Panelists: Jessica Keith, PhD Tawnia Lola, RN Tulika Singh, MD Moderator:Aimee Sanders, MD, MPH Mental Health Crises

2.2 million living women Veterans Of 350,000 women Veteran VA health care users, ~ 35% had at least one mental health diagnosis

44yo Veteran Mental health history ─PTSD ─History of MST and childhood abuse ─Psychiatric hospitalizations Today, during outpatient mental health appointment, made vague self-harm statement Escorted to ED, but no report provided Becky

First Response

5 Direct Communication

Trauma-informed Care SafetyTrustworthinessChoiceCollaborationEmpowerment

Trigger Responses

Minimize Likely Triggers BUT… Unexpected touchLoud or angry toneCrowding or cornering

Be Ready to Recognize When a Veteran is Triggered and Respond

Comfort and Safety

Effective Communication in a Crisis Situation

Do not act in ways that: REACT R estricts E scalates A voids C oerces T hreatens

Slow breathing Visceral Name objects in room Visual Name favorite animals, colors, songs Mental Notice and feel floor, wall or chair Physical Grounding Technique

Compassionate care Successful use of grounding technique Answers questions and leaves bathroom Prefers taking to female staff

Next Steps in Care TriageSecondary nursing assessmentSuicide assessmentMedical evaluationMental health

Vital signs: normal Pain: 2 LMP: 1 week ago Suicidal ideation ESI: 2 Triage 1:1 monitoring Safety Additional information Secondary Assessment

Medical Evaluation Suicide & mental health assessments – “Do you have a plan to harm yourself?” – “Have you done anything recently to harm yourself?” – Risk factors for suicide – Review of systems

Physical exam Suicide & mental health assessments Medical Evaluation

Physical exam Suicide & mental health assessments Lab testing Medical Evaluation

Physical exam Suicide & mental health assessments Lab testing Additional diagnostics as indicated Medical Evaluation

Suicide Assessment Ask directly and matter of factly – Means and accessibility – History of self harm – Protective factors Review chart for risk factors – Past attempts – Significant life changes – Medical problems – Social withdrawal

Becky’s ED Course

Other Considerations How would this case change if Becky didn’t meet hospitalization criteria?

Take Home Points Slow down Promote good communication

Take Home Points Slow down Promote good communication Provide choice Recognize and respond to triggers

Take Home Points Slow down Promote good communication Provide choice Recognize and respond to triggers Establish a trusting therapeutic relationship Provide trauma-informed care

Jenny 28yo Veteran “At the end of her rope” Frequent ED visits ─Migraines ─GI symptoms ─URI symptoms ─Depression ─Suicidal ideation Mental health history ─Anxiety ─Depression ─Borderline Personality Disorder Jenny

Managing Initial Reactions

Vital signs: normal Pain: 3 LMP: 3 weeks ago No suicidal ideation ESI: 3 Triage Communicate expectations Safety Additional information Secondary Assessment

Intimate Partner Violence (IPV) Red flags – Repeated medical visits – Complaints of stress, anxiety, depression – Recurrent physical symptoms Headaches and chronic pain GI distress Pelvic pain, gynecological problems Vague physical complaints – Childbearing age women

Intimate Partner Violence Screening

IPV and suicide assessments – Direct screening questions Medical Evaluation

Physical exam – Injury patterns or signs of trauma Face, head, breasts, abdomen Symmetric / bilateral Inconsistent with the explanation Various stages of healing Delayed presentation IPV and suicide assessments Medical Evaluation

Lab testing Physical exam IPV and suicide assessments Medical Evaluation

Additional diagnostics as indicated Lab testing Physical exam IPV and suicide assessments Medical Evaluation

Jenny’s Case Develops

If she says yes… Make eye contact Respond with empathy ValidateAvoid judgingAsk detailsShare that she is not alone

If she is not ready to leave… Provide information on IPV Be clear that violence or threats are not okay Review warning signs of escalation Discuss option should violence escalate Refer to community resources, support groups, crisis hotlines Involve ED care team, including social work

Internet Safety and other information from the National Coalition Against Domestic Violence: MyPersonalSafetyPlan.php or from the National Network to End Domestic Violence: org/projects/safetynet.html From the National Coalition Against Domestic Violence:

Other Considerations How would this case change if Jenny was pregnant?

Other Considerations What if Jenny had her young children with her in the ED?

Take Home Points Express empathy Ask screening questions

Take Home Points Document Respect decisions Express empathy Ask screening questions

Provide resources Risk assessment Document Take Home Points Respect decisions Express empathy Ask screening questions

Resources Sharkansky, E. Sexual Trauma: Information for Women’s Medical Providers. Washington, DC: US Department of Veterans Affairs, National Center for PTSD, n/ptsd-womens-providers.as n/ptsd-womens-providers.as Suicide Prevention Resource Center. Suicide risk: A guide for ED evaluation and triage. Bethesda, MD: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, n.d. ideRiskGuide8.pdf ideRiskGuide8.pdf

Resources The Safing Center. Domestic violence/intimate partner violence national resources. Bedford, MA: Safing Center, Edith Nourse Rogers Memorial Veterans Hospital, n.d. V_National_Resource_List.pdf V_National_Resource_List.pdf The Safing Center. Signs that you might not be safe in your relationship. Bedford, MA: Safing Center, Edith Nourse Rogers Memorial Veterans Hospital, n.d. kforexperienceIPV.pdf kforexperienceIPV.pdf