Suicide Prevention in Suicide Prevention in the Department of the Department of

Veterans AffairsVeterans Affairs

Juli McNeil, LCSWJuli McNeil, LCSW

Stephen Clark, LCSWStephen Clark, LCSW

Suicide Prevention ProgramSuicide Prevention Program

Jack C. Montgomery VA Jack C. Montgomery VA Medical Center and ClinicsMedical Center and Clinics

ObjectivesObjectives

• 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 Services VA Programs and Services

Initiation of ProgramInitiation of Program

2007 Joshua Omvig Veterans Suicide 2007 Joshua Omvig Veterans Suicide Prevention ActPrevention Act

The Joshua Omvig Suicide Prevention Act (H.R. 327) is The Joshua Omvig Suicide Prevention Act (H.R. 327) is designed to help address: designed to help address:

• Post Traumatic Stress Disorder (PTSD) Post Traumatic Stress Disorder (PTSD) among veterans by among veterans by requiring mental health training for Veterans Affairs staff; requiring mental health training for Veterans Affairs staff;

• Suicide Prevention Coordinator (SPC) Suicide Prevention Coordinator (SPC) at each VA medical at each VA medical facility;facility;

• MH screening and treatmentMH screening and treatment for veterans receiving VA for veterans receiving VA carecare

• Supports outreach and education Supports outreach and education for veterans and their for veterans and their familiesfamilies

• Peer support counseling Peer support counseling • Research into suicide preventionResearch into suicide prevention

Suicide Prevention Program StaffSuicide Prevention Program Staff

Juli McNeil, LCSW, 918-577-3087/3699/4144Juli McNeil, LCSW, 918-577-3087/3699/4144 Program Manager-Suicide Prevention Program Manager-Suicide Prevention

Stephen J. Clark, LCSW, 918-628-2659Stephen J. Clark, LCSW, 918-628-2659 Tulsa Suicide Prevention Coordinator Tulsa Suicide Prevention Coordinator

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Suicide Prevention Program StaffSuicide Prevention Program Staff

Alexa Youngblood, LCSW, 918-577-3672/3699/4144Alexa Youngblood, LCSW, 918-577-3672/3699/4144Suicide Prevention Case Manager Suicide Prevention Case Manager

Wendy Vogt, 918-577-4111/3699Wendy Vogt, 918-577-4111/3699Suicide Prevention/Suicide Prevention/IOP Administrative AssistantIOP Administrative Assistant

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Suicide Prevention Suicide Prevention ProgramProgram

• Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention efforts, such as the Suicide Hotline and hiring of Suicide Prevention Coordinators began in FY2007 with full Suicide Prevention Coordinators began in FY2007 with full implementation in FY08implementation in FY08

• A 24/7 Suicide Prevention Hotline. A 24/7 Suicide Prevention Hotline. – 330,241330,241 callers have called the hotline callers have called the hotline– 200,531 200,531 of those callers have identified themselves as Veterans of those callers have identified themselves as Veterans

or family members/friends of Veteransor family members/friends of Veterans– Over 11,329 Over 11,329 rescues of actively suicidal Veteransrescues of actively suicidal Veterans

• Online Chat ServiceOnline Chat Service– Initiated in July 2009Initiated in July 2009– Over Over 93359335 chatters; chatters; 37613761 mentioned suicide mentioned suicide

• VISN 16 Total Calls YTD 2010 –VISN 16 Total Calls YTD 2010 –9742 (29742 (2ndnd highest) highest)– VISN 22: 12365 (1VISN 22: 12365 (1stst highest) highest)

Suicide Prevention Suicide Prevention ProgramProgram

• Development of two centers devoted to Development of two centers devoted to research, education, and clinical practice in research, education, and clinical practice in the area of suicide preventionthe area of suicide prevention

– Center of Excellence in Canandaigua, NYCenter of Excellence in Canandaigua, NY• Develops and tests clinical and public health intervention Develops and tests clinical and public health intervention

strategies for suicide preventionstrategies for suicide prevention

– MIRECC in Denver, COMIRECC in Denver, CO• Focuses on clinical conditions and neurobiological Focuses on clinical conditions and neurobiological

underpinnings that can lead to increased risk as well as the underpinnings that can lead to increased risk as well as the implementation of interventions aimed at decreasing implementation of interventions aimed at decreasing negative outcomes and training future leaders in the areas negative outcomes and training future leaders in the areas of VA Suicide Prevention.of VA Suicide Prevention.

Program OutreachProgram Outreach• VA Participation in Suicide Prevention Awareness MonthVA Participation in Suicide Prevention Awareness Month

• Sponsoring public service announcements, web sites and Sponsoring public service announcements, web sites and display ads designed to inform Veterans and their families display ads designed to inform Veterans and their families of the VA Suicide Prevention Hotline of the VA Suicide Prevention Hotline ((1-800-273-TALK/82551-800-273-TALK/8255))

• VA has been distributing Suicide Prevention materials VA has been distributing Suicide Prevention materials

• Suicide Prevention Coordinators are required to do Suicide Prevention Coordinators are required to do outreach activities in all of their local communitiesoutreach activities in all of their local communities

• Family psycho-educational materialsFamily psycho-educational materials

Local Local Suicide Prevention Suicide Prevention

Program Program • Tracking High Risk PatientsTracking High Risk Patients• Ensuring they receive adequate care/case managementEnsuring they receive adequate care/case management• Responding to Hotline Referrals Responding 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 cliniciansOperation SAVE Training for non clinicians Operation SAVE for all new employeesOperation SAVE for all new employees LMS Training for CliniciansLMS Training for Clinicians Completion of Suicide Behavior Reports (SBRs)Completion of Suicide Behavior Reports (SBRs) Suicide Risk AssessmentsSuicide Risk Assessments Safety PlanningSafety Planning High Risk for SuicideHigh Risk for Suicide On new research and treatment regarding suicide/suicidal patientsOn new research and treatment regarding suicide/suicidal patients

Local Local Suicide Prevention Suicide Prevention

ProgramProgram• Community OutreachCommunity Outreach

Providing VA Guide training (Operation SAVE)Providing VA Guide training (Operation SAVE) Providing information about VA care and servicesProviding information about VA care and services Promoting Veteran and community suicide Promoting Veteran and community suicide

awarenessawareness Closely working with OEF/OIF VA StaffClosely working with OEF/OIF VA Staff

• Assisting the VA and community agenciesAssisting the VA and community agencies in the dissemination of new information about in the dissemination of new information about suicide and specific intervention strategiessuicide and specific intervention strategies

• Providing local providers and staff with Providing local providers and staff with the appropriate resourcesthe appropriate resources

• 32,000 US deaths from suicide/ year32,000 US deaths from suicide/ year– Centers for Disease Control and Prevention Centers for Disease Control and Prevention

• 91 people die from suicide every day/every 16 91 people die from suicide every day/every 16 minutesminutes

• Suicide is the Suicide is the 1111thth leading cause of death in the leading cause of death in the USUS

• Suicide is the Suicide is the 22ndnd leading cause of death among leading cause of death among 25-34 year olds25-34 year olds

• Suicide is the Suicide is the 33rdrd leading cause of death among leading cause of death among 15-24 year olds15-24 year olds

• Highest suicide rate is among 65 and older. Highest suicide rate is among 65 and older. Older white males are at highest risk. Older white males are at highest risk.

• 4 times as many men kill themselves compared 4 times as many men kill themselves compared to women, yet 3 times as many women attempt to women, yet 3 times as many women attempt suicide as compared to men.suicide as compared to men.

• Oklahoma is 10Oklahoma is 10thth in the Nation. in the Nation.

Important Facts about Important Facts about Suicide Suicide

Facts about Veteran Facts about Veteran SuicideSuicide

• 30,000-32,000 US deaths from suicide/ year30,000-32,000 US deaths from suicide/ year– Centers for Disease Control and Prevention Centers for Disease Control and Prevention

• About 20% are VeteransAbout 20% are Veterans National Violent Death Reporting SystemNational 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 SystemNational Violent Death Reporting System

• About 5 deaths from suicide per day among Veterans About 5 deaths from suicide per day among Veterans receiving care in VHA – receiving care in VHA – VA Serious Mental Illness Treatment, Research and Evaluation VA Serious Mental Illness Treatment, Research and Evaluation CenterCenter

• Veterans are more likely to use firearms as a means for Veterans are more likely to use firearms as a means for suicidesuicide

--National Violent Death Reporting SystemNational Violent Death Reporting System

• About 950 attempts/month among Veterans receiving About 950 attempts/month among Veterans receiving care in VHA as reported by VA Suicide Prevention care in VHA as reported by VA Suicide Prevention Program StaffProgram Staff• About 33% of recent Veteran suicides have a history About 33% of recent Veteran suicides have a history

of previous attempts- of previous attempts- VA National Suicide Prevention Staff reportsVA National Suicide Prevention Staff reports

• Preliminary data since 2006 show decreased suicide Preliminary data since 2006 show decreased suicide rates in Veterans aged 18-29 who use VA health care rates in Veterans aged 18-29 who use VA health care relative to Veterans in the same age group who do relative to Veterans in the same age group who do not. This decrease in rates translates to about 250 not. This decrease in rates translates to about 250 lives per year. – lives per year. – National Violent Death Reporting System and VA Serious Mental Illness National Violent Death Reporting System and VA Serious Mental Illness Treatment, Resource and Evaluation Center.Treatment, Resource and Evaluation Center.

General Risk FactorsGeneral Risk Factors• Thoughts about harming self that include plan & Thoughts about harming self that include plan &

methodmethod• Previous suicide attemptsPrevious suicide attempts• Alcohol or substance abuse Alcohol 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 suicide Family 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 16-24• 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 Demographic factors: White men over 70 years of age

are at increased riskare at increased risk• Burdensomeness, IsolationBurdensomeness, Isolation• Chronic Pain , PTSD, TBIChronic Pain , PTSD, TBI

Veteran Specific RisksVeteran Specific Risks

• Multiple deploymentsMultiple deployments• Length of deploymentsLength of deployments• Deployments to hostile environmentsDeployments to hostile environments• Exposure to extreme Exposure to extreme

stress/death/combatstress/death/combat• Physical/sexual assault while in the Physical/sexual assault while in the

service (not limited to women)service (not limited to women)• Service related injuries (TBI, PTSD, Service related injuries (TBI, PTSD,

other medical and mental health other medical and mental health diagnoses)diagnoses)

• Familiarity with weaponsFamiliarity with weapons

Protective FactorsProtective Factors

• Positive social support Positive 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 barrier Religious 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-Family or friends that act as barrier to self-

harmharm(Rudd, 2006)(Rudd, 2006)

Warning Signs Warning Signs

Give Added Consideration to Warning Give Added Consideration to Warning Signs:Signs:

• Prior suicide attempts/behaviorPrior suicide attempts/behavior• Agitatation, AnxietyAgitatation, Anxiety• Hopelessness and BurdensomenessHopelessness and Burdensomeness

– Trapped in physical/psychological painTrapped 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 Acting reckless or engaging in risky

activities without regard for safety activities without regard for safety or deathor death

SAFETY PLANNINGSAFETY PLANNING

• STEP 1: STEP 1: Warning Signs Warning Signs

• STEP 2:STEP 2: Internal Coping Strategies Internal Coping Strategies

• STEP 3:STEP 3: Social Contacts Who May Distract from the Social Contacts Who May Distract from the CrisisCrisis

• STEP 4:STEP 4: Family or Friends Who May Offer Help Family or Friends Who May Offer Help

• STEP 5:STEP 5: Professionals and Agencies to Contact for Help Professionals and Agencies to Contact for Help

• STEP 6: STEP 6: Making the Environment Safe Making the Environment Safe

Aggregate ReviewsAggregate Reviews 10/1/2008 to 6/30/200910/1/2008 to 6/30/2009

– 116 suicide attempts/behaviors 116 suicide attempts/behaviors (20 events, 18 (20 events, 18 uniques reviewed for report)uniques reviewed for report)

– 51/116 were “male other”51/116 were “male other”– FOCUS OF REVIEW--20/51 OD on meds, meds & FOCUS OF REVIEW--20/51 OD on meds, meds &

other substances (alc, illegal drugs)other substances (alc, illegal drugs)– 13/20 suicide attempts/behavior via gun13/20 suicide attempts/behavior via gun– Majority treated for pain, mood disorder and Majority treated for pain, mood disorder and

substance abusesubstance abuse– 11 with a previous attempt/behavior11 with a previous attempt/behavior

ACTIONSACTIONS Increase use in detailed suicide risk Increase use in detailed suicide risk

assessmentassessment Increase in use of safety planIncrease in use of safety plan Detailed treatment planningDetailed treatment planning

Aggregate ReviewsAggregate Reviews10/1/2008 to 6/30/200910/1/2008 to 6/30/2009• 1 suicide; 2 accidental overdoses (ODs)1 suicide; 2 accidental overdoses (ODs)

ACTIONACTION Same actions as with attempts/behaviors Same actions as with attempts/behaviors

plusplus Revamp Pain Management BoardRevamp Pain Management Board Establish a Pain ClinicEstablish a Pain Clinic

Aggregate ReviewsAggregate Reviews• 7/1/2009 to 3/31/20107/1/2009 to 3/31/2010

– 175 attempts/behaviors175 attempts/behaviors– FOCUS-32 events, 29 uniques (Veterans that OD and FOCUS-32 events, 29 uniques (Veterans that OD and

had one or more previous attempts/behaviors)had one or more previous attempts/behaviors)– 98/175 “male other”98/175 “male other”– 59/175 method OD59/175 method OD– 54/175 method Guns54/175 method Guns– Veterans in focus had mood disorder, substance abuse Veterans in focus had mood disorder, substance abuse

and chronic pain.and chronic pain.

ACTIONSACTIONS Limit number of dispensed meds at one timeLimit number of dispensed meds at one time Drug screens/Appropriate drug screensDrug screens/Appropriate drug screens Increase in Case ConferencesIncrease in Case Conferences Review/update/change policy regarding screensReview/update/change policy regarding screens

Suicide is PreventableSuicide is Preventable

Become a partner in Suicide Prevention Become a partner in Suicide Prevention

Ask Directly about Suicide Ask Directly about Suicide • Suicidal ideationSuicidal ideation• Suicide plansSuicide plans• Access to MeansAccess to Means• Suicidal ideation and behavior is often a Suicidal ideation and behavior is often a

“process” and habituation occurs to thoughts of “process” and habituation occurs to thoughts of death and the act of self –harm.death and the act of self –harm.

• Talking about suicide does not cause a person to Talking about suicide does not cause a person to be suicidal. Asking shows compassion, reduces be suicidal. Asking shows compassion, reduces isolation and stigma.isolation and stigma.

VA Programs and VA Programs and ServicesServices

• OEF/OIF COMBAT CARE STAFFOEF/OIF COMBAT CARE STAFF• MH (PTSD, Substance Abuse, Military MH (PTSD, Substance Abuse, Military

Sexual Trauma, Mental Health Intensive Sexual Trauma, Mental Health Intensive Case Mgmt, Homeless, etc.)Case Mgmt, Homeless, etc.)

• TBI/Polytrauma, SCITBI/Polytrauma, SCI• Pain Education Group Pain Education Group • Spiritual SupportSpiritual Support• Veteran Readjustment Veteran Readjustment

Counseling CentersCounseling Centers