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VETERANS HEALTH: MENTAL HEALTH CONDITIONS COMMON TO VETERANS AND THEIR FAMILIES

WILLIAM COOK, PhD

William A. Cook, Ph.D. is a licensed psychologist who worked for 15 years in private practice in Montana before leaving his practice to work full time as the Director of Ce4Less. He earned his doctorate degree from Texas A&M University, and focused much of his psychology practice in the area of child and family counseling, as well as psychological testing. Dr. Cook likes new challenges, foreign traveling to Africa and areas of Europe and the near East, scuba diving, running, music, and spending time with his family.

JENNIFER MCANALLY, DNP

Jennifer McAnally is a board certified psychiatric mental health nurse practitioner who sees patients across the lifespan. She currently practices in an integrated behavioral health clinic at a federally qualified health center. She has worked in child and adult mental health and substance use treatment settings for over 10 years. She worked previously in academic research settings and as the medical device division manager of a biomedical firm and tissue bank. She has also worked in regulatory oversight of Medicaid programs at the state level. Jennifer’s degrees include Doctor of Nursing Practiced, Bachelor of Science in Nursing and Bachelor of Science in Microbiology with emphasis on whole-genome bioinformatics, all from Montana State University - Bozeman. Jennifer is a passionate activist in the field of mental health services, and is dedicated as a mother of two children, to family and to her community in Montana. ABSTRACT

Current and former members of the United States military may not always volunteer information about their military service. Veterans may not be willing to share their experiences, especially when such awareness causes them mental anguish. Military deployment may have a profound effect on men and women that have served in regions of conflict and war. Understanding mental illness in the veteran population and how to screen, diagnose and treat mental illness is important for healthcare professionals committed to the health and welfare of veterans and their families.

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Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 3 hours at completion of the activity. Statement of Learning Need Healthcare professionals need to be able to identify the different mental health disorders that may inflict veterans, as well as the characteristic symptoms of each disorder. The criteria proposed for determining the use of screening procedures for mental illness and the treatment plans that may be used to manage a psychiatric diagnosis are important for all members of the health team to know who are involved in the initial and ongoing care of veterans and their families. Course Purpose To provide health professionals with knowledge and understanding of the issues that confront veterans and their families with respect to mental illness, and of how to screen and early diagnose mental illness in veterans so they may begin appropriate treatment for improved outcomes. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures William Cook, PhD, Jennifer McAnally, DNP, Kellie Wilson, PharmD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – All have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test: 1. Although each of the following are necessary for an effective

treatment program for mental disorders, the key to engagement and adherence to a treatment program is

a. the client’s education. b. the client’s understanding of mental illness. c. the client’s agreement to the treatment decision. d. the client knowing the options.

2. True or False: Screening involves an examination of a person with

symptoms to determine the specific medical condition that person has contracted.

a. True b. False

3. Screening for a mental disorder

a. replaces formal assessment of mental illness. b. is used in lieu of diagnosis. c. may be done by an untrained clinician. d. serves as a decision support tool.

4. When a veteran is referred to a mental health professional for

evaluation,

a. an initial evaluation should be done within 24 hours. b. a full evaluation should be done only if symptoms persist after 30

days. c. an initial evaluation should be done within 14 days. d. a full evaluation should be done within 24 hours.

5. Veteran status is not always disclosed to a healthcare provider

during behavioral health screening because

a. veteran status is not asked in traditional behavioral health screenings.

b. a patient’s military service is confidential. c. asking a patient about military service is not important. d. veterans routinely deny their service.

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Introduction

Veterans from recent military conflicts have, or have been diagnosed with post-traumatic stress disorder, major depression, or both at a significant rate. Of all active duty and reserve military personnel deployed to the wars in Iraq and Afghanistan, many of them will be diagnosed with a mental health condition requiring treatment. These issues arise during deployment, as well as when veterans and their families confront reintegration into their communities. Current and former members of the military may not always volunteer information about their military service. Also, veterans may not be willing to share their experiences, especially when they cause them mental anguish. Military deployment may have a profound effect on military personnel, therefore understanding mental illness and how to screen for depression and post-traumatic stress disorder to diagnose and develop treatment approaches is important for all health clinicians caring for veterans and their families.

Mental Health Disorders in Veterans

Studies have shown that 18.5% of all Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans have post-traumatic stress disorder (PTSD), major depression, or both PTSD and major depression. Other mental health disorders are estimated to affect 11.6% of those without PTSD or major depression.1,2 Yet, the RAND Center for Military Health Policy Research has reported that less than half of returning veterans with mental health needs will have treatment, and less than one-third of veterans receiving PTSD and major depression treatment are receiving evidence-based care.3

The most common medical and mental health conditions and symptoms include PTSD, suicide, depression, grief, drug and alcohol use, and intimate partner violence or child abuse.3,4 It is important for health clinicians to talk to patients and their family members about military involvement to assess the risk of mental health conditions, as well as the stress, grief, depression and risk of suicide that may exist. With the correct screening questions, healthcare

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professionals have the opportunity for early intervention to mitigate the impact of these conditions. Screening for Military Service

Screening involves examination of generally healthy people to identify their likelihood of developing a particular condition. Mental health screening on the veteran’s return home from deployment should include possible posttraumatic stress disorder (PTSD, depression, anxiety disorders, and alcohol and substance use disorders.5 The effectiveness of screening has been studied but its results remain unclear to date. Screening veterans for PTSD, mood disorders and substance use, post-deployment, was not found to be effective in reducing these disorders up to two years later.5 Further, screening did not appear to result in self-reporting by veterans who may have been experiencing symptoms and finding other ways to cope on their own.

Screening assessments can vary. Some may be performed in person while others may be through a computerized format or other manual approach. Research is needed that compares various screening methods of veterans upon their return home.5

It has been suggested that approximately half of veterans who screen

positive for mental illness actually seek mental health services.5 Suicide prevention programs that involve multidisciplinary team members may lower the rate of suicide in injured veterans or those suffering combat-related psychological and physical sequelae. These injuries have also been linked with a higher incidence of obesity, dyslipidemia, tobacco use, and hypertension associated with cardiovascular disease.5

Screening is not without cost or potential adverse effects; therefore, six criteria have been proposed for determining the acceptability of any given screening procedure.1

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1. The identified condition should be an important health problem. 2. The test should be clinically, socially, and ethically acceptable. 3. The test should be simple, precise, and valid. 4. The test should lead to reduced morbidity. 5. Staffing and facilities for all aspects of the screening program must be

adequate. 6. Benefits of screening should outweigh potential harms.

It is generally accepted that screening for PTSD, depression, and other mental health problems is ineffective unless it is integrated into a total management program with adequate follow-up to confirm or refute a positive screening result. The provider must also be able to provide appropriate treatment.1

Screening is not meant to replace assessment or diagnosis but it can serve as a decision support tool.1 For example, veterans who return home with a diagnosis of PTSD may benefit from screening with the use of the PTSD checklist (PCL5), based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria, and ongoing monitoring of their diagnosis and treatment.5 There are 20 questions in the PCL5; each item scores from 0 to 4, with a total score range from 0 to 80.5 A veteran who screens positive for PTSD should also undergo screening for suicidal ideation and intent.5

Another aspect of the management plan for veterans diagnosed with PTSD is that trauma-based mental illness related to war-time varies based on the war involved, the veteran population studied, and the length of time before PTSD assessment is performed after the veteran returns home. One cohort study of 289,328 Iraq and Afghanistan war veterans in the U.S., receiving Veterans Administration (VA) healthcare between 2002 and 2008 showed that “the overall prevalence of newly diagnosed PTSD was 21.8 percent, with the rate increasing over time.”5 The higher rates of PTSD and other mental illness being identified may be a result of improved screening and assessment tools, however this has not been confirmed yet in the research. It is believed that PTSD may not be apparent for a prolonged period of time following the

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veteran’s return home, and this delay in the manifestation of symptoms varies from months to years.5 Once diagnosed, veterans with PTSD may vary in their response to treatment (pharmacologic and nonpharmacologic) based upon their combat exposure.5

A veteran with a positive mental health screening result should undergo

a clinical assessment by a trained clinician in order to make appropriate diagnoses, including comorbid conditions, such as traumatic brain injury (TBI) or other co-occurring physical conditions. Additional information may need to be obtained to effectively plan treatment. A clinical assessment should consider the type and severity of symptoms experienced by the veteran, and any functional impairment associated with symptoms. While it is widely believed that screening for PTSD among current and former veterans is important to identify a problem early on in order to support appropriate treatment planning, there is no strong evidence that this approach prevents chronic suffering and maladjustment, and suicide.5

An estimated 85 percent of veterans who were asked about being

suicidal, and who subsequently committed suicide, had reportedly denied suicidal ideation.5 Suicide risk detection may be improved during clinical encounters by addressing the challenge of stigma and to encourage veterans with depression or PTSD to seek help. Helping veterans to improve their understanding of mental health issues, to recognize warning signs, and to learn ways to reach out for help should include introducing them to the available options for social reintegration.

Types of Screening Tests for Veterans

The major psychological conditions currently screened for in populations of active-duty military personnel and veterans are PTSD, depression, alcohol use disorders, sexual trauma, suicidality, and mild TBI. Combat and sexual assault traumas have been associated with a high prevalence of PTSD in this population, and several factors should be considered in implementing broad screening directives in this group.5,6

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For a screening program to be effective, adequate resources need to be in place to support it, such as appropriate personnel and time. There are important factors to designing a screening program, such as the choice of instrument, method of delivery (self-report versus clinician-administered), place of delivery (in the theater of war versus on the home front), and intended use of the results of the screen.5,6

In the Veterans Health Administration (VHA), positive screenings for PTSD, depression, suicidality, or military sexual trauma (sexual assault or extreme harassment that occurred during service in the military) result in referral of the veteran to a mental health professional for evaluation. Patients who are referred are scheduled to receive an initial evaluation within 24 hours and a full evaluation within 14 days after referral. However, no data is available to track what happens after referral; for example, what proportion engage and complete evaluations, enter and complete treatment, continue or return to active duty, or are discharged.6 Veteran Status

Veterans and service members may not self-identify as such to their healthcare professionals. Assessing veteran status should be integrated into the behavioral health screening process. The American Medical Association (AMA) has urged health clinicians to ask patients if they have served in the military and to include that experience in their records.7 The American Academy of Nursing (AAN) launched an awareness campaign in 2013 to encourage healthcare professionals to ask patients if they are veterans or family members of veterans. Health clinicians do not routinely ask this question. Only a small percentage of veterans receive services through the Veterans Health Administration. Many more veterans receive healthcare through community health professionals.8

The AAN program provides screening and intake questions and

information on general areas of concern for all veterans, such as post-traumatic stress, military sexual trauma, and blast concussions/traumatic brain injury, as well as health concerns for veterans of specific conflicts or

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deployment conditions. The initiative aims to ensure that individuals have appropriate access to services and to increase health clinicians’ awareness of service-related healthcare issues.8

Assessing veteran status is not included in traditional behavioral health screenings. Since patients may not volunteer this information, asking patients if they have served in the military has important implications for the available benefits and care. Screening for veteran status includes: 1) ensuring that veterans have access to health care and support services that they have earned, 2) informing treatment planning, and 3) increasing awareness of the extraordinary strengths that veterans often possess and unique challenges that they may face.9,10

A retrospective study was conducted involving the evaluation of mental

health wait times for veterans in 2014 and 2017. There were study outcomes in the area of medicine and wait times, however the study did not include mental health wait times. The study focused specifically on Veteran’s Administration medical centers located in 15 major metropolitan areas. A drawback of this study was raised by the researchers, noting that the study was unable to compare Veteran’s Administration data for rural areas or for mid-sized areas in 2014 with those of the private sector. The authors stated that although the study “was a comparative analysis of 30 large metropolitan regions in the United States, follow-up studies are critical to analyze access to the entirety of VA health care with the absence given that nearly one-quarter of veterans live in rural areas.”11 The researchers reported that the mental health data was not independently validated and had limitations, such as a lack of available private sector comparisons.11

Family Member of Veteran

Finding out if patients have close family members who are veterans can help health clinicians understand the patient’s family context and determine if the family could benefit from connection to veteran resources. In addition, individuals working with veteran family members must take their mental health into account. It is important to provide mental health assessments to

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the family members of veterans on a regular basis to ensure their needs are being met.11-13

The Institute of Medicine reports that the most common psychological

challenges experienced by both service members and their families include fears for the safety of the service member, feeling anxious or overwhelmed by deployment-related challenges and responsibilities, worry about children, and vulnerability to additional stressors that might arise.12 The Veteran’s Health Administration offers family services for veterans and their family members. These services include family education, brief problem-focused consultation, family psychoeducation, and marriage and family counseling.13

Family education provides families with the information they need to partner with a treatment team and support the veteran’s recovery. For brief family consultation, the family meets with a mental health provider as needed to resolve specific issues related to the veteran’s treatment and recovery.13 Family psychoeducation is a part of recovery services for veterans with serious mental illness. It focuses mainly on supporting the veteran’s wellbeing and functioning. The overarching goal of marriage and family counseling is to reduce relational distress and strengthen couple and family relationships.13

Screening Questions

The American Academy of Nursing suggests the following screening questions for determining military service of patients or family members of patients.14

● Have you or has someone close to you ever served in the military? ● When did you serve? ● Which branch did you serve? ● What did you do while you were in the military? ● Were you assigned to a hostile or combative area? ● Did you experience enemy fire, see combat, or witness casualties? ● Were you wounded, injured, or hospitalized? ● Did you participate in any experimental projects or tests?

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● Were you exposed to noise, chemicals, gases, demolition of munitions, pesticides, or other hazardous substances?

● Have you ever used the VA (Veterans Administration) for healthcare? - When was your last visit to the VA? - Do you have a service-connected disability or condition? - Do you have a VA primary care provider?

Mental health screening is an important part of patient evaluation and intake in both the outpatient and inpatient setting. Screening for a mental health condition, such as anxiety or depression, allows the mental health professional to identify a condition and intervene early to avoid a serious outcome and to help the patient begin the appropriate treatment needed.14

Research has shown that identifying primary psychiatric symptoms early helps to formulate an effective treatment plan which leads to improved mental health outcomes. Moreover, when a mental health condition is identified early, long-term distress and disability may be prevented. The following sections will discuss specific psychiatric diagnoses and screening instruments to early identify a mental health condition for appropriate treatment and follow-up care.

Post Traumatic Stress Disorder in Veterans

Post-traumatic stress disorder is a condition that can occur at any age, including childhood. PTSD is seen in war veterans and survivors of physical and sexual assault and abuse, accidents, disasters, and many other serious events.15 PTSD can cause many symptoms. These symptoms may include those listed below.15 Re-experiencing or Intrusive Thoughts: • Flashbacks, which involves reliving the trauma over and over, including

physical symptoms like a racing heart or sweating • Bad dreams • Frightening thoughts

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Avoidance or Numbing: • Staying away from places, events, or objects that are reminders of the

experience • Feeling emotionally numb • Feeling strong guilt, depression, or worry • Losing interest in activities that were enjoyable in the past • Having trouble remembering the dangerous event • Wanting to avoid thoughts about the trauma, including using alcohol or

drugs Increased Arousal or Vigilance: • Being easily startled • Feeling tense or “on edge” • Having difficulty falling or staying asleep • Irritability or angry outbursts • Difficulty concentrating Other Criteria for PTSD Diagnosis: • Duration of at least one month • Functional impairment (clinically significant)

Not everyone with PTSD has been through a dangerous event. Some people show signs of PTSD after a friend or family member experiences danger or is harmed. The sudden, unexpected death of a loved one can also cause PTSD. Mentally reliving a traumatic event can be almost as stressful and frightening to people with PTSD as the original trauma.15 People with PTSD often experience frustration, embarrassment, and confusion, in addition to the physical and psychological symptoms. Post-traumatic stress disorder strains relationships because many people with PTSD detach themselves from friends and loved ones and the activities that they used to enjoy.15

Screening for PTSD is usually not the sole focus of a clinical assessment but is combined with screening and assessment of other conditions. The Veterans Administration with the Department of Defense (VA/DoD) Clinical Practice Guidelines support assessment of patients for psychiatric and medical

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conditions, which includes prior and existing psychiatric and substance use disorders and treatment, history of trauma exposure, pre-injury environmental stressors, the level of social support, and the number of deployments.16-19

For those who screen positive for PTSD or when evidence suggests the presence of other disorders or comorbidities, the screening program should ensure rapid diagnostic evaluation by a trained clinician that includes the assessment of other possible causes of the symptoms and issues that are important for treatment planning. The use of a structured interview may improve the validity and reliability of such an evaluation. Evaluation should address comorbidities — such as traumatic brain injury, depression, other anxiety disorders, alcohol or substance use — and the presence of risky behaviors.16-19 In addition, determining the severity of symptoms, the degree and nature of functional impairments, and suicide risk are important in selecting treatment.16-19

During the evaluation, veterans being evaluated should be educated regarding PTSD and other relevant diagnoses, and should have their treatment options explained, and they should participate and agree with treatment decisions. The latter is key to later engagement with and adherence to treatment.16-19

One of the many considerations in screening for PTSD is when to screen.

In the active-duty, National Guard, and reserve force, screening can occur before deployment to a combat zone, during deployment in the theater of war, or after deployment.16-19 Because PTSD symptoms may not show up for months or years or may not be present when a service member transitions from active duty to the civilian population, screening for PTSD is also an important consideration for veterans.

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DSM-5 Diagnostic Criteria for PTSD

Health clinicians should be aware of the DSM-5 diagnostic criteria for PTSD. Currently, diagnosis of PTSD is based on eight criteria from the DSM-5.20 The first DSM criterion has four components:20

1. Directly experiencing the traumatic event(s) 2. Witnessing, in person, the event(s) as it occurred to others 3. Learning that the traumatic event(s) occurred to a close family member or

friend 4. Experiencing repeated or extreme exposure to aversive details of the

traumatic event(s); this does not apply to exposure through media such as television, movies, or pictures

The second criterion involves the persistent re-experiencing of the event

in one of several ways: thoughts or perception, images, dreams, illusions or hallucinations, dissociative flashback episodes, and intense psychological distress or reactivity to cues that symbolize some aspect of the event. Unlike adults, children re-experience the event through repetitive play rather than through perception.

The third criterion involves avoidance of stimuli that are associated with the trauma and numbing of general responsiveness, as determined by the presence of one or both of the following: 1) Avoidance of thoughts, feelings, or conversations associated with the event, and 2) Avoidance of people, places, or activities that may trigger recollections of the event. The fourth criterion comprises two or more of the following symptoms of negative alterations in cognitions and mood associated with the traumatic event(s):20

● Inability to remember an important aspect of the event(s) ● Persistent and exaggerated negative beliefs about oneself, others, or the

world ● Persistent, distorted cognitions about the cause or consequences of the

event(s) ● Persistent negative emotional state ● Markedly diminished interest or participation in significant activities ● Feelings of detachment or estrangement from others

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● Persistent inability to experience positive emotions

The fifth criterion is marked alterations in arousal and reactivity, as evidenced by two or more of the following:20

● Irritable behavior and angry outbursts ● Reckless or self-destructive behavior ● Hypervigilance ● Exaggerated startle response ● Concentration problems ● Sleep disturbance

The remaining three criteria include: 1) the duration of symptoms is more than 1 month, 2) the disturbance causes clinically significant distress or impairment in functioning, and 3) the disturbance is not attributable to the physiological effects of a substance or other medical condition.20

PTSD Screening in Primary Care

There are a number of reasons why healthcare professionals should assess patients for a history of trauma exposure. Some of the most important reasons include trauma and trauma-related problems, the effect of PTSD on health, trauma exposure and utilization of services, PTSD under-recognition by clinicians, identifying a PTSD consultant, and screening for PTSD.20-22

Trauma and Trauma-related Problems

Trauma and trauma-related problems are common. About 60% of men and 50% of women experience at least one trauma such as a disaster, war, or a life-threatening assault or accident at some point in their lives. Nearly 8% of the population has PTSD in their lifetimes.20-22

PTSD is highly comorbid with other disorders such as panic, phobic, or

generalized anxiety disorders, depression, or substance use.20-22

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Effect on Health

Reviews of the literature on trauma and health emphasize the role of PTSD as a mediator between trauma exposure and health effects. Such health effects include a variety of medical disorders as well as significant behavioral health risks.20-22 Trauma Exposure and Utilization of Services

The literature reviews also cite findings of high medical utilization rates for survivors of different types of trauma.20-22 PTSD Under-recognition

Research shows that many patients who seek physical healthcare have been exposed to trauma and have posttraumatic stress symptoms but have not received appropriate mental health care. As with anxiety disorders and depression, most patients with PTSD are not properly identified and are not offered education, counseling, or referrals for mental health evaluation.20-22 Health professionals should bear in mind that avoidance of trauma reminders is a prominent symptom of PTSD. This makes it even more likely that patients will not spontaneously report their trauma experiences or related symptoms.

Clinicians can increase the chances of improved patient health outcomes by identifying a PTSD consultant and by screening for PTSD. The first step is to identify a mental health care professional trained in PTSD. This professional should be able to provide the patient with consultation, and with education, assessment, and counseling. PTSD therapists come from a range of disciplinary backgrounds including psychiatry, clinical psychology, social work, and psychiatric nursing.20-22 When screening for PTSD health professionals can use screening questions to ask about trauma-related symptoms. Alternatively, a clinician can distribute a self-report screening instrument prior to a medical appointment. Completed screens are collected and reviewed by members of the interdisciplinary health team: the physician, nurse, physician's assistant, or a mental health consultant to identify patients who are likely to be

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experiencing distressing post traumatic stress. Screening items can also be added to the standard initial medical history forms.20-22

The Primary Care PTSD Screen (PC-PTSD) shown below has been designed for use in primary care and other medical settings.22-24 The PC-PTSD is brief and problem-focused. The screen does not include a list of potentially traumatic events. Studies on trauma and health in both male and female patients suggest that the active mechanism linking trauma and physical health is the diagnosis of PTSD.

PRIMARY CARE PTSD SCREEN22,23

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: 1. Have had nightmares about it or thought about it when you did not want to. YES___ NO___; 2. Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES ___ NO___; 3. Were constantly on guard, watchful, or easily startled? YES ___ NO___; 4. Felt numb or detached from others, activities, or your surroundings? YES ___ NO ___ Current research suggests that the results of the PC-PTSD should be considered "positive" if a patient answers "yes" to any three items. A positive response to the screen does not necessarily indicate that a patient has Posttraumatic Stress Disorder. However, a positive response does indicate that a patient may have PTSD or trauma-related problems and further investigation of trauma symptoms by a mental-health professional may be warranted. If the PC-PTSD screening instrument is utilized, clarify responses to determine: a. Whether the patient has had a traumatic experience: "I notice from your answers to our

questionnaire that you experience some symptoms of stress. At some point in their lives, many people have experienced extremely distressing events such as combat, physical or sexual assault, or a bad accident, and sometimes those events lead to the kinds of symptoms you have. Have you ever had any experiences like that?"

b. Whether endorsed screen items are really trauma-related symptoms: "I see that you have said you have nightmares about or have thought about an upsetting experience when you did not want to. Can you give me an example of a nightmare or thinking about an upsetting experience when you didn't want to?”

If a patient gives an example of a symptom that does not appear to be in response to a traumatic event, it may be that the patient is ruminating about a negative life event rather experiencing intrusive thoughts about a traumatic stressor. c. Whether endorsed screen items are disruptive to the patient's life: "How have these

thoughts, memories, or feelings affected your life? Have they interfered with your relationships? Your work? How about with recreation or your enjoyment of activities?"

Positive responses to these questions in addition to the endorsement of trauma symptom items on the PC PTSD Screen indicate an increased likelihood that the patient has PTSD and needs further evaluation. Discern whether traumatic events are ongoing in a patient's life If ongoing traumatic events are a part of the patient's life, it is critical that the primary care practitioner discern whether the patient needs an immediate referral for social work or

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mental-health services. Ask: "Are any of these dangerous or life-threatening experiences still continuing in your life now?" If ongoing family violence is suspected, it is imperative that the patient be told the limits of confidentiality for medical professionals, who are mandated to report suspected ongoing abuse of children and dependent adults. Discussion of possible abuse should take place in the absence of the suspected perpetrator; if the abuser is present, victims may deny abuse for fear of retaliation. If ongoing threats to safety are present: 1) Acknowledge the difficulty in seeking help when the trauma has not stopped. 2) Determine if reporting is legally mandated. If it is, develop a plan with the patient to file the report in a way that increases rather than decreases the safety of the patient and his or her loved ones. If reporting is not appropriate, provide written information (or oral if written might stimulate violent behavior in the perpetrator) about local resources that might help the situation. Establish a plan that the patient will agree to in order to move toward increased safety.

A symptom-driven screen, rather than a trauma-focused screen, is

attractive to healthcare staff that may not be able to address a patient's entire trauma history during their visit.22-24 A trauma-focused inquiry might be especially problematic with veterans where the average number of traumatic events meeting criterion A for PTSD is over four. It is important to discuss the results, provide a referral, provide educational materials, and follow up with the patient.22-24

Symptom-Driven Diagnostic Screening for Primary Care

The Symptom-Driven Diagnostic Screening for primary care (SDDS-PC)

assesses multiple mental disorders that are common to primary care. It serves as a sensitive, valid, and patient-friendly first step in a new approach to recognizing and managing mental disorders in primary care. Finally, it aids the primary care clinician in selecting an appropriate diagnostic interview module for the disease for which the patient screened positive. Screening questionnaires have been developed to try to improve recognition of mental disorders in primary care practice. These questionnaires either assess general distress, such as the General Health Questionnaire, or symptoms of specific mental disorders, but they do not screen for multiple specific mental disorders simultaneously.23,24

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In the SDDS-PC, a brief screen for multiple mental disorders are linked to a group of brief disorder-specific criterion based interview modules, which include ruling out a diagnosis.23,24 These modules are based on DSM-5 criteria for each mental disorder and assist the clinician in making specific mental disorder diagnoses. The screen scores for the diagnoses indicate which modules are appropriate to use.

The screen is designed to be a brief, easy to use, and efficient way to

simultaneously screen for multiple mental disorders in a primary care setting. The screen results can be followed by the appropriate confirmatory test; a brief structured interview by the patient's own clinician.23,24 Trauma-Driven Screening

The stress to veterans that is created by exposure to traumatic events is very real. These kinds of experiences happen with unfortunate regularity because they are an essential part of the military experience especially during times of war.

It is important that veterans be prepared to deal with the impacts of these exposures, and that clinicians provide access to resources that can make a difference. The actions recommended reflect best practices based on current research, and should fit easily into the operations and support systems that most veteran treatment practices have in place. The key elements of this model is outlined below.23,24 Potentially Traumatic Event

A trauma for one veteran may be a routine event for another. Reaction to a trauma is subjective, driven by an individual’s experience, sensibilities and personal situation. After exposure to a Potentially Traumatic Event (PTE), members should be asked if they require assistance and what is needed. If no assistance is needed, expression of support may be all that is required.23,24

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After Action Review

The After Action Review (AAR) is a mechanism that allows those affected by an event to review what happened, what was successful, what could have gone better and how they might improve the next time they respond to a similar situation. This post-incident assessment will often help individuals put the event into perspective. After a brief “time out,” they may elect to return to service.23,24

Trauma Screening Questionnaire

The Trauma Screening Questionnaire (TSQ) is a straightforward and easily scored instrument to identify who is progressing well, and who may need additional help down the road. Used 3-4 weeks after the PTE, it consists of ten simple questions about recent symptoms. More than six positive responses suggest that a more complete screening by a competent behavioral health professional may be warranted.23,24

Complete Assessment

The complete assessment can typically be accomplished by a referral to a department or jurisdiction’s Behavioral Health Assistance Program (BHAP) or other competent behavioral health professional. Behavioral Health Assistance Program counselors can often help with managing specific symptoms and dealing with other non-event related stressors of daily living (such as marital problems, financial issues, etc.) that might be interfering with a member’s recovery from exposure to a traumatic event.23,24

Treatment by Specialty Clinician

In some cases, a patient may require more intensive treatment for PTSD, anxiety disorders and depression. In these cases, a specialist with advanced training and supervised clinical experience in specific evidence-based treatment for these conditions should provide the care. A specialist may

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be a psychiatrist, doctoral-level psychologist, licensed clinical social worker or licensed professional counselor.23,34

Self-Report Screening Instruments

Several self-report measures exist to help screen patients for PTSD. These may include the Adult PTSD Self-Report Measures, Davidson Trauma Scale (DTS), Mississippi Scale for Combat Related PTSD (M-PTSD), Modified PTSD Symptom Scale (MPSS-SR), Post-traumatic Diagnostic Scale (PDS), Screen for Post-traumatic Stress Symptoms (SPTSS), and the Trauma Symptom Checklist–40 (TSC-40). There is no single best PTSD measure. The correct tool depends on the goal. For example, a quick screen self-report measure might be best, or a longer interview that assesses for frequency and severity of symptoms might be appropriate.23,24

Depression in Veterans

Those that have served in the military are prone to depression, at least

partially as a result of exposure to traumatic experiences, including witnessing combat and separation from family during deployment or military training. Consistent with the U.S. Preventive Services Task Force (USPSTF) recommendation, screening for a major depressive disorder (MDD) and follow-up of a positive screen should be standard clinical practice. The current policy for the Veteran’s Administration (VA) and Department of Defense (DoD) recommends annual screening for major depressive disorder (MDD).25,26

Screening for major depressive disorder as an accepted and routine part of primary care practice has depended on a number of developments, which are illustrative for integrating screening for and management of PTSD in primary care practice. These are of particular concern in practices outside the DoD and the VA systems.26,27 Although many patients with depression receive care exclusively within a primary care setting, up to half of depression cases in these settings go unrecognized. This may be due to the clinician’s limited time with the patient as well as the patient’s focus on somatic symptoms that co-occur with depression. Since almost two-thirds of patients with depression

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receive treatment in primary care, the responsibility of assessing and treating these patients falls heavily upon primary care clinicians.26,27 By using a quick, efficient, and valid screening mechanism, primary care clinicians can increase the rates of detection within a primary care setting.

A number of self-administered questionnaires are available to assist primary care clinicians in the assessment, diagnosis, and ongoing management of depression in adults. Both the Patient Health Questionnaire-2 (PHQ-2) and the Patient Health Questionnaire-9 (PHQ-9) are reliable and valid measures of detecting depression and identifying the level of depression severity. Moreover, ease of use makes both the PHQ-2 and PHQ-9 useful and efficacious clinical tools for the primary care setting.26-28 Patient Health Questionnaire-2

The Patient Health Questionnaire-2 screen is a two-item self-report that inquires about the frequency of depressed mood and anhedonia over a two week period. The purpose of the PHQ-2 is to screen for depression in a “first step” approach. The PHQ-2 includes the first two items of the PHQ-9, which screens for and diagnoses depression based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. All patients seen in primary care settings should complete screening with the PHQ-2 annually. Patients who screen positive on the PHQ-2 should be further evaluated with the PHQ-9, other diagnostic instruments, and a direct interview. The PHQ-2 has a reported sensitivity and specificity of between 82% to 97% and 78% to 91%, respectively, for major depression using a cut off score of ≥ 3.28

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PATIENT HEALTH QUESTIONNAIRE-2: SCREENING INSTRUMENT FOR DEPRESSION OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY ANY OF THE FOLLOWING PROBLEMS?

NOT AT ALL

SEVERAL DAYS

MORE THAN ONE-HALF THE DAYS

NEARLY EVERY DAY

Little interest or pleasure in doing things

0 1 2 3

Feeling down, depressed, or hopeless

0 1 2 3

NOTE: If the patient has a positive response to either question, consider administering the Patient Health Questionnaire-9 or asking the patient more questions about possible depression. For older adults, consider the Patient Health Questionnaire-9 or the 15-item Geriatric Depression Scale. A negative response to both questions is considered a negative result for depression. Patient Health Questionnaire-9

The nine-item Patient Health Questionnaire or PHQ-9 is a validated self- or interviewer-administered instrument that assesses patient symptoms and effects on functioning, according to DSM criteria.29,30 The PHQ-9 can be administered in less than two minutes and it is simple to score, easily understood, and available in multiple languages. It can be a powerful tool to assist clinicians with assessing depression and monitoring treatment response.

Specifically, the PHQ-9 can help track a patient’s overall depression severity as well as the specific symptoms that are improving (or not) with treatment. PHQ-9 scores have been validated against the DSM using independent structured interviews. Validity has been assessed against an independent structured mental health professional interview. A PHQ-9 score ≥10 had a sensitivity of 0.88 and a specificity of 0.88 for major depression.29,30

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PATIENT HEALTH QUESTIONNAIRE-9: SCREENING INSTRUMENT FOR DEPRESSION OVER THE PAST TWO

WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY ANY OF THE FOLLOWING

PROBLEMS?

NOT AT ALL

SEVERAL DAYS

MORE THAN

ONE-HALF THE DAYS

NEARLY EVERY DAY

Little interest or pleasure in doing things

0 1 2 3

Feeling down, depressed, or hopeless

0 1 2 3

Trouble falling or staying asleep, or sleeping too much

0 1 2 3

Feeling tired or having little energy

0 1 2 3

Poor appetite or overeating 0 1 2 3

Feeling bad about yourself—or that you are a failure or have let yourself or your family down

0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

0

1

2

3

Thoughts that you would be better off dead, or of hurting yourself in some way

0 1 2 3

Total: ____+ ____+ ____

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Interpretation:

Total score

Depression severity

1 to 4 Minimal

5 to 9 Mild

10 to 14 Moderate

15 to 19 Moderately severe

20 to 27 Severe

Adapted from patient health questionnaire (PHQ) screeners Interpreting the PHQ-9

Research has shown that certain scores on the PHQ-9 are strongly correlated with a subsequent major depression diagnosis. However, not everyone with an elevated PHQ-9 is certain to have major depression.29,30 The PHQ-9 is intended as a tool to assist clinicians with identifying and assessing depression but is not a substitute for diagnosis by a trained clinician. A positive response to the screen does not necessarily indicate that a patient has depression. However, a positive response does indicate that a patient may have symptoms of possible depression and that further investigation of symptoms by a mental health professional may be warranted.29,30

Those screening positive for moderate, moderate-severe, or severe depression should be further evaluated and assessed for the presence of depression. Moreover, patients that have a positive response to question #9 should be further assessed for suicidal ideations and/or intent.29,30 This strategy increases a clinician’s ability to detect depression and to initiate

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appropriate referral and treatment. Proper triage should occur within 24 hours of the screen indicative of possible depression.29,30 Monitoring Depression with the PHQ-9

The PHQ-9 can be used to monitor the severity of depressive symptoms and to assess response to treatment. PHQ-9 scores of 5 points or higher reliably indicate mild depressive symptoms. Scores of 15 points or higher reliably indicate moderate to severe impairment from depression.29,30 Screening Recommendations for PHQ-2 and PHQ-9

The PHQ-2 should be completed annually on all patients seen in primary care settings. Patients who screen positive on the PHQ-2 should have both a documented assessment using a quantitative questionnaire to further assess whether the patient has sufficient symptoms to warrant a diagnosis of clinical major depression and a full clinical interview that includes evaluation for suicide risk.31,32

Patients with certain medical illnesses (i.e., Hepatitis C starting interferon treatment or post-myocardial infarction) may be at higher risk for developing depression and should be given a diagnostic assessment tool such as the PHQ-9 when depression is suspected. Caution should be used in screening elderly subjects because screening instruments may not perform as well as to detect depressive disorder in elderly with chronic physical diseases including diabetes, chronic obstructive pulmonary disease/asthma, and coronary artery disease.33

Grieving in the Veteran Population

Although research into the prevalence and intensity of grief symptoms in war veterans is limited, clinicians recognize the importance for veterans of grieving the loss of comrades. Grief symptoms can include sadness, longing, missing the deceased, non-acceptance of the death, feeling the death was unfair, anger, feeling stunned, dazed, or shocked, emptiness, preoccupation

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with thoughts and images of the deceased, loss of enjoyment, difficulty in trusting others, social impairments, and guilt concerning the circumstances of the death.

Recent research results have supported findings in the general bereavement literature that unresolved grief could be detected as a distress syndrome distinct from depression and anxiety. In a sample of combat veterans, grief symptoms were detected at very high levels of intensity, 40 years post-loss.34 The authors stated that “few studies have longitudinally examined predictors of posttraumatic stress disorder (PTSD) in a nationally representative sample of US veterans. The National Vietnam Veterans Longitudinal Study (NVVLS) is a follow-up study of Vietnam theater veterans (N = 699) previously assessed in the National Vietnam Veterans Readjustment Study (NVVRS), a large national-probability study conducted in the late 1980s.”34 The authors reported that they assessed 22 premilitary, warzone, and post-military variables to determine the current severity of warzone-related PTSD symptom severity in male veterans participating in the NVVLS. Data included a self-report Health Questionnaire survey and a computer-assisted telephone Health Interview Survey. Primary outcomes were self-reported PTSD symptoms assessed by the PTSD Checklist for DSM-5 (PCL 5) and Mississippi PTSD Scale (M-PTSD).34

The intensity of symptoms experienced after forty years was similar to

that reported in community samples of grieving family members at six months post-loss. This supports clinical observations that unresolved grief, if left untreated, can continue unabated and increases the distress load of veterans. Traumatic Grief

Traumatic grief refers to the experience of the sudden, unexpected loss of a significant and close attachment.35 Having a close buddy, identification with soldiers in the unit, and experiencing multiple losses were the strongest predictors of grief symptoms in the above sample of Vietnam veterans. Other factors that may influence the development of prolonged grief syndrome include: survivor guilt, feelings of powerlessness in not being able

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to prevent the death, anger at others who are thought to have caused the death, anger at oneself for committing a self-perceived error resulting in the death, tasks of survival in combat taking precedence over grieving, not being able to show emotional vulnerability, numbing and defending against overwhelming emotions, not having an opportunity in the field to acknowledge the death, and an increased sense of vulnerability by seeing someone close killed.36

Factors important in the Iraq War may include exposure to significant numbers of civilian casualties, exposure to death from friendly fire or accidents resulting from massive and rapid troop movements, and concern about culpability for having caused death or harm to civilians in cities. These factors may contribute to experiences of shock, disbelief, and self-blame that increase risk of traumatic and complicated grief reactions.37 Acute Traumatic Grief

Survivors of traumatic events can experience acute symptoms of distress including intense agitation, self-accusations, high-risk behaviors, suicidal ideation, and intense outbursts of anger, superimposed on the symptoms of normal bereavement. For example, a soldier in combat may act wildly heroic to save a comrade or recover a comrade’s body. Some soldiers have reacted with rage at the enemy, risking their lives with little thought of the danger ("gone berserk" or "kill crazy"). Other soldiers withdraw and become loners, seldom or never again making friends; and, some express extreme anger at the events and personnel that brought them to the conflict.

There are soldiers who are inclined to mask their emotions, believing that any sign of vulnerability or "losing it” may indicate that they are not tough enough to handle combat. Delaying grief may well postpone problems that can become chronic symptoms weeks, months, and years later. The returning veteran who has developed PTSD and/or depression may be masking grief symptoms.38

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Complications of Bereavement

Bereavement is a universal experience. Intense emotions, including sadness, longing, anger, and guilt, are reactions to the loss of a close person.38 Intense emotions are common in the initial phases of grieving. Often, individuals experiencing a loss and deep grieving will have accompanying somatic sensations, such as gastrointestinal symptoms, shortness of breath, intense fatigue, feeling faint, agitation, and helplessness. Lack of motivation, loss of interest in outside activities, and social withdrawal are also fairly common.38

A person experiencing normal grief will have a gradual decline in symptoms and distress. When grief symptoms persist for a prolonged period of time at severely discomforting levels, a referral to a bereavement therapist should be considered. If intense symptoms persist after six months, a diagnosis of complicated grief can be made and this is an indication for clinical intervention.38 Complicated grief prolonged over time has been shown to have negative effects on health, social functioning, and mental health.38

Sometimes sustained and intense grief can become a chronic

debilitating condition.38 Approximately one in ten bereaved people experience complicated grief, with higher rates amongst those bereaved by disasters or violent death, or with parents who lose a child. Complicated grief involves prolonged experiences of grief, usually for more than one year, intense yearning for the deceased; and, rumination about their death, ongoing reactive distress related to their death, i.e., anger, bitterness and self-blame, and a sense that life is futile or meaningless, detachment from others.39

For veterans who have experienced the death of a close friend or relative

at least 12 months earlier, they should be asked if they have experienced any of the following symptoms more days than not at levels that impair functioning and cause significant distress.39-42

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● Persistent yearning for and/or preoccupation with the deceased ● Reactive distress to the death, i.e., difficulty accepting the death,

emotionally numb, bitterness related to death and difficulty having positive feelings related to the deceased

● Disruption of social roles and identity, i.e., difficulty trusting and feeling detached from others, feeling that life is meaningless without the deceased.

If the patient endorses more than one of the above experiences, further

assessment of complicated grief is warranted. Veteran’s who experience complicated grief will have prolonged painful emotions and sorrow often lasting more than one year. A new consensus is that 7% to 10% of bereaved individuals experience prolonged grief with symptoms of intense and chronic reactions to a loss.42 They are at risk of developing mental health and physical health issues. Complicated grief can be a risk factor for suicide. The clinician should ask about suicidal ideation using direct and unambiguous questions.39-

42

Complicated grief symptoms including sadness, distress, guilt, anger, intrusive thoughts, and preoccupation with the deceased after six months during a normal grieving process warrants clinical intervention. There are several instruments that may be helpful in assessing complicated grief in a veteran. The Inventory of Complicated Grief-Revised is perhaps most widely used and reflects current bereavement research. Another instrument is the Texas Revised Inventory of Grief, which has been used in a variety of populations and has been well validated. The US Department of Veteran Affairs has a helpful website that lists all measures for providers who are assessing veterans suffering from grief and trauma-related disorders.43,44 Such measures allow comparisons with normative populations.

Risk of Veteran Suicide

Suicide prevention experts usually use the term suicide screening to refer to a procedure in which a standardized instrument or protocol is used to identify individuals who may be at risk for suicide. Suicide screening can be

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done independently or as part of a more comprehensive health or behavioral health screening. Screening may be done orally (with the screener asking questions), with pencil and paper, or by using a computer.

Suicide assessment usually refers to a more comprehensive evaluation done by a clinician to confirm suspected suicide risk, estimate the immediate danger to the patient, and decide on a course of treatment.44,45 Although assessments can involve structured questionnaires, they also can include a more open-ended conversation with a patient and/or friends and family to gain insight into the patient’s thoughts and behavior, risk factors (i.e., access to lethal means or a history of suicide attempts), protective factors (i.e., immediate family support), and medical and mental health history.44,45

Suicide assessment is characteristically used when there is some

indication that an individual is at risk for suicide; for example, when a patient has been identified as such by a suicide screening or a clinician notices some signs that a patient may be at risk. Suicide assessment is also used to help develop treatment plans and track the progress of individuals who are receiving mental health treatment because they have been assessed as being at risk for suicide.44-46

Suicide and other forms of suicidal self-directed violence are a persistent

and growing public health problem for the U.S. and for U.S. veterans. The VA National Suicide Data Report provided new findings about veteran suicide “based on National Death Index mortality data through 2016 for all 50 states and the District of Columbia.”46 The report focused on both veterans who had used and have not recently used Veterans Health Administration (VHA) services, comparing suicide rates among veterans with non-veteran adults in the United States.46,47 The report considered counts, rates, and breakdowns by suicide method among varied veteran populations, such as women, former and reserve members, and varied age groups.46,47 Key points included in the VA National Suicide Data Report are listed below.46,47

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● 2008 - 2016: > 6,000 veteran suicides each year ● 2005 - 2016: Suicide rates increased 25.9 percent for veterans and 20.6

for non-veteran adults ● 2015 - 2016: There was a decrease from 30.5 per 100,000 population to

30.1 per 100,000 population in veteran suicide rates. ● 2016: After adjusting for age and gender, the suicide rate was 1.5 times

greater for veterans than for non-veteran adults ● 2016: 69.4 percent of veteran suicides were caused by a firearm injury.

As compared to non-veteran adults in the U.S., 48.4 percent of suicides resulted from a firearm injury.

● 2015-2016: No increase in the suicide rates for veterans ages 35–54, 55–74, and 75 and older.

● 2015 - 2016: Veterans ages 18–34 had a substantial increase in the suicide rate (40.4 suicide deaths per 100,000 population in 2015; 45 suicide deaths per 100,000 population in 2016).

● 2016: Veterans who recently used VHA services had higher rates of suicide than Veterans who did not recently use VHA services (considering unadjusted and age-adjusted suicide rates). Veterans using VHA services “have physical and mental health care needs and are actively seeking care because those conditions are causing disruption in their lives. Many of these conditions — such as mental health challenges, substance use disorders, chronic medical conditions, and chronic pain — are associated with an increased risk for suicide.”47

● 2005 - 2016: Suicide rate among veterans in VHA care had a lower increase (13.7 percent) than among veterans not in VHA care (26.0 percent).

● 2016: Suicide rate for women veterans was 1.8 times greater than the suicide rate for non-veteran women (after adjusting for age).

● 2005-2016: Suicides among federally activated National Guard and Reserve former Service members increased.

Statistics have shown that all veteran men and women are at greater

risk for suicide than the general population. Some study results show that psychological distress still exists many years after deployment. For this

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reason, a suicide risk assessment is vital to perform in all psychiatric interviews.

Assessing a patient requires effective communication skills for interviewing, behavioral observation, and comprehensive assessment of the patient and relevant systems.47 This enables the clinician to make clinical judgments and plan appropriate interventions with the patient. Furthermore, the use of an assessment tool can only help in evaluating the patient. The provider must use every skill and resource available to achieve the ultimate goal of prevention of suicide attempts and completions.

Whether or not all veterans are at increased risk, suicide rates are substantially increased among those who use VHA health care services. The VA National Suicide Data report stated that the “number of Veteran suicides per year decreased from 6,281 deaths in 2015 to 6,079 deaths in 2016 (Figure 1). The number of Veteran suicides in 2016 remains greater than the 5,797 Veteran suicides that occurred in 2005. From 2005 to 2016, the Veteran population decreased by about 4 million people. Given that the Veteran population decreased in size, the number of Veteran suicides per year can also decrease even while the rate of Veteran suicide increases.”47

The VA examined the rates of U.S. veteran and non-veteran adults and

used unadjusted, or crude rates as a helpful means to better understand the mortality for each population group. As noted above, in 2016 the unadjusted suicide rate among veteran adults/100,000 were higher than non-veteran adults. The researchers stated that when making comparisons it is important to adjust for differences, i.e., population age and gender. They pointed out that the veteran population is “older and has a higher percentage of men compared to the non-veteran population.”47 The study authors also noted that in 2016, the age- and gender-adjusted rates of suicide were higher in veteran than non-veteran adults; and that the suicide rates for both veterans and non-veteran adults increased between years 2005 and 2016.47

The suicide count and rate among women veterans between 2005 and 2016, showed an increase in the suicide count, which coincided with the

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women veteran population.47 The suicide rate among women veterans was higher than non-veteran women. The suicide rate among women veterans showed a decrease between 2015 and 2016, however this was reportedly not statistically significant.47 Suicidal Ideation

Suicidal events often start with suicidal ideations and progress over minutes, days, or years toward suicidal and potentially injurious behaviors. Each step along this progression presents an opportunity to intervene to prevent a suicidal attempt. Suicidal ideations are thoughts of suicide-related behaviors and/or wanting to die in a self-inflicted manner. Early identification of suicidal ideations before suicide attempts is critical as it provides the greatest opportunity to reduce risk of suicide injuries and death.48

Important aspects to consider while inquiring about suicidal ideations

include onset, duration, intensity, frequency, active versus passive nature, plan lethality, recent stressors, relieving and aggravating factors, association with substance use, and level of comprehension of potential outcomes of actions.48 Suicidal intent should also be assessed and involves explicit or implicit evidence that the person wants to die, has the ability to act on thoughts, and understands the potential outcome of the actions.

Factors to consider while evaluating suicidal intent include impulsivity, amount of determination to act, and strength of desire to die.48 Suicidal or preparatory behaviors include any behavior that indicates preparation for self-directed death. Inquiry may comprise questions about practicing a suicidal plan, seeking a location for the event, determining the likelihood of rescue, lethality of plan, and making life changes to prepare for self-directed death.48 In addition to inquiring about suicidal ideation, intent, and behavior in a patient at risk for suicide, risk factors should also be considered.

Ideally, a patient is identified before any suicidal behavior occurs. Early identification of suicidal ideation presents the greatest opportunity to reduce the risk of suicide attempt and death. The suicide continuum is understood to

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begin with suicidal thoughts, evolving into a wish to die, consolidated into an intention to act, and resulting in a methodology or plan formulated to end one’s life.48,49 The evolution of these steps can vary from being very quick to taking years. Each step along the continuum presents an opportunity to intervene and prevent the act of suicidal self-directed violence. All too often, a patient is identified after a suicide attempt is made. Often the first opportunity to assess an individual’s suicide risk occurs because of the demonstration of warning signs that are identified by a caregiver, gatekeeper, or loved one. Recognition of warning signs is the key to creating an opportunity for early assessment and intervention.48,49

Suicide risk assessment is not absolute. There are no clear, validated

predictive models or risk stratification definitions. Many guidelines will recommend a three-tier stratification system to define those patients in need of immediate intervention in order to prevent a suicide attempt, at elevated risk of suicidal behavior in the future and in need of a clinical intervention, and where the risk of suicide is not significantly elevated but the individual may benefit from an intervention. The stratification of assigned level of the acute risk of suicide (high, intermediate, and low) was developed by consensus.48,49 The importance of determining the level of risk is that it will inform the decision made to select a care setting, and the management and treatment plan to follow.48,49 Suicide Risk Factors Although healthcare professionals have an opportunity to identify at-risk individuals and engage them in treatment to reduce suicidal self-directed violence, many health clinicians are uncertain how to assess for suicide risk. Several risk factors for suicide and suicidal self-directed violence have been identified, most notably older age, male gender, physical and mental health disorders (including depression and substance use disorders), familial and genetic influences, impulsivity, poor psychosocial support, and access to and knowledge of firearms.48-50, Several psychological autopsy studies of the events leading up to suicide have suggested the majority of individuals who

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die by suicide exhibit symptoms of depression or other mental health issues prior to death.

The relative importance of some of these traditional risk factors, as well as the influence of population-specific risk factors, may be unique among military personnel and veterans. The prevailing male demographic, along with high rates of post-traumatic stress disorder, substance use disorders, and other mental health disorders, may especially contribute to the risk of suicidal self-directed violence in military and veteran populations. In addition, several aspects of military experience can increase the risk for mental health and substance use, which in turn are risk factors for suicide.51 Other risk factors unique to the military experience could also contribute to overall suicide risk, including military rank, combat exposure, traumatic brain injury, habituation to violence, and deployment-related stressors (i.e., strained or long distance relationships, relocation, post-deployment adjustment).51,52

Many military and veteran personnel will have one or more of these

individual risk factors, but relatively few of them are truly at-risk for suicidal self-directed violence. Suicide risk assessment tools need to account for the relationship among these different risk factors and identify risk factors or combinations of risk factors that are particularly associated with suicidal self-directed violence.51,52 To be practically useful, risk assessment tools would identify a threshold beyond which preventive action should be taken and be brief enough to be conducted in primary care settings where many of the at-risk persons may be seen. Ideally, such tools would identify all persons truly at-risk for suicidal self-directed violence (i.e., have high sensitivity), while minimizing misidentification of persons who are not truly at high-risk (i.e., high specificity) because subsequent preventive therapies may be time-consuming and costly.52

Risk assessment tools should be able to identify those at high- and low-risk for suicidal self-directed violence. The challenges of identifying those at risk of suicide require an enhanced understanding of suicide risk assessment in military and veteran populations.52 It is necessary for primary care and mental health clinicians to review the available evidence for risk factors and

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assessment tools developed for use in healthcare and other community settings that have been tested with veteran and military populations. Three direct warning signs are particularly indicative of suicide risk; these are when the patient is communicating suicidal thoughts verbally or in writing, is seeking access to lethal means such as firearms or medications, and is demonstrating preparatory behaviors such as putting personal affairs in order.52 Presence of one or more of these warning signs is a strong indication that further assessment is needed.

The evidence is insufficient to recommend a specific suicide risk assessment tool that can predict those who will commit suicide with definitive accuracy. In addition, there is a lack of validated predictive or risk stratification models. However, a comprehensive clinical assessment informed by identified risk factors in combination with an assessment of content of suicidal thoughts and behaviors may improve risk management and allow opportunities for intervention.53 Although not intended to be all-inclusive, the aim of the following section is to discuss key risk factors for suicide, including those that are particularly applicable to the veteran population. Demographic and Family History Factors

Some of the known demographic risk factors for suicide in veteran and nonveteran populations include Caucasian race, male sex, adolescence, and old age. Younger age, marital status, lower education level, and unemployment are also possible risk factors for suicidal behaviors. Other risk factors include childhood maltreatment and family history of suicidal behavior and mental disorders.53 Demographic and family history factors add a potentially predictive component to overall suicide risk assessment and may act as moderating agents for other, more modifiable risk factors. Psychiatric Factors

Prior suicidal behavior is a strong risk factor for future suicide in veteran and nonveteran populations. Clinicians should consider screening for prior suicide attempts and inquiring about the details surrounding any past suicidal

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events, including seriousness of intent and lethality of attempt. While a history of suicidal behavior is a clear predictor of suicide risk, the most common risk factor for suicide is the presence of psychiatric illness. Detection of certain mental health disorders with subsequent behavioral health referral or treatment may affect suicide risk. Depression, PTSD, and substance use disorders have a high prevalence in veteran populations and in primary care settings.53

Depression has been identified as a key risk factor for suicide and, as mentioned, is prevalent in veteran and nonveteran populations and commonly encountered in primary care. Studies suggest a need for improved assessments of depression and suicide risk, detection of comorbid substance use, optimization of psychiatric management, and adherence to guideline-based treatment in patients with depression.53 In addition, veterans often have difficulty disclosing symptoms of depression. The use of validated depression screening tools in this population may be particularly useful; as suggested previously, veterans have been reported to have positive depression screens 6 to 12 months, and this could occur after an initial negative, immediate post-deployment screen. Reassessment for mental health disorders, such as depression, may be warranted, even after an initial negative screen.53

Post-traumatic stress disorder has been described as a clinical syndrome

characterized by various combinations of intrusive experiences, avoidance, and hyperarousal behaviors following exposure to a trauma or stressor. A 2013 literature review of PTSD and suicide risk among veterans showed a significant association between PTSD and increased risk for suicidal ideations, attempts, and completions in veterans.54 These findings are of particular concern considering PTSD has been reported in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans receiving VA care. Even subthreshold PTSD symptoms have been found to be associated with increased expression of hopelessness and suicide ideations.54

Substance use disorders are highly prevalent in the veteran population

and associated with an increased risk for suicide.55 The VA has stated that

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“More than 2 of 10 Veterans with PTSD also have SUD. Almost 1 out of every 3 Veterans seeking treatment for SUD also has PTSD. The number of Veterans who smoke (nicotine) is almost double for those with PTSD (about 6 of 10) versus those without a PTSD diagnosis (3 of 10). In the wars in Iraq and Afghanistan, about 1 in 10 returning Veterans seen in VA have a problem with alcohol or other drugs. War Veterans with PTSD and alcohol problems tend to binge drink. Binge drinking is when a person drinks a lot of alcohol (4-5 drinks or more) in a short period of time (1-2 hours).”56

Comorbid psychiatric disorders may further increase the risk for suicidal

behavior in veterans with substance use disorders. In addition to routine, repeat assessments for substance use in individuals at risk for suicide, the VA/DoD guideline recommends intoxicated patients at acute risk for suicide be monitored in an acute care setting and reassessed after they are sober.57

Access to Means

Access to means is another established risk factor for suicide and is particularly relevant to the veteran population. Male veterans are more likely to use firearms to complete suicide than the general population, and guns are the most common means of suicide among male veterans. Furthermore, higher rates of firearm ownership have been associated with higher rates of suicide by firearms.58 Evidence supports the effectiveness of means restriction as a suicide prevention strategy. Veterans Health Administration suicide prevention initiatives include a gun safety program comprising distribution of gun locks and safety literature, as well as discussions of safe storage of firearms with patients and their families, particularly when veterans are experiencing crises.58

Protective Factors

Protective factors are personal qualities and environmental resources that may buffer the risk for suicide. Examples include good impulse control, strong bonds to family, responsibilities to others, and spiritual and religious beliefs. While evidence on protective factors is limited, clinicians are

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encouraged to incorporate protective factors in risk formulations and treatment planning.59

Once assessment is complete, clinicians should consider all gathered information to formulate the patient's level of risk in one of the following three categories: high risk, intermediate risk, and low risk.60

High Risk:

High risk includes patients with a recent suicide attempt, serious suicidal thoughts or plans and limited impulse control. The patient requires constant observation and monitoring while arranging for immediate transfer for psychiatric evaluation or hospitalization. Intermediate Risk:

Intermediate risk comprises patients with current suicidal ideations but with good impulse control and no intent or preparatory behavior; individuals identified to be at intermediate risk in primary care settings should be evaluated by a behavioral health professional. Low Risk:

Low risk includes patients with recent suicidal ideations who have good impulse control and no current suicidal thoughts, plans, or intent; patients identified as low risk in primary care should be considered for referral to a mental health clinician.

Suicide Risk Prevention

The VA has adopted a multifaceted approach to develop a comprehensive suicide prevention program and reduce suicide in the veteran population. This effort includes an increase in resources and funding to allow ready access to high-quality mental health treatment, suicide prevention research and data collection, mandated staff education, and improved peer-

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support services. In addition, VA medical centers have added suicide prevention coordinators, staff members who are primarily responsible for coordinating mental health care for veterans at risk for suicide and educating patients, health professionals, and community stakeholders about suicide risk and prevention.54 Intervention and prevention activities target veterans who show imminent risk, short-term risk, and long-term risk.

Selective prevention focuses on veterans with known risk factors for suicide. Individuals with only unmodifiable risk factors may be monitored more closely than other veterans. The modifiable risk factors most commonly targeted are PTSD, depression, and other mental health disorders associated with the risk of suicide.54 Interventions designed to improve the care and outcomes of mental health disorders apply to veterans of all eras including the oldest age veterans who are in the demographic subgroup of the general population whose rate of suicide is the highest.54,61

Interventions to reduce the symptoms and outcomes of mental disorders include access to evidence-based psychiatric treatments as well as evidence-based services delivery models. For example, the VHA supports several primary care models of mental health care, including co-location of mental health professionals into primary care clinics and collaborative care models including the use of depression care managers in primary care.61 Indicated prevention interventions focus on individuals who have expressed suicidal thoughts and behaviors. The interventions therefore specifically target suicide and not just proximal risk factors. At the system level, interventions include training clinicians in high suicide risk management and supporting suicide crisis lines for veterans. At the patient level, interventions include intensive monitoring and safety plans for such high-risk patients and evidence-based pharmacotherapy and psychotherapy treatments for suicidal risk.61

Case Study: PTSD in an Afghanistan Veteran

The following case study was obtained from PubMed and involves a 32-

year-old Afghanistan war veteran who had been experiencing PTSD symptoms

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for more than five years.62 She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck.

The authors reported that the patient became increasingly depressed and began using alcohol on a daily basis to help relieve her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children. In addition to a range of other PTSD symptoms, she had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly to repair it. Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed.”62

After a thorough assessment of her PTSD and comorbid symptoms,

psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, the patient received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings. These worksheets were used to sensitize the patient to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on.” She recorded her related feeling guilt. The patient’s therapist used this worksheet as a starting point for engaging in Socratic dialogue.

The patient reported experiencing 100 percent intensity of guilt and 75

percent intensity of anger at herself in relation to the thought "I should have seen the explosive device to prevent my friends from dying."62 She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information

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(because others don't blame her), and that her feelings are not based on facts (i.e., she feels guilt and therefore must be guilty). The alternative thought raised in therapy was that "The best explosive devices aren't seen and Mike (driver of the second truck) was a good soldier. If he saw something he would have stopped or tried to evade it."62 She rated this thought as 90% confidence in believing. She consequently believed her original thought at a significantly reduced level of 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self. Discussion

The patient was evaluated as having a high level of guilt over her friend’s death. She reportedly had responded to the traumatic event with the statement “I should have seen the explosion was going to happen to prevent my friends from dying.”62 Her related feelings were guilt and self-directed anger.

The therapist used the patient’s guilty thoughts to introduce the cognitive intervention of "challenging thoughts" and provided a worksheet for practice. The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors.

VA Study: Opioid Safety and Veteran’s Suicide

The following research report by the Veteran’s Health Administration was obtained through a PubMed search. This report discusses the development of system wide protocol for opioid prescribing and safety and corresponding data on death by suicide among veteran populations.63

The researchers begin by noting the increase of pain treatment with

prescription opioids over the past several decades. Veterans, especially those

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returning home from combat, will often report chronic physical pain management. The increase of opioid use has corresponded with an increase of adverse drug reactions that include suicide by intentional overdose. The authors reported that drug-related suicide attempts have increased by more than 50% between 2005 and 2007, and overdose with opioid use rates tripled from 1999 to 2006, and these adverse events continue to grow.

System-focused interventions with the Department of Veterans Affairs

(VA) “took the lead in 2003 in joining the Department of Defense (DOD) to formulate specific clinical practice guidelines on healthcare provider- and facility-level practices to maximize safe use of opioid treatment for chronic pain. Building upon this and others’ work, VA/DOD updated and revised these recommendations in 2010. Soon thereafter, Midboe and the VA Opioid Metric Development Team used expert consensus procedures and national VA electronic patient treatment data to generate a panel of metrics that define and measure the implementation of the main recommendations of the 2010 VA/DOD clinical practice guidelines for opioid therapy for pain. These metrics tap a total of eight recommendation domains (e.g., postprescription clinical follow-up, avoidance of opioid-only pain treatments), and include the recommendation to order appropriate lab tests, including urine drug screens (UDS), for all opioid-prescribed pain patients.”63 In their research, the authors focus on the implementation of the VA/DOD UDS recommendation as a leading strategy of opioid-management and the use of UDS as it correlates with patient treatment outcomes.

The VA/DOD UDS recommendation is based upon the following rationale

to promote safe opioid prescribing:63

● Urine drug screens help clinicians detect use of illicit drugs by opioid-prescribed patients and to monitor patient adherence to the prescribed medication.

● UDS help guide clinicians in ongoing opioid therapy decision making ● UDS enhances clinician-patient communication about the risks and

benefits of opioids ● UDS contributes to clinicians’ satisfaction, confidence, and sense of

mastery in opioid treatment

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The authors emphasized that not enough is known about the effects of UDS on opioid-prescribed patients’ health outcomes, including the risk of suicide- and overdose-related events. Links between healthcare facility-level UDS practices and suicide-related drug overdose events among opioid-prescribed patients would require a large, robust study. One recent large study showed that VA treated patients prescribed opioids and followed up with UDS were found to be at lower risk of suicide attempts than in facilities where fewer UDS were ordered. However, this study data was limited to 2010, which the authors noted was the first year that VA/DOD opioid-therapy guidelines were initiated within the national VA healthcare system.

Since 2010, prior studies that reviewed facility adherence to the VA

healthcare UDS guidelines have allowed researchers to determine how well the UDS implementation rate has influenced veteran risk of suicide and drug overdose events among opioid-prescribed patients. In this study, the researchers focused on the changes within the VA UDS guidelines over a 4 year period (2010–2013) within the entire system and rate of opioid-prescribed patients’ risk of suicide- and overdose-related events. They reported that since VA/DOD opioid-therapy guidelines were implemented system-wide in 2010, the authors identified that VA facility practices to follow the UDS guidelines had increased nationwide (average drug-screening coverage of opioid-prescribed patients increased from approximately 29% to 42%). Also, they discovered that in 2010 and 2013 “the percentage of VA opioid-prescribed patients who received UDS was 2 to 6% in facilities with the lowest UDS coverage and exceeded 75% in facilities with the highest UDS coverage.”63 System-wide longitudinal data was reviewed to determine 4-year within-facility rates of change in the delivery of UDS to VA opioid-prescribed patients, and the authors reported variability among the facilities relative to implementation rate, which they attributed to clinical decision-making.

Veterans who underwent UDS in 2012 were found to be at elevated risk

of subsequent suicide and overdose events, which the authors suggested had something to do with clinician recognition of patient risk and selection. The authors also opined that because the “VA/DOD guideline’s UDS recommendation was based solely on expert consensus and not on research

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evidence, clinicians may not be convinced of the value of UDS outside of the context of suspected substance misuse or medication diversion.”63 They also considered facility-level barriers and variation in clinician skills to interpret UDS. They noted there was significant variability among VA facilities to implement the VA/DOD opioid treatment recommendation to enhance opioid-prescribed patients’ safety, and suggested VA facilities needed encouragement to carry out the UDS recommendation through increased dissemination of research evidence regarding UDS as a way to improve opioid therapy safety.

Discussion

The authors suggested that UDS has a positive effect on clinician

confidence and comfort to prescribe opioid, however there is a paucity of published evidence supporting the benefit of UDS on opioid-prescribed patient health and safety. Veterans receiving opioid treatment where UDS implementation was practiced (2010–2013) showed a reduced risk of suicide and overdose events in 2013. The authors reported that “even modest boosts in UDS at the facility-level pay off in some subsequent reduction of suicide and overdose events at the patient level. This is an important outcome given that suicide and overdose are arguably the most serious adverse medical events associated with opioid therapy.”63 However, while higher UDS levels appear more attainable in medical centers with advanced laboratory and other clinical resources, more rural or smaller community hospitals may not carry the same resources.

The authors reported that they could not conclude “UDS alone predicts

subsequent suicide/overdose risk.”63 Prior VA studies had proposed that the “additive effects of multiple guideline-concordant activities in VA facilities, or related elevations in their overall quality improvement efforts, rather than UDS practices alone, may account for the reduced risk of suicide and overdose events observed here.”63 The authors in this VA study maintained that prior data “may not be completely accurate because we cannot be certain of patients’ opioid prescription compliance. MCA pharmacy data only indicate whether a patient has filled an opioid prescription and not his or her opioid use. Moreover, this data source does not inform us of opioid-prescribed

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patients’ medical treatments and adverse health events occurring outside the VA healthcare system. Finally, we do not know whether the findings reported here are generalizable to non-VA healthcare systems or to non-VA opioid-prescribed patients.”63

Despite study limitations, the authors concluded that their findings and

prior foundational work of other VA researchers allowed for more reliable data generation, study interpretation, and recommendations to implement UDS guidelines based on opioid-prescribed patient health outcomes. Additionally, the authors proposed that study follow up of UDS guideline adherence and patient risk or outcomes would help to develop clinical knowledge of opioid treatment recommendations, sustain UDS practices, and of preventive impact of UDS on adverse medical events. They suggested that “further research should aim to identify clinician- and healthcare facility-level factors that pose barriers to or predict faster and more thorough implementation of VA/DOD opioid therapy guideline recommendations. This information can support the formulation of clinician- and facility-level interventions to support faster and more complete implementation of VA/DOD clinical treatment guidelines to facilitate safer opioid therapy for pain patients.”63

The authors of this study believe that the research on UDS in the

prevention of adverse events in opioid-prescribed veterans, including suicide risk and death by suicide, hold promise and that it supports a wider national action plan to improve opioid treatment safety for patients with issues of pain. They suggested that the VA research on the development of opioid treatment guidelines since 2010 can continue to be measured and prospectively evaluated relative to opioid-prescribed patient outcomes.

Summary

Military deployment may have a profound effect on military personnel, and understanding mental illness and how to screen, diagnose and treat mental illness is important for the healthcare professional. Veterans and their families may experience medical and mental health issues as they reintegrate into their communities during or after their terms of military service.

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Veterans from recent military conflicts have, or have been diagnosed

with post-traumatic stress disorder, major depression, or both PTSD and major depression at significant rates. These issues arise during deployment, as well as when veterans and their families confront reintegration into their communities.

Current and former members of the military may not always volunteer information about their military service. Furthermore, veterans may not be willing to share their experiences, especially when they cause them mental anguish. It is important for healthcare professionals to ask patients and their family members about military involvement to properly assess the risk of mental health conditions, including PTSD, depression, grief, and risk of suicide. With the right screening questions, mental health and primary care clinicians have the opportunity for early intervention to mitigate the impact of these conditions.

The VA/DOD opioid treatment guidelines were raised as an example of

system wide initiatives that were adopted by the VA system since 2010. Facility-level compliance with the UDS guideline were identified by the authors as essential to ensure improved safety of opioid therapy. The goal of the study was to evaluate VA system initiatives to ensure that veterans have access to pain relief using evidence-based practices that support clinicians to implement treatment that prevents the occurrence of adverse medical events associated with opioid therapy, including the risk of suicide and death by suicide as a result of opioid overdose.

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Self-Assessment of Knowledge Post Test: Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 1. Although each of the following are necessary for an effective

treatment program for mental disorders, the key to engagement and adherence to a treatment program is

a. the client’s education. b. the client’s understanding of mental illness. c. the client’s agreement to the treatment decision. d. the client knowing the options.

2. True or False: Screening involves an examination of a person

with symptoms to determine the specific medical condition that person has contracted.

a. True b. False

3. Screening for a mental disorder

a. replaces formal assessment of mental illness. b. is used in lieu of diagnosis. c. may be done by an untrained clinician. d. serves as a decision support tool.

4. When a veteran is referred to a mental health professional for

evaluation,

a. an initial evaluation should be done within 24 hours. b. a full evaluation should be done only if symptoms persist after 30

days. c. an initial evaluation should be done within 14 days. d. a full evaluation should be done within 24 hours.

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5. Veteran status is not always disclosed to a healthcare provider during behavioral health screening because

a. veteran status is not asked in traditional behavioral health

screenings. b. a patient’s military service is confidential. c. asking a patient about military service is not important. d. veterans routinely deny their service.

6. Exposure to which of the following events is NOT a basis for a

diagnosis of PTSD?

a. Witnessing, in person, the event(s) as it occurred to others. b. Learning that traumatic event(s) occurred to a close family

member. c. Learning that traumatic event(s) occurred to a close friend. d. Exposure to an event through media such as television.

7. True or False: There IS evidence that identifying primary

psychiatric symptoms early and formulating an effective treatment plan improves mental health outcomes.

a. True b. False

8. A diagnosis of PTSD under the criteria of the DSM-5 requires

duration of PTSD symptoms for what period of time?

a. There is no minimum period b. More than 1 month c. It depends on the objective severity of the event d. Not less than six months

9. Which of the following explains why patients are more likely

NOT to spontaneously report their trauma experiences or related symptoms?

a. Denial of veteran status b. No follow-up to confirm a veteran completed PTSD evaluation c. Avoidance of trauma reminders d. Traditional behavioral health screenings do not ask about veteran

status

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10. Reaction to a trauma is ____________, driven by an individual’s experience, sensibilities and personal situation.

a. objective b. straightforward c. subjective d. spontaneous

11. For patients in primary care settings, how often should the

Patient Health Questionnaire-2 (PHQ-2) be completed?

a. Annually b. Whenever a patient asks for the questionnaire c. Every two years d. Whenever a patient is symptomatic

12. True or False: A patient with an elevated Patient Health

Questionnaire-9 (PHQ-9) is certain to have major depression.

a. True b. False

13. A soldier in battle who reacts with rage at the enemy and who

risks his or her life with little regard to the danger of the situation may be exhibiting

a. suicidal ideation. b. chronic traumatic grief. c. severe impairment from depression. d. acute traumatic grief.

14. Which of the following is one of the three direct warning signs

particularly indicative of suicide risk?

a. Putting affairs in order b. Training with firearms c. Chronic traumatic grief d. Denial of veteran status

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15. A diagnosis of PTSD under the criteria of the DSM-5 requires a mental disturbance that

a. is caused by a medical condition. b. is attributable to substance use. c. causes clinically significant distress or impairment in functioning. d. All of the above

16. Suicide prevention programs that involve

__________________ may lower the rate of suicide in injured veterans or those suffering combat-related psychological and physical sequelae.

a. traditional behavioral health screenings b. deployment screening c. selective prevention d. multidisciplinary team members

17. An “After Action Review” (AAR) is a mechanism that allows

those affected by an event to review what happened and to

a. determine if any of the individuals has PTSD. b. put the event into perspective. c. be referred for an initial mental evaluation, if necessary. d. determine who was to blame for the event.

18. Which of the following screening tools is a self-reporting tool?

a. PTSD checklist (PCL5) b. DSM-5 diagnostic criteria for PTSD c. Davidson Trauma Scale (DTS) d. The Primary Care PTSD Screen (PC-PTSD)

19. True or False: Substance use disorders among the veteran

population is not associated with an increased risk for suicide.

a. True b. False

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20. Risk factors for suicide among veterans include

a. older age and male gender. b. veterans between the ages of 20-30 years of age. c. female gender. d. denial of veteran status.

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Reference Section

The References below include published works and in-text citations of published works that are intended as helpful material for further reading. 1. Keane TM, Chaudhry B, Docherty JP, Jesse RL, Lee J, McNurlen J, et al.

Caring for returning veterans: Meeting mental health needs. Vol. 74, Journal of Clinical Psychiatry. 2013; p. 22–8.

2. Evaluation of the Department of Veterans Affairs Mental Health Services. Clinical Management of Mental Health Conditions at the Veterans Health Administration. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division. Board on Health Care Services. Committee to Evaluate the Department of Veterans Affairs Mental Health Services. Washington (DC): National Academies Press (US). 2018; Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK499503/pdf/Bookshelf_NBK499503.pdf

3. Reisman, M. PTSD Treatment for Veterans: What’s Working, What’s New, and What’s Next. PT. 2016; 41(10): 623-627, 632-634.

4. Garcia HA, Finley EP, Ketchum N, Jakupcak M, Dassori A, Reye SC. A survey of perceived barriers and attitudes toward mental health care among OEF/OIF veterans at VA outpatient mental health clinics. Mil Med. 2014; 179(3):273–8.

5. Roy, M and Perkins, J. Medical care of the returning veteran. UpToDate. 2019; Retrieved from https://www.uptodate.com/contents/medical-care-of-the-returning-veteran?search=veterans%20and%20mental%20health%20screening&source=search_result&selectedTitle=7~150&usage_type=default&display_rank=7

6. Anderson, C, Hoelzle, J, Arbisi, P. Psychological Assessment of Veterans in Outpatient Mental Health Settings. In Psychological Assessment of Veterans. Ed. Shane S. Bush. Oxford: Oxford University Press. 2014; 17-50.

7. Hopp F, Whitten P, Subramanian U, Woodbridge P, Mackert M, Lowery J. Perspectives from the Veterans Health Administration about opportunities and barriers in telemedicine. J Telemed Telecare. 2012; 12:404–9.

8. Kuehner CA. My military: A navy nurse practitioner’s perspective on military culture and joining forces for veteran health. J Am Acad Nurse Pract. 2013; 25(2):77–83.

9. Fromson JA, Iodice KE, Donelan K, Birnbaum RJ. Supporting the returning veteran: Building linkages between clergy and health professionals. J Psychiatr Pract. 2014; 20(6):479–83.

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10. McKenzie G, Freiheit H, Steers D, Noone J. Veteran and Family Health: Building Competency With Unfolding Cases. Clin Simul Nurs. 2016; 12(3):79–83.

11. Penn, M, et al. Original Investigation: Health Policy Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Network Open. 2019; 2(1).

12. Institute of Medicine. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Initial Assessment. IOM. 2012; Retrieved from http://www.ncdsv.org/images/IOM_TreatmentForPTSDinMilitaryAndVeteranPopulationsInitialAssessment_FullReport_2012.pdf

13. Barrera TL, Mott JM, Hundt NE, Mignogna J, Yu HJ, Stanley MA, et al. Diagnostic specificity and mental health service utilization among veterans with newly diagnosed anxiety disorders. Gen Hosp Psychiatry. 2014; 36(2):192–8.

14. Allen, J, et al. Mixed methods evaluation research for a mental health screening and referral clinical pathway. Worldviews Evid Based Nurs. 2012; 9(3):172–85.

15. Erdtmann, F. Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations: Final Assessment. Mil Med. 2014; 179(12):1401–3.

16. Goldberg, J, et al. The association of PTSD with physical and mental health functioning and disability (VA Cooperative Study #569: The course and consequences of posttraumatic stress disorder in Vietnam-era Veteran twins). Qual Life Res. 2014; 23(5):1579–91.

17. Maguen, S, et al. Suicide risk in Iraq and Afghanistan veterans with mental health problems in VA care. J Psychiatr Res. 2015; 68:120–4.

18. Duax, JM, Waldron-Perrine, B, Rauch, SAM, Adams, KM. Prolonged Exposure Therapy for a Vietnam Veteran With PTSD and Early-Stage Dementia. Cogn Behav Pract. 2013; 20(1):64–73.

19. Conner, KR, et al. Posttraumatic stress disorder and suicide in 5.9 million individuals receiving care in the veterans’ health administration health system. J Affect Disord. 2014; 166:1–5.

20. Weathers, FW, et al. The PTSD Checklist for DSM-5 (PCL-5). Natl Cent PTSD. 2013; 5:2002.

21. Daggett, V, et al. Feasibility and satisfaction with the VETeranS Compensate, Adapt, REintegrate (VETS-CARE) intervention. Brain Inj. 2014; 28(5–6):554–5.

22. Tiet, QQ, Schutte, KK, Leyva, YE. Diagnostic accuracy of brief PTSD screening instruments in military veterans. J Subst Abuse Treat. 2013; 45(1):134–42.

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23. Lee DJ, Warner CH, Hoge CW. Advances and Controversies in Military Posttraumatic Stress Disorder Screening. Current Psychiatry Reports. 2014; 16:467.

24. Spoont, MR, et al. Screening for post-traumatic stress disorder (PTSD) in primary care: a systematic review. Evidence-based Synth program, 09-009. 2013; 2-NaN,63.

25. Byers, AL and Yaffe, K. Depression and dementias among military veterans. Alzheimer’s Dement. 2014; 10(3 SUPPL.).

26. Department of Veterans Affairs/Department of Defense. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF MAJOR DEPRESSIVE DISORDER. Version 3. 2016; Retrieved from https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf

27. Waltz, TJ, et al. Veterans with depression in primary care: provider preferences, matching, and care satisfaction. Fam Syst Health. 2014; 32(4):367–77.

28. Fuchs, CH, et al. Physician actions following a positive PHQ-2: implications for the implementation of depression screening in family medicine practice. Fam Syst Health. 2014; 33(1):18–27.

29. Kroenke, K, et al. The Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS): Initial Validation in Three Clinical Trials. Psychosom Med. 2016; 78(6):716-727.

30. Louzon, S, Bossarte, R, McCarthy, J, Katz, I. Does Suicidal Ideation as Measured by the PHQ-9 Predict Suicide Among VA Patients? Psychiatric Services. 2016; Vol 67,Issue 5:517-522.

31. Funderburk, J, Possemato, K, Maisto, S. Differences in What Happens After You Screen Positive for Depression Versus Hazardous Alcohol Use. Military Medicine. 2013; 178,10:1071.

32. Williams, J and Nieuwsma, J. Screening for depression in adults. UpToDate. 2019; Retrieved from https://www.uptodate.com/contents/screening-for-depression-in-adults

33. Park, S-C, et al. Screening for Depressive Disorder in Elderly Patients with Chronic Physical Diseases Using the Patient Health Questionnaire-9. Psychiatry Investig. 2017; 14(3):306–313.

34. Steenkamp, MM, et al. Predictors of PTSD 40 years after combat: Findings from the National Vietnam Veterans longitudinal study. Depress Anxiety. 2017; 34(8):711-722.

35. Substance Abuse and Mental Health Services Administration. Tips for healthcare practitioners and responders: Helping survivors cope with grief after a disaster or traumatic event. SAMHSA. 2019; Retrieved from https://store.samhsa.gov/product/Tips-for-Health-Care-Practitioners-and-Responders-/sma17-5036

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36. Lawthorne, S and Philpott, D. Military Mental Health Care: A Guide for Service Members, Veterans, Families. Library of Congress. 2013; Rowman & Littlefield Publishers.

37. Dursa, EK, Reinhard, MJ, Barth, SK, Schneiderman, AI. Prevalence of a positive screen for PTSD among OEF/OIF and OEF/OIF-era Veterans in a large population-based cohort. J Trauma Stress. 2014; 27:542-549.

38. Worden, JW. Grief Counseling and Grief Therapy, Fifth Edition. 2018; Springer Publishing Co. New York.

39. Shear, MK, Ghesquiere, A, Glickman, K. Bereavement and Complicated Grief. Curr Psychiatry Rep. 2013; 15(11):10.

40. Simon, NM, et al. The loss of a fellow service member: Complicated grief in post-9/11 service members and veterans with combat-related posttraumatic stress disorder. J Neurosci Res. 2018; 96(1):5-15.

41. Shear, MK, Reynolds, CF, Simon, NM, Zisook, S. Complicated grief in adults: Epidemiology, clinical features, assessment, and diagnosis. UpToDate. 2017; Retrieved from https://www.uptodate.com/contents/complicated-grief-in-adults-epidemiology-clinical-features-assessment-and-diagnosis?search=complicated%20grief&source=search_result&selectedTitle=1~28&usage_type=default&display_rank=1

42. Liu, WM, Forbat, L, Anderson, K. Death of a close friend: Short and long-term impacts on physical, psychological and social well-being. PLOS-ONE. 2019; 14(5): Retrieved from https://doi.org/10.1371/journal.pone.0214838.

43. Bui, E, et al. The Structured Clinical Interview for Complicated Grief: Reliability, Validity, and Exploratory Factor Analysis. Depress Anxiety. 2015; 32(7):485–492.

44. National Center for PTSD. US Department of Veteran Affairs. 2019; Retrieved from https://www.ptsd.va.gov/professional/assessment/list_measures.asp.

45. US Department of Veteran Affairs. National Strategy for Preventing Veteran Suicide 2018–2028. National Strategy for Preventing Veteran Suicide. VA Utilization Profile FY 2016. 2017.

46. US Department of Veteran Affairs. VA Releases National Suicide Data Report for 2005-2016. VA. 2018; Washington DC. Retrieved from https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5114

47. US Department of Veteran Affairs. VA National Suicide Data Report 2005–2016 Office of Mental Health and Suicide Prevention. 2018; Washington DC. Retrieved from https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf

48. Schreiber, J and Culpepper, L. Suicidal ideation and behavior in adults. UpToDate. 2019; Retrieved from

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https://www.uptodate.com/contents/suicidal-ideation-and-behavior-in-adults

49. O’Connor, E, Gaynes, B, Burda, BU, et al. Screening for Suicide Risk in Primary Care: A Systematic Evidence Review for the U.S. Preventive Services Task Force [Internet]. Evidence Syntheses. 2013; No. 103. Rockville, MD.

50. National Alliance on Mental Illness. Risk of Suicide. NAMI. 2019; Retrieved from https://www.nami.org/learn-more/mental-health-conditions/related-conditions/suicide

51. U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention (OMHSP) Facts About Veteran Suicide. VA. Washington, DC. 2018; Retrieved from https://www.mentalhealth.va.gov/docs/FINAL_VA_OMHSP_Suicide_Prevention_Fact_Sheet_508.pdf

52. Haney, EM, O'Neil, ME, Carson, S, et al. Suicide Risk Factors and Risk Assessment Tools: A Systematic Review. Washington (DC): Department of Veterans Affairs (US). Washington, DC. 2012; Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK92671/pdf/Bookshelf_NBK92671.pdf

53. Franklin, J, et al. Risk Factors for Suicidal Thoughts and Behaviors: A Meta-Analysis of 50 Years of Research. American Psychological Association. 2017; Vol. 143, No. 2, 187–232.

54. Peterson, K, Anderson, J, Bourne, D. Evidence Brief: Suicide Prevention in Veterans. Washington (DC): Department of Veterans Affairs. 2018; Retrieved from https://www.hsrd.research.va.gov/publications/esp/suicide-prevention-brief-supplemental.pdf

55. US Department of Veteran Affairs. PTSD and Substance Abuse in Veterans. Washington, DC. 2019; Retrieved from https://www.ptsd.va.gov/understand/related/substance_abuse_vet.asp

56. Stefanovics, EA and Rosenheck, RA. Predictors of Post-Discharge Suicide Attempt Among Veterans Receiving Specialized Intensive Treatment for Posttraumatic Stress Disorder. Clin Psychiatry. 2019; 80(5).

57. National Center for PTSD. Understanding PTSD and Substance Use. n.d. 2019; Retrieved from https://www.ptsd.va.gov/publications/print/sudptsdflyer.pdf

58. Dempsey, C, et al. Association of Firearm Ownership, Use, Accessibility, and Storage Practices With Suicide Risk Among US Army Soldiers. JAMA Netw Open. 2019; 2(6).

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59. Adams, RE, et al. Social and Psychological Risk and Protective Factors for Veteran Well-Being: The Role of Veteran Identity and Its Implications for Intervention. Mil Behav Health. 2019; 7(3):304-314.

60. O'Rourke, MC, Jamil, RT, Siddiqui, W. Suicide Screening and Prevention. STAT Pearls. 2019; Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK531453/

61. National Academies of Sciences, Engineering, and Medicine. Evaluation of the Department of Veterans Affairs Mental Health Services. Washington, DC: The National Academies Press. 2018; Retrieved from https://doi.org/10.17226/24915.

62. Monson, CM. and Shnaider, P. Treating PTSD with cognitive behavioral therapies: Interventions that work. Washington, DC. American Psychological Association. 2014; Retrieved from https://www.apa.org/ptsd-guideline/resources/cognitive-behavioral-therapy-example.pdf

63. Brennan, PL, Del Re, AC, Henderson, PT, Trafton, JA. Healthcare system-wide implementation of opioid-safety guideline recommendations: the case of urine drug screening and opioid-patient suicide- and overdose-related events in the Veterans Health Administration. Transl Behav Med. 2016; 6(4):605-612.

The information presented in this course is intended solely for the use of healthcare professionals taking this course, for credit, from NurseCe4Less.com. The information is designed to assist healthcare professionals, including nurses, in addressing issues associated with healthcare. The information provided in this course is general in nature, and is not designed to address any specific situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation of healthcare professionals. Hospitals or other organizations using this publication as a part of their own orientation processes should review the contents of this publication to ensure accuracy and compliance before using this publication. Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from liability resulting from the use of this publication. The contents of this publication may not be reproduced without written permission from NurseCe4Less.com.