Assessing and Addressing Suicide in Medical Settings Ali Abbas Asghar-Ali, MD 1,2,3 Michelle Craft, LCSW 1 1 Michael E. DeBakey VA Medical Center 2 South Central Mental Illness, Research, Education Center 3 Baylor College of Medicine
Objectives Recognize and enumerate risk factors for suicide among Veterans Increase comfort with identifying risk factors Have a means of responding to Veterans who are at high risk of suicide
Common Myths Asking about suicide may lead to someone taking his or her life There are talkers and there are doers If somebody really wants to die by suicide, there is nothing you can do about it.
Suicide Facts 42,773 U.S. deaths from suicide per year among the population overall (2014) 16,121 U.S. deaths from homicide per year Less than 1/2 the number of annual suicides Suicide is the 10 th leading cause of death in the U.S. (13 per 100,000) Every 12.3 minutes someone dies by suicide An estimated one million people attempt suicide attempt each year One attempt every 35 seconds
Suicide By Ethnicity/Race
Suicide Facts Women attempt suicide 3 times more often than men 1 Men die by suicide almost 4 times more often than women Veterans age 18-44 are most at risk of suicide However, Veterans aged >/= 50yrs old are still almost twice as likely to die by suicide vs. non Veterans In 2014, approximately 65% of all Veterans who died from suicide were aged 50 years or older [Drapeau, C.W., & McIntosh, J. L. (for the American Association of Suicidology), (2015)]
https://www.va.gov/opa/publications/factsheets/suicide_prevention_factsheet_new_va_stats_070616_1400.pdf Suicide By Veterans Veterans are at greater risk than those in the general population 18% of all deaths by suicide among U.S. adults were Veterans (8.5% of US population) About 20 suicides per day are Veterans ~ 6 suicides per day among Veterans receiving care in VHA (VA Serious Mental Illness Treatment, Research and Evaluation Center)
Suicide By Veterans 66% of all Veteran deaths from suicide were the result of firearm injuries. On average, 764 suicide attempts per month among Veterans receiving recent VA health care services 11% of Veterans who survive a first suicide attempt will reattempt within 9 months, and 6% of those will die. 25% of Veteran suicides have a history of previous suicide attempts
Risk Factors for Death by Suicide Age (younger) Gender (men) Race (white) Marital status (divorce, separate, widowed) Family history of a suicide attempt Mental illness (including substance use) Trauma - physical/ psychological/sexual Childhood maltreatment Lower education level Same sex orientation (LGBT) Cultural or religious beliefs (suicide being noble ) Impulsivity or aggression Previous suicide attempt Access to means Unwillingness to seek help b/c of stigma
Risk Factors for Death by Suicide Psychological factors: Bereavement Loss of relationship Loss of status or respect Social factors: Financial/legal/social stress Chronic stressors Medical conditions: Brain injury Terminal illness HIV/AIDS New diagnosis of major illness Worsening of chronic illness Intoxication and withdrawal
Military-Specific Risk Factors for Death by Suicide Disciplinary action/reduction in rank Career change Sense of injustice or betrayal Deployments to hostile environments Exposure to extreme stress Physical/sexual assault while in the service (not limited to women) Service-related injury
Protective Factors Economic security Positive parent/child relationship Ability to derive support from spiritual belief Pregnancy/responsible for children under 18 Effective clinical care for mental, physical, and substance abuse disorders Easy access to variety of clinical interventions
Protective Factors Support for help seeking Family and community support (connectedness) Support from ongoing medical and mental health care relationships Skills in problem solving, conflict resolution, and nonviolent ways of handling disputes Cultural and religious beliefs that discourage suicide and support instincts for self-preservation
Risk Factors for Suicidal Behaviors Acute state of substance - Associated with impaired judgment and impulsivity Access to means Evidence of multiple risk factors and lack of protective factors concern when Veteran denies suicidal ideation but the behaviors indicate suicide behavior or warning signs
Assessing for Suicidality Assess for Suicidal Ideation: Are you thinking of killing yourself? Assess for Suicidal Intent: Do you have a plan on how to kill yourself? Do you think you will act on that plan? Assess for Suicidal Behaviors: Have you done anything to act on your suicidal thoughts such as preparing for your death? ***Assess for means: guns, pills, toxins etc.*** ***Look at risk factors and protective factors*** ****Consult, Consult, Consult****
Operation S.A.V.E. The acronym S.A.V.E. encapsulates the important steps involved in suicide prevention: Signs of suicidal thinking should be recognized Ask the most important question of all Validate the Veteran s experience Encourage treatment and Expedite getting help
Warning Signs of Suicidal Thinking Hopelessness, feeling like there s no way out Anxiety, agitation, sleeplessness, or mood swings Feeling like there is no reason to live Rage or anger Engaging in risky activities; impulsivity Increasing alcohol or drug use Withdrawing from family and friends
Warning Signs of Suicidal Thinking The presence of any of the following signs requires immediate attention: Thinking about hurting or killing themselves Looking for ways to die Talking about death, dying, or suicide Self-destructive or risk-taking behaviors, especially when it involves alcohol, drugs, or weapons
Ask the Question Are you thinking about killing yourself? Are you thinking of suicide? Have you had thoughts about taking your own life?
Ask the Question Ask the question if you ve identified warning signs or symptoms Ask the question in such a way that is natural and flows with the conversation Ask the question in an supportive, nonthreatening manner that minimizes stigma. Avoid: You aren t thinking of killing yourself are you? Ask the question calmly and give the Veteran time to respond
Ask the Question Remain calm Listen > speak Maintain eye contact Act with confidence Avoid arguing Use open body language Use supportive, encouraging comments Be honest There may be no quick solutions but help is available
Means Restriction Most people who die by suicide die on their first attempt (VA Safety Plans Stanley & Brown, 2008) Attempts with firearms have an 85% fatality rate (Vyrostek, Annest, & Ryan, 2004) Firearms in the home double the odds for death by suicide (Brent & Bridge, 2003; Brent et al., 1991; Brent et al., 1993; Kellermann et al., 1992) Potential impact for means restriction probably greatest for firearm-related suicides (Bryan, et al., 2011)
Validate Talk openly about suicide Be willing to listen and allow the Veteran to express his or her feelings Recognize that the situation is serious Avoid passing judgment Reassure that help is available
Encourage Treatment and Expedite Getting Help Examples of encouraging treatment: Don t keep the Veteran s suicidal behavior a secret Do not leave him or her alone Try to get the person to seek immediate help from his or her provider or the nearest hospital emergency room, or Call 911 Reassure the Veteran that help is available
Encourage Treatment and Expedite Getting Help Call the Veterans Crisis Line at 1-800-273-8255, Press 1 Never negotiate with someone who has a gun Get to safety and call 911 If the Veteran has taken pills, cut himself or herself, or done harm to himself or herself in some way Call 911 Veterans Crisis Line number 1-800-273-8233 Press 1 for Veterans Veterans Crisis Line brochures and wallet cards
VA TOOLS TO IDENTIFY AND ENHANCE CARE FOR VETERANS AT RISK FOR SUICIDE!!
Suicide Behavior Report
High Risk Flag Veteran is seen 4 times in 1 st 30 days after assignment Once per month, or as clinically indicated thereafter Safety plan and treatment plan updated regularly to guide the treatment process Flags are reviewed every 90 days If Veteran is admitted to the inpatient unit the 4 visits in 1 st 30 days requirement is restarts after discharge
Free Gun Locks for Veterans Protect Yourself and Your Family:! Free Gun Locks Available Gun safety locks are available from VA primary care physicians, mental health providers, patient advocates, and at VA Outpatient Clinics