Kate Mostkoff, LCSW Mia Ihm, PhDSuicide Prevention CoordinatorNYHHS – Manhattan VA ext ext. 3182

2 It’s a big problem:  10th leading cause of death  ~43,000 suicides occur each year in the U.S.  One suicide occurs every 12.3 minutes  More suicides than murders (10 th vs. 17 th )  Suicide method:  Firearms (50%), Hanging (27%), Poisoning (16%), Cutting (2%), Drowning (1%)  New York State has the lowest rate  8.6 per 100,000 vs per 100,000 nationally *Based on 2014 US Suicide Data

3  Gender  Women make more suicide attempts than men  Men take their lives at 3.5 times the rate of women  Age  Suicide is the 2 nd leading cause of death among year olds  Persons aged 65 years and older have the highest suicide rate* *Age demographic appears to be changing  Race  White > Native American > Black > Asian > Hispanic  Veteran Status  Veterans are at even greater risk than those in the general population *Based on 2014 US Suicide Data

 21% of males age 18+ in the US are veterans (22 million)  Veterans account for ~22% of suicides in US  Male veterans are twice as likely as civilians of either gender to commit suicide  Multiple deployments are a risk factor, yet half of the Army’s suicides never deployed  There are differences between branches of service, deployment with combat vs. no combat, job type during deployment, adaptation to military service, and pre-military mental health issues that contribute to a very complicated and dynamic picture that can’t easily be explained  The overall rate of suicide among veterans is stable  However, the rate of suicide among female veterans and veterans age is increasing 4

Data from 2000 – 2011 (Hoffmire et al., 2015)  Non-Veteran suicide rate (per 100,000):  Men = 20.9 vs. Women = 5.2  Increased by 12% during study period  Veteran suicide rate (per 100,000):  Men = 32.1 vs. Women = 28.7  Increased by 25% during study period  Over 11 years, 40,571 male and 2,367 female veterans died by suicide  The rates are highest for young veterans & female veterans  The rate for female veterans age is almost 12 times that of non-veteran females (higher rates date back to 1950s). 5

 Veterans without a history of VHA service use are at particularly high risk of suicide 6  1,000 suicides occur per year among VA users vs. 5,000 for all living veterans  5 suicides vs. 22 suicides* per day  17 of the 22 veterans who die by suicide are not receiving care at VA  Suicide rates among VA Mental Health Service users have decreased  Suicide rates among recent attempters receiving VA care have decreased

 Only 15% visit Mental Health Professional in the month of their death  75% saw Primary Care MD within 3 months of completing suicide  50% within one month  20% within 24 hours  “A systematic clinical approach in health systems is needed so that prevention does not rely on the efforts of crisis staff or individual clinicians but is the responsibility of the entire system.” - Adam Chu, Suicide Prevention Resource Center 7

 Veterans are at a higher risk for suicide  We need to do more to reduce risk  Suicides are preventable in most cases 8

 Myth or Fact? Asking about suicide will plant the idea in a person’s head.  Reality: Asking a veteran about suicide does not create suicidal thoughts any more than asking about chest pain causes angina. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. 9

 Myth or Fact? There are talkers and there are doers.  Reality: Most people who die by suicide have communicated some intent. Someone who talks about suicide gives the guide and/or clinician an opportunity to intervene before suicidal behaviors occur. 10

 Myth or Fact? If somebody really wants to die by suicide, there is nothing you can do about it.  Reality: Most suicidal ideas are associated with the presence of underlying treatable disorders. Providing a safe environment for treatment of the underlying cause can save a life. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and the overcome the strong intent to die by suicide, you have gone a long way toward promoting a positive outcome. 11

 Myth or Fact? He/she wouldn’t commit suicide because…  he just made plans for a vacation  she has young children at home  he made a verbal or written promise  she knows how dearly her family loves her  Reality: The intent to die can override any rational thinking. “No Harm” or “No Suicide” contracts have been shown to be ineffective from a clinical and management perspective. A veteran experiencing suicidal ideation or intent must be taken seriously and referred to a clinical provider who can further evaluate their condition and provide treatment as appropriate. 12

Operation S.A.V.E. will help you act with care and compassion if you encounter a veteran who is suicidal. The acronym “SAVE” summarizes the steps needed to take an active and valuable role in suicide prevention.  S igns of suicidal thinking  A sk questions  V alidate the veteran’s experience  E ncourage treatment and Expedite help 13

 Suicidal individuals are not always easy to identify.  There is no single profile to guide recognition.  There are a number of warning signs and symptoms.  Some of the signs of suicidality are obvious, but others are not.  Signs and symptoms do not always mean the person is suicidal but:  When you recognize signs, it is important to ask the veteran how they are doing because they may mean that a veteran is in trouble. 14

 Threatening to hurt or kill self  Looking for ways to kill self  Seeking access to pills, weapons or other means  Talking or writing about death, dying or suicide  Hopelessness – no reason for living, no sense of purpose in life  Rage, anger  Seeking revenge 15

Less obvious warning signs:  Feeling trapped  Increasing drug or alcohol abuse  Withdrawing from friends, family and society  Anxiety, agitation  Dramatic changes in mood  Acting reckless or engaging in risky activities  Difficulty sleeping or sleeping all the time  Giving away possessions  Increase or decrease in spirituality 16

To effectively determine if a patient is suicidal, one needs to interact in a manner that communicates concern and understanding. Also, one needs to know how to manage personal discomfort (i.e., anxiety, fear, frustration, personal/cultural/religious values) in order to directly address the issue. Know how to ask the most important question: “Are you thinking of killing yourself?” 17

Things to consider when you talk with the veteran:  Remain calm  Listen more than you speak  Maintain eye contact  Act with confidence  Do not argue  Use open body language  Limit questions to gathering information casually  Use supportive and encouraging comments  Be as honest and “up front” as possible DON’T ask the question as though you are looking for a “no” answer: “You aren’t thinking of killing yourself, are you?” 18

Validate the veteran’s experience:  Show the veteran that you are following what he or she is saying.  Accept his or her situation for what it is, do not minimize.  You are not passing judgment.  Let him or her know that their situation is serious and deserving of attention.  Acknowledge his or her feelings.  Let him or her know you are there to help. 19

Tips for encouraging treatment:  Explain that there are trained professionals available to help them.  Explain that treatment works.  Explain that getting help for this kind of problem is no different than seeing a specialist for other medical problems.  Tell the veteran that getting treatment is his or her right.  If the veteran tells you that they have had treatment before and it has not worked, try asking: “What if this is the time it does work?” 20

Tips for expediting a referral:  Know the referral process in your program.  Know what roadblocks might exist and how to deal with them.  Set the stage and tell the veteran exactly what to expect with regard to the referral.  Answer any questions the veteran may have about the referral process.  Be honest about things such as emergency room wait times and the limits of confidentiality. 21

As you encourage the veteran to seek help, some situations may involve people who are hostile and aggressive. Here are some useful safety guidelines for working with seriously and acutely distressed veterans: [These rules are both for the veteran’s safety and yours.]  If you are not in face-to-face contact but are speaking over the phone with a veteran who expresses intent to harm self or others - call 911 if you know his or her location. 22

 Any time a veteran has a weapon or object that can be used as a weapon – Call Security or 911  If a veteran tells you that he/she has overdosed on pills or other drugs or there are signs of physical injury – Call Security or 911  In addition to calling for help, if you are confronted with a hostile or armed veteran, leave the area and attempt to isolate the person. If the veteran leaves your area, attempt to observe his or her direction of movement from a safe distance and report your observations as soon as authorities arrive on scene. 23

Never attempt to subdue or detain a hostile or armed veteran! Never try to negotiate with a hostile or armed veteran! Review your organization’s process for referring both cooperative & uncooperative vets, i.e., arrange for escort, move to E.R., remain with veteran. 24

 Veterans Crisis Line – 24-hr resource  Phone: (Press 1 for Veterans)  Confidential Chatline:  Confidential Texting: send text message to  LIFENET  A mobile crisis service that can be initiated when you would like a wellness check performed on a veteran (must provide home address)  Mobile crisis teams consist of mental health professionals who will assess veterans for safety within 48 hours of referral  If the veteran requires further psychiatric evaluation, he/she will be taken to the nearest Emergency Department (not necessarily VA)  Emergency Room or 911  You can always walk the veteran to their nearest Emergency Room for evaluation or call 911 to initiate a rescue if you know the veteran’s location 25

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By participating in this training, you have learned:  The scope of the problem of suicide in the veteran population  The importance of suicide prevention  The negative impact of myths and misinformation  How to identify a veteran who may be at risk  Some of the signs and symptoms of suicidal thinking  How to effectively communicate with a suicidal veteran  How to gather information to help the veteran  How to refer a veteran for evaluation and treatment  When calling security or 911 is necessary 27