the highest rate 19.0 (45-64) and elderly, white men have a rate of 16.1.

5. Recognizing the Potential… Male Veterans have more than twice the risk for suicides and account for 1 in 5 deaths. Female Veterans have a rate that is twice that of their non-Veteran counterparts. (Psychiatric Services, 2010). Female Veterans 18-34 have the highest risk. It’s not just about diagnosis, but about the stressors and symptoms that are going on in the person’s life

6. Recognizing the Potential…. In 2007, the Joshua Omvig Suicide Prevention law went into effect: It mandated a Suicide Prevention Coordinator in every VA Medical Center It mandated comprehensive programming in each VA Education to ALL staff, even Mental Health staff Mandated outreach in our communities Flagging high risk patients and case managing for at least 90 days Partnering with the military and the community Analyzing environments for safety—psych units and ER’s SPC’s are clinical experts putting national standards into their facility We are consultants to other staff members

7. Recognizing the Potential… What we know: There will never be a tool to predict suicide We need to get to a point where we can have conversations with people about their distress Suicide prevention is more of a primary care and specialty care issue than a mental health issue…WHY? Suicide is always multi-faceted, multidimensional and requires a multi-disciplinary approach (Cutcliff, 2004). Although there are MANY tools, the basis of the risk assessment must be looking at the personal, interpersonal and social circumstances of the person. Clinical judgment is essential

8. Recognizing the Potential… 50-75% of Americans who die of suicide had contact with their Primary Care provider within 30 days of their death (Luoma, 2002). To have a comprehensive conversation with a distressed person means that you look at the following, not just, “…are you having suicidal thoughts?” Risk factors Protective factors Means reduction Involving the family Safety planning

9. Assessment… RISK FACTORS: Current thoughts, plans, intentions, rehearsal/practicing, taking risks, setting timetables, lethality? Previous attempts, especially recently? Current or increased alcohol, drug or prescription use New or worsening mental health symptoms New or worsening physical health issues, especially if life changing/complicating Psychosis Recent psychosocial stressors that OVERWHELM coping—relationship, job, finances, legal Family history of suicide Recent discharge from a psych unit, addiction program, MST or PTSD program Demographics PAIN—emotional and physical ANGRY, seeking revenge INSOMNIA Perceived burdensomeness History of being abused—physically, emotionally, sexually Disgusted with life

10. Assessment… Protective factors: Positive social support Spiritual beliefs in a power greater than self Reality testing History of positive coping/resiliency Having a purpose or feeling meaning in life Responsibility for family/children in the home

11. Assessment… Means Reduction: Since 74% of suicides happen in the home, what can be done to make the home as safe as possible? Working with the patient and family on securing potentially dangerous objects—guns, meds, sharps, cords, vehicle What have they done in the past can give a glimpse to the future The key is not to have available means easily accessible in a “bad” moment. Also work with the family to confirm. Sometimes law enforcement will secure the weapon when they are called. Gun locks, devices for meds, limiting access to scripts

12. Assessment… Involving the family: Would the person give us permission to speak with family? Working with the family regarding safety at home, emergency resources, 911 The importance of telling family that if their loved ones makes intent statements, engages in behavior CALL 911 RIGHT AWAY. Families tend to wait

13. Assessment…. Safety Planning: Best practice clearly states that safety planning works for some patients, not all, but NOTHING works for ALL Components of effective safety planning What are the triggers of that person? What can THEY do to help themselves in a bad moment? What can distract them? What social situations are helpful? Who can they call or approach when distressed? Who are their professional contacts? What can they agree to do to make their home environment as safe as possible? If possible, discuss safety planning with family, also

14. Assessment and Intervention… We have honest conversations about securing/safe storage of the potential means of suicide—guns, sharps, extra meds, how to handle suicidal thoughts while driving or using machinery. The National Veterans’ Crisis Line is available to Veterans and their families 24/7/365. We do teaching with patients and families about calling early/recognizing the triggers before there are escalation of symptoms. There is NO SAFETY WITHOUT SOBRIETY!!!! May involve calling law enforcement to do a safety check. Helping families know that law enforcement are first responders, and can assist with safety in ways we cannot.

15. Assessment and Intervention… Always error to the point of safety. Think through a situation that you have done all you can which helps greatly if the WORST thing happens. Telephone calls from/to a distressed person: Try to get the following information: where are they, get an address, do they have a weapon, where is the weapon, is anyone with them, can I speak with that person, is the person intoxicated, any other information??? TRY to stay on the line with them until police show up, then warmly hand off to them so that information is fully received.

16. Key Points…. You never know when you will be in the presence of a hurting person. That can be at home, work or school, in your personal life or professional life. We need to all hear the distress in a person’s life and ask that life saving question, “…_____, you are talking about a lot of difficult things, I need to ask you if you are thinking about suicide?” Then ask if they have a plan? Intent? Practicing? ANYONE can ask these questions!!! The first person that a distressed person talks to will likely get the most accurate story of distress and symptoms. Make sure that information is passed on to the medical providers, law enforcement or other helpers!!! This is critical!!!

17. Key Points… Middle aged people are especially vulnerable to economic stressors—lost job, lost investments etc.

18. A tool for conversation….WHAT’S HAPPENING IN MY LIFE? Symptoms: Feeling hopeless and worthless Hearing voices, feeling like someone is trying to hurt me Worsening mental health symptoms—depression, anxiety, PTSD Worsening physical health problems Thoughts of suicide Recent suicide attempt Feeling like a burden Considering a plan (for suicide), or making preparations Thoughts of harming or killing someone else Drinking alcohol, taking street drugs, misusing prescription drugs Anger at self or others

19. WHAT’S HAPPENING IN MY LIFE? Stressors: Experiencing more stress on the job with supervisors, co-workers Worried about employment Relationship concerns—significant others, children, parents or friends Worried about finances Concerns about medications—side effects, drowsy, weight gain Housing concerns or crisis Conflict with important people in my life Recent or troubling death of friend or family member Other issues?

20. What we have learned in the VA… Suicide attempts: Men, 51-60 36% had previous attempts Diagnoses: depression: 78%, alcohol/drug use, 31%, PTSD, 17%, chronic mental illness, 51%. Medical diagnoses: chronic pain, 44%, heart disease, 25%. Means: overdose (65%) 74% were known to have mental health problems 42% were seen within 7 days 44% were seen within 30 days of their attempt. 63% had a safety plan 82% had a recent pain assessment done, 63% score was 0-2

21. What we have learned in the VA… Suicide Completions: Male, 51-60 No previous attempt Mental health diagnoses of depression, anxiety, alcohol and personality disorder Medical diagnoses: chronic pain, heart disease and sensory loss Means was gunshot Not seen within 7 days, but 50% were seen within 30 days for VA services (but not necessarily mental health) 50% were known mental health patients

22. Thank You… Janell.Christenson@VA.gov Veteran’s Crisis Line: 1-800-273-8255 #1 if a Veteran or calling on behalf of a Veteran Don’t hesitate to get involved, ask questions with sensitivity and compassion, hearing the distress or stressors or symptoms.