PhD/PsyD Article about vet suicide and VA

[erg923]

http://www.usatoday.com/story/news/2015/01/19/va-hospitals-veteran-suicides/22003413/

Does anyone have thoughts about this? I am not psychotropic cheerleader by any means, but I can help but sense an total externalization of blame here.

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[cara susanna]

That actually reminds me of a Vice news report I saw.

Written article: https://news.vice.com/article/im-ptsd-paid-till-suicide-or-death

Video: http://www.vice.com/video/watch-our-hbo-report-on-ptsd-in-american-veterans

 

[erg923]

That actually reminds me of a Vice news report I saw.

Written article: https://news.vice.com/article/im-ptsd-paid-till-suicide-or-death

Video: http://www.vice.com/video/watch-our-hbo-report-on-ptsd-in-american-veterans

"Instead of helping, the VA is actually creating addicts, she tells us. "Narcotics are very cheap."

"As Gray says, "I do not understand how any medical institution in good conscience can perpetuate a therapy that is harmful to the people that they are supposed to serve."

Ah yes, "the demonization of the opiate"..... as I like to call this trend. Because the patient clearly has no role or responsility in his/her addiction or problems.

 

[DynamicDidactic]

this seems to clearly underscore the reality that our healthcare system as a whole does not practice evidence-based treatment for suicide.

He tried to kill himself for the first time in 2010.

That effort put him in the hospital for three days

we have no single piece of evidence that hospitalization reduces suicidality.

She also wants to know why, when a VA doctor wrote in Lutz's record that benzodiazepines should not be used in patients with PTSD — straight out of VA's 2010 clinical practice guidelines — that recommendation was ignored.

negligence, malpractice?

Lutz was in and out of military health facilities, in-patient private clinics and the VA, seeking to get his life on track.

did he ever receive a treatment shown to reduce suicidality?

Congress is considering a bill aimed at reducing suicides among veterans by encouraging psychiatrists to work at VA,

absolutely no evidence that theses 2 variables are related or causal.

requires VA to establish pilot programs in each region that create peer support networks for veterans.

wow, this one is even worse. My anecdotal experience tells me this is almost completely useless.

 

[DynamicDidactic]

Suicide is the 10th leading cause of death in the US. Vet status is a risk factor for suicide attempts.

You would think the VA would take this more seriously as opposed to reinforcing the same untested practices.

 

[DynamicDidactic]

Peer support actually has a good evidence base for helping to facilitate mental health referrals in patients who otherwise might refuse treatment and reducing days in the hospital for those with SMI. There is a movement to include peers in suicide prevention (with a current NIMH pilot grant investigating this). I don't know that I would say there is no evidence for a peer model - take a look at crisis lines - those are a peer model (even though the peers in that case may or may not have lived experience). There's also good theory-based reasoning to support the use of peers, from a social connectedness standpoint. I think the training peers receive is the main thing to consider here.

my skepticism may definitely be over-the-top. Will await the actual evidence from the pilot you mention.

 

[cara susanna]

Isn't the link between PTSD and vet suicide also not really established? I remember reading that on SDN somewhere.

 

[Therapist4Chnge]

Suicide is the 10th leading cause of death in the US. Vet status is a risk factor for suicide attempts.

You would think the VA would take this more seriously as opposed to reinforcing the same untested practices.

Treatment of our Veterans is as much a political football as it is medical treatment. Unfortunately the interaction between mental health and violence (against self or others) is becoming a "3rd rail" conversation. I don't have good answers for the problem, but I think acknowledging the insufficient support for current policies is a good start.

 

[Therapist4Chnge]

It'll be interesting to see the NIMH data on peer support, as I think that could be a component to reducing risk. I did some research in risk assessment ~7yrs ago and the research back then in regard to treatment focused on a team approach. I believe a multi-modal team based approach is still going to be the best approach, though I think it is quite possible that having a peer support component can be beneficial.

 

[PsyDr]

Except there isn't a substantially increased incidence of suicide in veterans or service members when compared to age and SES matched samples.

Service Members:

http://www.forbes.com/sites/timwors...nt-an-epidemic-of-suicide-in-the-us-military/


Veterans:

Miller, M., Barber, C., Young, M., Azrael, D., Mukamal, K., & Lawler, E. (2012). Veterans and Suicide: A Reexamination of the National Death Index–Linked National Health Interview Survey. American Journal of Public Health, 102(Suppl 1), S154–S159. doi:10.2105/AJPH.2011.300409

 

[PsyDr]

Except combat has shown to have little to no effect on suicide rates.

Engel CC. Suicide, Mental Disorders, and the US Military: Time to Focus on Mental Health Service Delivery. JAMA. 2013;310(5):484-485. doi:10.1001/jama.2013.92420

LeardMann CA, Powell TM, Smith TC, Bell MR, et. al. Risk Factors Associated With Suicide in Current and Former U.S. Military Personnel. JAMA. 2013;310(5):496-506. doi:10.1001/jama.2013.65164.

 

[WisNeuro]

Meh, more of the same, the media loves to **** on the VA, without telling the whole story, or actually looking at the system in comparison to other health care systems. If anything, the media attention and subsequent boneheaded moves by congressman who have no understanding of how healthcare operates will just make the system more enabling and lead to poorer outcomes.

Granted, I do agree with med mis-management to a lesser extent.

 

[Therapist4Chnge]

We also now have evidence-based treatments (e.g., DBT - Linehan, Cognitive Therapy for Suicide Prevention - Brown & Beck) that have demonstrated reductions in suicidal behavior compared to treatment as usual. Unfortunately, these treatments have not enjoyed as wide-spread dissemination as is needed. How many suicidal Veterans have access to an evidence-based treatment specifically for suicide prevention? Probably not very many.

I saw "DBT informed" treatment in the VA system, though I'm not sure it was as efficacious as a true DBT treatment program. I don't actively work in this research area anymore, but I'd love if people have any recs for more recent (2008-present) citations about treatment options and efficacy.

 

[cara susanna]

I saw "DBT informed" treatment in the VA system, though I'm not sure it was as efficacious as a true DBT treatment program. I don't actively work in this research area anymore, but I'd love if people have any recs for more recent (2008-present) citations about treatment options and efficacy.

Quite a few VAs offer full model DBT now.

 

[starsinnight]

According to the EBP training protocol for VAs, these are the "roll-outs" listed: CPT or PE for PTSD, ACT or CBT for depression, SST (social skills training) for SMI (serious mental illness), CBT-I for insomnia, behavior couples therapy (BCT-SUD) or CBT-SUD or motivation enhancement therapy (MET) for substance abuse, and MI for treatment engagement. According to the EBP training schedule though, they also have IPT for depression.

No sign of DBT or what to do with suicide prevention, atleast where I am looking- and I was hoping to get some additional EBP training today and haven't had any luck finding what I want, so I will have to go old-fashioned to some EBP manuals (non-veteran focused).

Personally, I think that the meds had nothing to do with his suicide - as his note said he was going to do it somehow. Reminds me of this recent suicide in the news article: http://kxan.com/2015/03/02/teen-gir...ter-for-encouraging-friend-to-commit-suicide/ I think people are eager to find blame when something so tragic happens, unfortunately. But sometimes it can lead to policy changes and commitment of VA employees to work harder to make sure veterans don't fall through the cracks. I definitely think VA hospitals are more diligent than regular hospitals, especially after all this media and critcism... but then again each VA is so very different. It does sound though like there was some negligence there and he shouldn't have been prescribed so many meds in one day by 2 different prescribing providers, who must not have read his charts. Is there a policy that says providers HAVE to read charts and communicate with all other providers for patients? Nope, not that I know of. But this MAYBE could have saved his life, not because of the meds, but if his doctors recognized the warning signs and got him immediate help, even more so, had someone gotten him some EBP for depression/suicide/PTSD/whatever his primary concern of the moment happened to be. Unfortunately, I've had physicians ask me to do a suicide risk assessment in primary care because they don't know how to handle mental health concerns, when technically everyone at a VA is initially trained in suicide prevention. Thankfully, they were refreshed on suicide prevention rather than me or someone else do it for them.

 

[WisNeuro]

Is there a policy that says providers HAVE to read charts and communicate with all other providers for patients? Nope, not that I know of. But this could have saved his life, not because of the meds, but if his doctors recognized the warning signs and got him immediate help, even more so, had someone gotten him some EBP for depression/suicide/PTSD/whatever his primary concern of the moment happened to be.

I think this is easier said than done. Our "frequent flyers" sometimes have thousands of chart notes. This is not an exaggeration. Also, there is no field that is all that good at predicting certain low base rate behaviors (e.g., suicide and violence). You could be overly cautious, push treatment on any and every predictor of suicide, but then you get longer waiting lists and not enough providers to see patients. That happens, someone on a waiting list commits suicide, once again, it's the VA's fault. Not saying that it's not a good idea, just that the practice side makes things difficult, and that we need a multi-disciplinary approach that takes practical and clinical challenges into effect.

 

[cara susanna]

They can put flags on the chart if the patient is high risk, though, can't they?

 

[WisNeuro]

They can put flags on the chart if the patient is high risk, though, can't they?

Yes, and that is routinely done. But you have sensitivity/specificity questions there as well. At one point do you flag? how often do you follow-up? Same questions of resources arise. not too mention that from data that I've seen in the past, the majority of the suicides occur in people who are not engaged in VA care at all (if someone has updated info on this, please share). The flag does no good there.

 

[cara susanna]

Yes, and that is routinely done. But you have sensitivity/specificity questions there as well. At one point do you flag? how often do you follow-up? Same questions of resources arise. not too mention that from data that I've seen in the past, the majority of the suicides occur in people who are not engaged in VA care at all (if someone has updated info on this, please share). The flag does no good there.

Yes, the majority of suicides occur in veterans who are unegaged in VA care. Good point! I guess I was thinking for this one specific case, which did sound pretty high risk. Apparently he was doing his own means restriction by giving his meds to his mother, but I'm unsure of how well that was known or documented amongst the VA providers.

 

[starsinnight]

They can put flags on the chart if the patient is high risk, though, can't they?

Yes they can, just like they do for a fall risk or MRSA patient. And then they are required to have additional screenings until the flag is removed. However, this requires someone to initially detect they are high risk from the get-go. Seems like he was, according to the article, denying suicidal inclinations. But his prior suicide attempt (and other possible risk factors on the SRA) could have been warning for a high risk flag. Perhaps standardization of SRA (suicide risk assessment) and suicide prevention EBP training is in order? If physicians and clinicians aren't triaging and asking these questions upon intake, then no one will know. If they properly assess but the veteran denies it, then it's out of our hands, right?

 

[WisNeuro]

Perhaps standardization of SRA (suicide risk assessment) and suicide prevention EBP training is in order? If physicians and clinicians aren't triaging and asking these questions upon intake, then no one will know. If they properly assess but the veteran denies it, then it's out of our hands, right?

The VA's have teams that decide on the flags and re-assess risk at certain intervals. And yes, we can assess it, and order welfare checks, but ultimately, if they deny ideation, it's hard, if not impossible, to get an involuntary hold in a lot of cases.

 

[starsinnight]

Yes, and that is routinely done. But you have sensitivity/specificity questions there as well. At one point do you flag? how often do you follow-up? Same questions of resources arise. not too mention that from data that I've seen in the past, the majority of the suicides occur in people who are not engaged in VA care at all (if someone has updated info on this, please share). The flag does no good there.

Technically, the charting system has a standardized procedure and protocol for SRAs. All veterans have to have one completed upon initial review. If not done or done incorrectly, then they get lost in the system. If flagged, there are definitely procedures there. It's a standard checklist form of primary, secondary, and tertiary risk factors, then protective factors, and finally, risk assessment flag: high (one or more primary with multiple secondary and tertiary), moderate (one or more primary with less secondary or tertiary and presence of protective factors), or low (primary risk factor but no secondary or tertiary and considerable protective factors). They then pop-up in the system for "review" I believe every 3 or months (but I am not certain on this one for the duration), until the flag is removed.

 

[WisNeuro]

I haven't had to do the formal one since my time on SCI more than a year ago, but we ranked those risk factors, and the final judgment on risk was left up to the clinician rather than an algorithm. May have changed, or may be different in different VA's.

 

[Sanman]

Properly is the key word. I know that it happens routinely that "No SI/HI" gets entered into the chart, but that does not mean that a question was asked (in many cases it is not) or that it was asked in a way likely to encourage a disclosure (versus asking something like "you're not suicidal, are you?"). We have to acknowledge that "business as usual" in our healthcare systems is not doing enough to prevent suicide. So either the healthcare environment and culture needs to make a shift to facilitate doing things in such a way that will reduce suicide (i.e., the Zero Suicide Initiative which has demonstrated success in systems such as Henry Ford) or needs to just say that the hassle of change outweighs the desire to reduce suicide rates.

I have to agree with this. The issue is a larger one in my eyes though. There needs to be a culture change in Healthcare overall. When you push multiple assessments like this (SI, pain, etc) and have initiatives. Then, on the other hand push seeing more clients and productivity, things get missed. This is not just the VA, but a frustration I continue to have. Until compensating quality of care and communication over quantity becomes the standard, nothing will change.

Reading the article, the quality of care really was not that bad. I have seen,more egregious TX on a regular basis during my VA days.

 

[Fan_of_Meehl]

http://www.usatoday.com/story/news/2015/01/19/va-hospitals-veteran-suicides/22003413/

Does anyone have thoughts about this? I am not psychotropic cheerleader by any means, but I can help but sense an total externalization of blame here.

Hopefully we're seeing the crest (in terms of societal trends) of externalization of responsibility for mental illness (away from the veteran/client him or herself) right now...hopefully. Reality has a certain gravity to it and let's hope it takes over soon to bring things back to a more reasonable framework of looking at these kinds of problems. The current status quo in the VA/media is irrational, countertherapeutic and downright harmful. I think that, in general, holding people accountable for their actions is a form of treating people with dignity and the highest form of respect. Infantalizing people, telling them that they can't make it on their own (and need a disability check for life) is both a form of cowardice/laziness (not wanting to deal with the difficult realities/work of helping people slog out of a hole) and counterfeit respect.

I am really getting a taste of it working outpatient in the OEF/OIF clinic. Recently had a mother of a veteran push her way into sitting into session 2 of individual therapy for PTSD/depression with an attitude and demands that I write a letter establishing individual unemployability for her son because he is depressed and can't do anything to help himself (her words). I politely explained the C&P process, clarified what my role was/wasn't and invited her to leave to allow her son and me to continue to engage in INDIVIDUAL therapy for PTSD/depression. It was clear in her attitude what form of 'help' she was demanding and she didn't seem at all interested in the whole therapy/treatment bit. I also deal with patient 'advocates' who want to turn my clinic into a drive-thru PTSD diagnosis dispensing factory to facilitate service-connection for mental illness ASAP. Ain't happenin'. I am not committing to spitting out a firm diagnosis of PTSD based on a single 45-50min session (intake) where I have to focus on so many different areas and do too many potential rule-outs (that's a big reason why I left full-time C&P). I am still figuring out how to handle these requests (can't just say 'I don't do evaluations for PTSD, I only do treatment'). Right now I am doing an intake (for the purposes of diagnosis, case formulation, and treatment) and then scheduling one or two follow up appointments to administer the CAPS (structured interview for PTSD). I ain't doing what I have seen so many other clinicians do routinely which is do a 45-50 min general interview, administer the PCL, and give a diagnosis based on self-report.

 

[erg923]

The psychological reaction we now call PTSD has been around for thousands of years certainly, but there is no doubt in my mind that there is a profound cultural/societal/generational component to the disability that results...which is of course what makes something a "disorder."

If we buy into the escape conditioning explanatory model of symptoms, and the notion the avoidance fuels PTSD symptoms, I think we have to ask whether society encourages the disability mindset that results in the avoidance that then serves to exacerbate/continue/worsen the trauma reaction. The impairing disability associated with trauma reaction did not seem nearly as prominent/widespread in the WWII generation? Is there any literature on this? I wonder if my grandfather (91 year old D-day invasion survior) would like to have this discusion with me?

 

[AcronymAllergy]

The psychological reaction we now call PTSD has been around for thousands of years certainly, but there is no doubt in my mind that there is a profound cultural/societal/generational component to the disability that results...which is of course what makes something a "disorder."
If we buy into the escape conditioning explanatory model of symptoms, and the notion the avoidance fuels PTSD symptoms, I think we have to ask whether society encourages the disability mindset that results in the avoidance that then serves to exacerbate/continue/worsen the trauma reaction. The impairing disability associated with trauma reaction did not seem nearly as prominent/widespread in the WWII generation? Is there any literature on this? I wonder if my grandfather (91 year old D-day invasion survior) would like to have this discusion with me?

Very much agreed; there are of course other components as well, such as treatment options. One example a supervisor used to use was near-sightedness. A thousand or so years ago, may have been fairly debilitating with significant subsequent disability; nowadays, not so much.

Although I'll say that we need to of course exercise some caution. I've worked with more than a few Korea-era veterans who would tell me that while they never sought help for PTSD, they'd been doing things like pulling over to the side of the road to just cry multiple times per week/month, without knowing why, for decades. However, they "self-medicated" (often their own words) by working and staying busy; but once they retired, a variety of things hit them particularly hard.

Oh, and yes, some of the most potentially frustrating cases can involve situations in which the caregiver is receiving financial assistance to "care" for the patient. As erg mentions, in such situations, are we really fostering recovery with the current approaches?

 

[WisNeuro]

If you give any population incentive to be and stay sick, a proportion will do so at a greater clip than those without that incentive.

I do agree with AA though, it's a shame there are so many out there that are not, or have not gotten help in the past. I keep those in mind when I get below chance scores on my effort testing.

 

[erg923]

Although I'll say that we need to of course exercise some caution. I've worked with more than a few Korea-era veterans who would tell me that while they never sought help for PTSD, they'd been doing things like pulling over to the side of the road to just cry multiple times per week/month, without knowing why, for decades. However, they "self-medicated" (often their own words) by working and staying busy; but once they retired, a variety of things hit them particularly hard.

Yes, i agree. However for the average man in 1955, it was not really acceptable to avoid life responsibilites in the name of a psychiatric disorder. So, they didnt. I dont think there was as much avoidance and thus, i think people's symptoms faded OR were simply less intense and impairing.

 

[WisNeuro]

Well, I think that we have to also keep in mind that more than 500k people were institutionalized in the 50s and 60s before deinstitutionalization took place. It was more that we just threw people into a facility rather than trying to keep them in the community with moderate to severe mental illnesses. I'm not so sure about symptoms being less intense or impairing. Also, the wars have been much different in terms of length, combat exposure, and details of insurgency. I don't think we can make a 1:1 comparison with the cohorts involved. While I agree with some internal locus of control, you cannot completely discount the environment, milieu. and historical context of the time when talking about mental illness.

 

[psych844]

I think a lot of it has to do with increasing urbanization and being more dependent on employers to make a living. Back in the day a lot of people could be self-sufficient and you could live off little money and even share resources with family. You might have a ****ty life but there was little competition and reliance on others. Now people are moving to big cities, getting separated from family, feeling like they have to compete with others, and having to work for others and being dependent in that sense.

 

[smalltownpsych]

One thing the article doesn't comment on is the pressure that patients and society puts on providers to fix problems with a prescription. Also, it doesn't comment about the issue of a patient with a substance abuse history using abusable substances such as benzos and opiates. The people that I know who are solid in their recovery from substances don't take benzos and are extremely cautious about use of opiates and limit them to acute pain.

 

[QAsPsych]

Yes, i agree. However for the average man in 1955, it was not really acceptable to avoid life responsibilites in the name of a psychiatric disorder. So, they didnt.

I'd love to see the evidence for that.

 

[erg923]

I'd love to see the evidence for that.

My grandpa said so.