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Trust is the Basis for Effective SuicideRisk Assessment in Veterans
Linda Ganzini, Lauren Denneson,Nancy Press, Matt Bair,
Drew Helmer, Jennifer PoatSteve Dobscha
VA Health Services Research & Development Center to Improve Veteran Involvement in Care (CIVIC), Portland VA Medical CenterOregon Health & Science UniversityRichard Roudebush VA Medical Center, IndianapolisWar-related illness and Injury Study Center, VA New Jersey Healthcare System
Presenter Disclosures
(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
Steven K. Dobscha MD
No Relationships to Disclose
VA suicide risk assessment initiativeSuicide risk assessment for patients with
depression and PTSD became national performance goal in 2007.
Routine screening for depression and PTSD takes place using PHQ-2 or PHQ-9 and PC-PTSD
Electronic Medical Record (CPRS) triggers a reminder
Administered in primary care by MAs or nurses; mental health clinicians often do their own
Positive depression or PTSD screen activates brief suicidal ideation risk assessment template.
Templated risk assessment tools to be used in conjunction with clinical judgment to assess risk
Suicide risk assessment and screeningLimited empiric support for screening
O’Connor et al, Annals Int Med 2013
Veterans who die by suicide may deny suicidal ideation at last clinic appointments
Denneson et al, Psychiatric Services, 2011
Studies of Afghanistan and Iraq Veterans support that only a minority who screen positive for depression or PTSD engage in mental health care
Hoge et al, NEJM 2004, Lu Psych Services 2011
Little is known about factors that promote or discourage honest disclosure of suicidal ideation.
VA HSR&D Study: Outcomes and Correlates of Suicidal Ideation in OEF/OIF Veterans
Mixed methods studyMain research questions:
What are the correlates of positive brief suicide risk assessments among OEF/OIF Veterans?
To what extent are processes of care affected by positive assessments?
What are Veterans’ experiences of the risk assessment process and their perceptions of clinicians’ responses to assessment results?
Qualitative study methodsParticipants
OEF/OIF Veterans in Oregon, Indiana, and Texas VAsPositive screen for PTSD/depression and positive SI
risk assessment in non-mental health ambulatory setting
Individual interviews 2 to 6 months after assessmentPatients with psychiatric instability or cognitive
impairment excluded by primary care providerRecruitment was purposive with attempts to
enrich with women and ethnically diverse Veterans
Veterans completed phone interviews, which were audiotaped, transcribed and de-identified
Modified grounded theory used to analyzeStrauss and Corbin, Basics of Qualitative Research, 1998
Interview guideRecollections of suicide assessment processComfort/discomfort with assessment processHow the care setting influenced their
responsesRegarding suicidal ideation—
Hesitance to discussReactions from providers and staffPositive and negative views and consequences
of disclosureExperiences in the military with mental
health and suicide screening/assessment
Results—Demographic Characteristics34 Veterans
Mean age 35 years91% men73% non Hispanic white42% had served in the army
Assessment processPrimary care or post-deployment clinicsMultiple disciplines involved in assessments:
Physicians (15) nurses (12) psychologists (1), social worker (1) physician assistant (1), multiple providers (4)
Results: Positive views of SI assessmentStraightforward, clear, expected, devoid of
ambiguous language
“they seemed to be pretty straight and cut and dry questions…. You got the initial standardized questions then, if the solider answered a yes to certain questions, it’s going to pop up with a different standardized question. Then eventually they figure out what going on with Veterans.” (Participant N)
“They are standard. They were what I was here for. I kind of expected them….She didn’t sugar coat it. I mean there’s not a delicate way to say, ‘Hey you’re thinking about killing yourself.’ You just have to ask it. …she didn’t pussyfoot around it either. She was as delicate as you can be asking the questions, but direct about it.” (Participant J)
Criticisms of assessment processPainful and shameful
“I’ve gotten used to it and know you guys are going to ask me every time…it is like sticking a needle through your eye sometimes.” (Participant R)
Repetitive, sense of communication gaps, leading to sense of futility about getting mental health needs assessed.
“It’s repetitive. Annoying. It feels like I have already answered the questions for you. And you’re in the same damn office, why should I go to somebody else and answer them all over again. It is a massive waste of time to have to spend seven hours at that place answering the same questions over and over again. But apparently these three people cannot talk to each other.” (Participant O)
“But I mean that was about the gist of it. So I just, I felt like I gained nothing. I felt like it wasn’t, there was no attempt to figure out what’s going on. It was just, “Uh…yep checking the box, it’s still there, see you later.” (Participant AE)
Criticism—inability to provide context
Questions too simple, no opportunity to clarify their thoughts or give complex answers.
“I mean if I were in her shoes I think I would have asked a little bit more questions. I would have made sure the individual understood the questions… I mean it almost seemed like waste of time… it was too short, too simple. I had thoughts that I wanted to share and I did not get the opportunity to share them.” (Participant AF)
Barriers to disclosure of SIVeterans accustomed to minimizing and
suppressing thoughts of suicide. Believed they should cope on their own.
“That’s the heartache…I just try to cover it up and faking it to make it. I know I am hurting, physically and mentally, but the thought of trying to get help is a sign of weakness.” (Participant F)
Veterans were sensitive toward feeling lack of respect, particularly on initial interactions
“Those that are nice to me and treat me with respect right away, then they will get the respect—they will get all the information that they need from me.” (Participant W)
Barriers to disclosure of SI—experiences in the military
Stigma and concerns admission of SI might delay return home
“I finally started accepting that [having suicidal thoughts] was an issue for me, but prior to that there had been several times I filled out those questionnaire…and it was just something you had to go through to get home. You knew pretty much to say no to everything.” (Participant U)
“They ask you, “Do you need to talk to mental health?” you say, “no.” It does not matter if you do or not. You say no because if your commander finds out you said yes they give you shit. What, you’re a soldier. You don’t need any fluffy bunny mental health crap.” (Participant J)
“The doctor I am seeing is supposed to know everything. Not ‘Oh I am only a doctor for you today’…They are doing their job, I’m just a number, expendable, I‘m a soldier, I don’t complain and stuff, I feel like a weak person being in there talking about it.” (Participant F)
Barriers to disclosure—trust and privacy“If that is the first thing someone were to say to me, I would just say no, because I wouldn’t want to tell them because I don’t know them. I don’t trust them. I don’t know who they are.” (Participant AG)
“I wouldn’t feel comfortable. If it was a new doctor or a new nurse, I don’t feel—it wouldn’t feel comfortable—I’d be too afraid of them. I wouldn’t know how to explain it. I’d be too uncomfortable with the strangers.” (Participant H)
“I don’t want to mess up my life even more by being honest with somebody. And they are strangers so I don’t really want to talk to strangers about things that are in my head ‘cause they’re my thoughts.” (Participant E)
“I mean people don’t really want to be asked, ‘Hey are you trying to kill yourself?” You know that like ‘Hey that none of your business,’ you know, that’s mine—that’s what I’m thinking in my head.” (Participant W)
Barriers to disclosure—consequencesWorry about hospitalization and medication.
“It’s difficult for me, one of the reasons I was worried about talking about it is she going to try and lock me up in a straight jacket, I have no ideas what the response if going to be if I talk to someone honestly.” (Participant O)
“And to tell someone that you want to admit them, it don’t make them feel at ease. Now I’m scared to tell you something. ‘Cause you’re telling me, I’m telling you my feeling and you want to admit me to the hospital, that sometimes makes a person, especially a soldier clam up. Now we open a can of worms. Who’s going to take care of my kids? My kids is coming home from school at 5:00. I mean when you talk about admitting me you scare the shit out of me.” (Participant AC)
Facilitators of DisclosureTrust, provider attitudes of genuine concern,
questions of SI in context of Veteran-centered goals
“Whereas when speaking with (the therapist), it’s ‘Well, you have kids, you gotta make sure that they’re okay, though to make sure they’re okay, you have to be okay.’ So it’s a more looking down the road to ‘help me,’ not checking the blocks, but to help me.” (Participant AB)
“Cause I’ve seen people do that on their screen ‘Have you ever attempted suicide,’ click on the screen. He didn’t do that. He actually sat down. He talked to me. He looked at me. He didn’t take his eyes off me. He talked to me and that’s what made me feel a lot better.” (Participant AG)
“Of course it was difficult. Not so much being asked, he was fairly gentle and not aggressive. But he was pretty comfortable to talk to. More than anything else I got the impression right off the bat that he was there to be supportive.” (Participant C)
RecommendationsSI risk assessment should be performed by
provider who knows the patient best, not by triage personnel
Repetitive assessment should be avoidedMisperceptions about the consequences of
disclosure should be exploredRisk assessment should be part of a
conversationThe patient should be warned that her/she
is likely to be asked about SI in future and rationale for this
Providers should be aware of potential for shame and avoidance around suicidal thoughts.