November 11, 2019
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Working to 'change the trajectory' for veterans' suicide prevention, awareness

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Wanda Montalvo

In 2017, the suicide rate for U.S. veterans was 1.5 times the rate for non-veteran adults, according to the U.S. Department of Veterans Affairs.

The average number of veteran suicides per day rose from 15.9 in 2005 to 16.8 in 2017, with veterans accounting for 13.5% of all deaths by suicide in the U.S. An overall increase of 43.6% in deaths by suicide occurred between 2005 and 2017, with a 6.1% increase among veterans, suggesting an urgent need for effective clinical prevention strategies.

In observance of Veteran’s Day, Wanda Montalvo, PhD, RN, FAAN, executive director of Jonas Nursing and Veterans Healthcare at Columbia University School of Nursing, spoke with Healio Psychiatry regarding veteran suicide prevention and awareness in clinical practice. - by Eamon Dreisbach

Question: Do you feel v eteran’s suicide prevention is a topic that is adequately addressed by clinicians? If not, what can be done to improve the situation?

Answer: Suicide in general is a national concern, affecting all Americans as the 10th leading cause of death whether or not they have served. Within the VA system, preventive screening for at-risk veterans is standardized, helping to proactively identify people at risk for suicide. The Veterans Association Suicide Prevention teams are hard at work to help prevent suicide every hour responding to 2,000 calls, 300 chats and 100 text messages.

For those who have served in the military entering the civilian world for clinical and mental health services, it is important they their health care provider that they are veterans. Clinicians working in primary care settings, walk-in clinics or ED need to be made aware they are caring for a veteran. Identifying the veteran population is the first step toward improving the accuracy and timeliness of screening for risk factors associated with suicide.

Q: What are some major warning signs of suicide in veterans that clinicians can look for?

A: Initial intake questions by clinicians should include type of military service and any experiences with trauma or stressful situations, like witnessing causalities and experiencing enemy fire. Certain observable cues can range from agitation, irritability or anxiety to rage or anger. These observations should prompt clinicians to conduct further screening using validated tools, especially if the veteran expresses feelings of life not worth living, feel like life has no purpose or they express a sense of hopelessness or despair. Resources for clinicians and veterans include the Veterans Crisis Line (1-800-273-8255, dial 1) and the Veterans Self-Check Quiz offered by the American Foundation for Suicide Prevention.

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Q: What factors do you believe contribute to the rising suicide rates for veterans? How can the factors be addressed?

A: Suicide among veterans in 2016 was 6,079, and 6,139 died by suicide in 2017. In 2017, the rate of suicide was 1.8 times higher among female veterans and 1.4 times higher among male veterans, with 18- to 34-year-old male veterans experiencing the highest rates of suicide.

Risk factors among veterans include exposure to a suicide event, periods of transition from substance or opioid usage, transition from in-patient to outpatient care and transitions of relationships to isolation. Veterans in rural areas have a 20% increased risk for suicide. A major risk factor is veterans having access to lethal means, like guns, resulting in 69% of suicide deaths. A particular acute period is when a veteran experiences homelessness, in particular 16 days prior to homelessness to day zero, placing this population at high risk for suicide. Suicide rates are highest among veterans living with bipolar disorders and those with opioid use disorders.

To address these risk factors, partnerships between federal agencies, public and private organizations, faith-based communities and providers of health care services, especially nurses, as the largest clinical workforce in our country, are required. The risk factors are complex and signal the need to address social determinates of health from education, employment and housing to improved access to mental health services, rehabilitation from substance abuse disorders to gun safety policies.

Q: Is there any specific advice you would give to clinicians for discussing suicide or mental health with patients who are veterans?

A: Recently, Jonas Nursing and Veterans Healthcare hosted a conference where Matthew Miller, PhD, MPH, director of the Veterans Crisis Line’s department of veterans affairs, provided valuable guidance. We need to improve access to mental health services. The integration of primary care with behavioral health holds promise because 45% of individuals who die by suicide have contact with a primary care provider in the month prior to their death.

Assessment of suicide risk is a critical part of work in the primary care. Nurses, as a valuable member of the health care team, can initiate screening to help identify patients at risk. This increased screening in primary care for suicide will facilitate the identification of veterans at risk because a large percentage of veterans will not go to a mental health clinic. In an integrated primary and mental health scenario, a warm handoff can occur to keep the patient in care while decreasing no-show rates.

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Once the patient discloses they are struggling with depression, the clinician can prescribe the appropriate medications and be treated by a care manager nurse who will on regular intervals assess the patient’s progress using evidence-based guidelines to help facilitate adherence. Clinicians will benefit from additional training to better understand veterans and better communicate to engage in dialogue to help address suicide or mental health needs. Clinicians can find training resources at the PsychHub.com website.

Q: What aspects of care should clinicians prioritize to minimize the risk for veteran suicide?

A: Clinicians, especially nurse practitioners, are an important part of the solution, especially when they work in primary care because 70% of mental health services are provided solely in primary care by primary care clinicians. In the primary care setting, clinicians are well-positioned to conduct mental health screenings. Patients often choose not to follow through on community-based mental health referrals provided by primary care providers outside of a primary care setting, in part due to stigma, but at times due to lack of culturally appropriate and or readily available services and insurance constraints.

Therefore, we need to advance toward integrated models of care where nurses, physicians and mental health providers are co-located in primary care, which is especially valuable when social workers are added to this integrated team model. The National Association of Community Health Centers offers information on several federally qualified health centers with implemented integrated primary and mental health models.

Q: Are there any specific areas of study or research that you believe can be further explored to aid suicide prevention in veterans?

A: In the primary care sector, the EHR demographic question, “Have you ever served in the military?” must be added as an initial step to identify the veteran population. There are many research opportunities, beginning with how to best train civilian clinicians to better understanding military-service connected conditions. We need to consider the impact military service has on family members, especially children and long-term impact of suicide on family survivors.

How can we better address the social determinants of health among the veteran population, especially as more veterans and their families seek primary care services? What is the economic impact of implementing universal screening in primary care, schools or hospital settings? We should research and disseminate the interventions that best meet the needs of rural health and female veterans to reduce suicide risk. The window of time between ideation and actually engaging in suicide is 5 to 60 minutes, but the majority of time if they survive, they regret the decision. If firearms are lethal 95% of the time, we need to advance gun safety. We should identify what interventions within this 5- to 60-minute interval will change the trajectory and help identify the best ways to reach our rural veterans and deliver mental health services.

References:

American Foundation for Suicide Prevention Department of Veterans Affairs. Veterans Self-Check Quiz. Available at: vetselfcheck.org/welcome.cfm. Accessed November 5, 2019.

National Association of Community Health Centers. Veterans Health. Available at: nach.org/focus-areas/policy-matters/emergin-issues/veterans-health. Accessed November 5, 2019.

PsychHub. Resources for Assessing Your Patients’ Mental Health Needs. Available at: psychhub.com/providers. Accessed November 5, 2019.

U.S. Department of Veterans Affairs. 2019 National Veteran Suicide Prevention Annual Report. Available at: https://www.mentalhealth.va.gov/docs/data sheets/2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf. Accessed October 31, 2019.

Disclosures: Montalvo reports no relevant financial disclosures.