Harold is 72 years old and a Vietnam vet Harold is 72 years old and a Vietnam vet. Betty, his wife of 47 years died a year ago after a long fight with cancer. A devoted caregiver, Harold gave up his previous activities to care for his wife. In the past six months, he has seen you, his PCP, a number of times for a variety of physical complaints. In the past three weeks, he has made and broken two appointments which is totally out of character. During today’s appointment, when you ask, “What brings you here today?”, Harold says, “Same old thing. I just don’t feel myself.” When you say, “What do you think would make you feel better?”, Harold replies, “Probably just a shot in the head from my trusty service revolver.” Be direct in asking about suicidal thoughts – Have you been having thoughts of suicide? Listen carefully and follow up. Probe about depression, “not feeling himself” and concerns you have – withdrawn, missing appointments, etc. Discuss options for reducing access to guns. Is there someone you would trust to hold on to your guns while you are feeling this way? Continue to probe until a solution is found. Try to involve a family member or friend. Develop a treatment plan including safety planning and follow up Maintain connection You may be the first or the only person he shares these feelings with!

MaryAnn is a 30 year old who has recently given birth to her second son in less than two years. You are making the second new baby home visit. This time, MaryAnn seems somewhat disinterested in both boys, the house is really dirty with stinky diapers on the coffee table and she has trouble making eye contact. You know that she had been taking anti-depressants before this pregnancy but discontinued them while pregnant. Her PCP suggested that she go back on them and she resumed taking them two weeks ago. When you ask her whether she is seeing any improvement from them, she replies, “I think the only way they’ll do me any good is if I take the whole three month supply at once and never wake up again.” Then she starts to cry. Be direct in asking about thoughts of suicide and of making an attempt Ask about other meds in the home Ask about options for reducing her access to these quantities while she is feeling like this. Try to get someone else involved – husband, other family, friend, neighbor. If husband, make sure she is comfortable with this. Document this info. Share with your supervisor and with PCP and others re: duty to report. Ask about firearms in the home and other methods Do not leave her alone with children and meds

Tom is a 24 year old veteran who has recently returned from Afghanistan where he was in a motor vehicle crash, with significant injuries to his spinal cord. After spending time in both acute care and rehab facilities, he has moved back home with his parents and is now receiving in-home physical therapy services. He has been making excellent progress and has regained most of the function in his upper body though there is still marked disability in both his legs. Today, during therapy, he is not cooperative with you. When you ask what is going on, he says, “What’s the point? I’m going to be stuck in this chair for the rest of my life. I think I should make things easier for everyone and just shoot myself. I used to be a hunter and still have a loaded shotgun in my closet.” Ask directly about suicidal thoughts and actions and access to the loaded shotgun. Listen carefully Do not leave him alone with access Who to engage/inform? Get his permission or acknowledgement. Follow up to be sure that a treatment plan has been developed Maintain connection

Tammy is a 17 year old, straight A student at a local high school Tammy is a 17 year old, straight A student at a local high school. She has had some counseling for anxiety in the past, but is not currently in treatment. She struggles with perfectionism and is obsessed with getting into a top-notch school. Her SAT results came back much lower that she expected, and her boyfriend has decided they should “have some time apart” Tonight, in the ER, she says she is in “crisis” and that her “whole world is falling apart”. When you question her further, she says that she thinks that she should just end all this pain by taking some prescription pills in the medicine cabinet and a whole lot of Tylenol. Ask directly about suicidal thoughts and actions Reference to Tylenol is a red flag Ask about other methods including firearms Involve parents and discuss reducing access to most common and most lethal Ensure that a safety plan is established including treatment and follow up by parents and professionals Follow up is crucial

Stan is a 56 year-old, married veteran with two daughters in college Stan is a 56 year-old, married veteran with two daughters in college. He lost his job at a high-tech firm eighteen months ago due to downsizing. Though he has been actively searching, he has yet to find anything, but he has been able to do some small consulting jobs. Stan has had problems with sleep over the past two to three months, and he has seen Dr. Johnson, his primary care provider for complaints of chronic back pain and headaches. Today, when his wife accompanies him to the doctor, she reports that Stan has been very moody, and he has said more than once, “You know that if something happens to me, you’ll have all the life insurance money. That’s better than I can do for you and the girls right now.” Make a specific plan for reducing access to all lethal means Create a comprehensive safety plan Provide support for both Stan and his wife Utilize wife to confront about the last part of his statement

James is a 27 year old Army veteran James is a 27 year old Army veteran. He completed one tour in Afghanistan. He struggles with PTSD and major depression. His wife called you and reported that he had locked himself in the bathroom last night and wouldn’t respond to her. He eventually came out and was quite calm though his wife was clearly shaken. Today he says that he isn’t sleeping and is plagued by hypervigilance, and feelings of being useless. But he insists that he’s not suicidal and that he wouldn’t put his family through that. He wants to “get better” for his wife and kids. When you ask about whether he has any firearms, he says that he has to have a loaded firearm at his bedside at night and worries that without it his anxiety will get worse. Focus on SAFETY – his, his wife’s and his kids Ask him what would make him feel safer. Engage him in discussion about reducing access to increase everyone’s safety Involve others in support for him and his family – family and friends, VA, peer support, work, etc Develop a comprehensive safety plan and follow up

Rob is a 34 year old, medically retired Marine with 8 years of service Rob is a 34 year old, medically retired Marine with 8 years of service. He completed 2 tours of duty in Iraq. He presents as a “walk-in” to the Primary Care Clinic stating, “I need to talk with someone”. He reports “…not being able to get along with anyone…”. He is separated from his wife of 10 years, his 2 children (aged 9 and 7, both boys) “don’t want to see me…”. Stated that he finds it hard to get up in the morning and go to work, “drinking too much and sleeping like crap…”. Was suspended from his job, is behind on his bills and just got his 2nd DUI. “…I just want it all to end…one way or another….I can’t take this anymore…. ”. High risk situation Two pluses – he has come in “to talk with someone” And he says “one way or another” Ask him what would help him Seek support – other family, friends, peer support, AA, work Discuss access to lethal means as part of a comprehensive safety plan