Psychiatr Q DOI 10.1007/s11126-012-9241-3 ORIGINAL PAPER

Veteran-Specific Suicide Prevention Janet A. York • Dorian A. Lamis • Charlene A. Pope Leonard E. Egede

•

Ó Springer Science+Business Media New York 2012

Abstract Suicide rates have been increasing in some subgroups of Veteran populations, such as those who have experienced combat. Several initiatives are addressing this critical need and the Department of Veterans Affairs (VA) has been recognized for its leadership. This integrative review adopts the Research Impact Framework (RIM) to address suicidespecific prevention activities targeting Veterans. The RIM is a standardized approach for developing issue narratives using four broad areas: societal-related impacts, researchrelated impacts, policy-related impacts, and service-related impacts. The questions addressed in this review are: (1) What are the major initiatives in Veteran-specific suicide prevention in four areas of impact—society, research, policy, and services? (2) Are there gaps related in each impact area? and (3) What are the implications of this narrative for other strategies to address suicide prevention targeting Veterans? Systematic application of the RIM identifies exemplars, milestones, gaps, and health disparity issues. Keywords

Suicide
Veterans
Suicide prevention

Multiple policy reports underscore the elevated risk as well as increased rates of suicide morbidity and mortality in subgroups of Veterans and the need for Veteran-specific

J. A. York
C. A. Pope
L. E. Egede Ralph H. Johnson Veterans Medical Center, Medical University of South Carolina, 109 Bee St., Charleston, SC 29425, USA e-mail: [email protected] C. A. Pope e-mail: [email protected] L. E. Egede e-mail: [email protected] D. A. Lamis (&) Department of Psychiatry and Behavioral Sciences, Emory School of Medicine/Grady Health System, 80 Jesse Hill Jr Drive, Atlanta, GA 30303, USA e-mail: [email protected]

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prevention [1–4]. This integrative review adopts the Research Impact Framework (RIM) to address suicide-specific prevention activities targeting Veterans served by the VA [5]. The questions addressed in this review are: (1) What are the major VA activities and initiatives in Veteran-specific suicide prevention in four areas of impact—society, research, policy, and services? (2) Are there gaps related to each impact area? and (3) What are the implications of this narrative for other strategies to address suicide prevention targeting Veterans? Systematic application of the RIM identifies exemplars, milestones, gaps, and health disparity issues.

Application: Research Impact Framework The RIM is a standardized, practical approach for developing health research narratives using four broad areas (and descriptive categories): societal-related impacts (health status, changes in knowledge, education, and skills), research-related impacts (problems, knowledge, studies, methods, and networks), policy-related impacts (activity, nature, and networks), and service-related impacts (health services and evidence-based practices) [5]. The framework was developed from the research impact assessment literature and was tested by analyzing selected research projects. The RIM can assist experts in suicide prevention with Veterans as well as assess and describe their work in a systematic method for dissemination, funding applications, to identify gaps, testimonies, and press releases. Comparisons have been made between bodies of research and various periods as the primary expansion of activities in suicide prevention has occurred within the last 25 years. The RIM is also consistent with the VA’s emphasis on identifying the potential impact of projects to improve care for Veterans. Although scientific and policy reports on suicide in Veterans have been released, none have summarized the multiple impacts which address suicide prevention in this population. Operationally, the authors use the RIM to frame broad areas of impact related to suicide prevention in Veterans. This manuscript does not address suicide in the military and branch-specific prevention efforts; however, several reports review these issues, most recently the exemplar report by the Rand Center for Military Policy Research [1, 6]. There is often overlap and collaboration between the VA and active duty military. Veteran refers to retired and discharged military populations and is capitalized, consistent with the recommendations from the VA Central Office (VACO). VA is used to refer to the Department of Veterans Affairs. Suicide in Veterans must be contextualized within the overlapping ecologies of mental health and disparities in Veterans (gender, age, race, ethnicity, and residence) [7–9]. The term suicidology is used to refer to suicide-specific epidemiology and etiology, training and education, research, clinical services, and advocacy and policy activities [10]. This review was investigator-initiated and emerged from the authors’ roles in VA funded projects on both suicide prevention and disparities in Veterans and suicide-specific training activities on military bases. We conducted a literature search of electronic databases and reviewed relevant articles in adult populations. The databases searched included PsycINFO and PUBMED/MEDLINE and the review focused on literature specific to suicidology in Veterans and the VA. In particular, we selected articles illustrating the role of the VA in suicide prevention during the last two decades. We then described major activities in each area of impact, followed by summaries of each section, and addressed gaps in the literature. In the last section, we suggest additional activities based on these gaps.

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Societal Impact: Suicide Epidemiology and Education Societal Impact includes research on health status (suicide morbidity and mortality and health disparities) and education/and training to address knowledge, attitudes, and skills in suicide prevention [5]. Suicide Morbidity, Mortality and Risk in Veterans The suicide of Veterans served by the VA was 1,609 in 2001 and 1,909 in 2008; which was actually a decrease in rate, given the increase in the number of Veterans served by the VA during that period [11]. Some experts argue that the literature does not support universal suicide risk among all Veterans, but there is evidence of elevated risk among some: those in psychiatric treatment, those with selected conditions (depression) or untreated depression and those in certain risk periods (12 weeks after medication initiation or changes and 12 weeks after hospitalization) and age groups (18–25 and 60–80 years) [12–17]. The highest rates of suicide in Veteran populations mimic those of the general population-being male, White, and elderly [18]. Similarly, the primary methods used in suicide deaths for the general population and Veterans are firearms. Yet researchers have suggested women with past military experience may comprise a hidden epidemic. Female Veterans (including active duty) were more likely to die by suicide than women nonVeterans in a study of the National Violent Reporting System of 5,948 women ages 18–64 from 2004 to 2007 in 16 states [19]. Table 1 illustrates risk factors linked to the increased rate of suicides in Veterans [1–4, 11–17, 19]. Several VA studies illustrate these risk factors and Veteran groups with elevated risk. For example, a chart review of 1,075 Veterans from an urban VA in 1998 identified 19 Veterans who died by suicide (confirmed or suspected). The majority of these 19 Veterans had previous but not recent VA psychiatric care, elderly Veterans were more likely to be

Table 1 Risk factors for veteran suicide [1-4, 11-1, 187] Individual

Environmental

Familial

Male gender

High combat stress exposure

Relationship problems

Females with military history

Long and multiple deployments

Financial problems

White

Exposure to traumatic events

Age (young and elderly)

Availability of weapons

Mood and substance abuse disorders

Skill using firearms

Untreated PTSD and depression

Rural residence

Comorbidity Legal problems Health problems (pain, disabling chronic medical illness, traumatic brain injury) Daily life limitations Psychiatric hospitalization (12 weeks) Medication changes (12 weeks)

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undiagnosed or untreated for psychiatric disorders, and rates were similar in Black and White Veterans [20]. Veterans in the VA (n = 175) with self-injurious injury and high intent were characterized by male gender, older age, planning of self injury, no wish to be saved, and a negative feeling about having survived [20]. Planning of self-injurious behavior was associated with higher intent in 175 VA patients with self injurious behavior and 10 patients who died by suicide were older and more likely to have experienced combat than those with non-fatal self-injurious behavior [21] during the 2.5 year study (2006–2008). Suicide attempts were significantly lower in 226,866 depressed Veterans of all age groups (except those 18–25 years) treated with antidepressants compared to those depressed Veterans not treated with antidepressants [14]. Those Veterans treated with SSRI’s and tricyclics had the lowest rates of suicide within the treatment group. A recent retrospective review of suicide in 887,859 Veterans receiving a depression intervention in VA medical centers found significantly elevated rates of suicide 12 weeks after medication initiation or changes, and 12 weeks after hospitalization [16]. Veterans aged 61–80 years had the highest suicide rate. These studies support elevated risk in Veterans with depression segmented by treatment and treatment intervals, a research impact that can sharpen clinicians’ focus on diagnosis and monitoring. Recent VA reports have also focused on health disparities in the elevated risk for mental health disorders and suicide in Veterans [7, 8]. Health disparities in Veterans include associations with gender, race and ethnicity, and rural residence [9]. VA health researchers have identified potential mental health-related disparities in rural Veterans as compared to urban Veterans. More rural Veterans are unemployed, disabled, or receive VA disability compensation, have a payee or fiduciary, and have a poor health related quality of life. Rural Veterans had lower rates (10–22 %) of mental health disorders as compared to urban Veterans, yet burden, defined as lower quality of life scores, was higher in rural Veterans for six psychiatric disorders (depression, anxiety, post traumatic stress disorder, alcohol dependence, schizophrenia, and bipolar disorder) as compared to suburban/urban Veterans [22]. Clinical outcomes, hospitalization and suicide attempts, were also worse among rural, depressed Veterans than among urban/suburban depressed Veterans in a sample of 173,104 Veterans [23]. Veterans residing in rural or highly rural areas are a significant subpopulation, comprising 41 % of those enrolled in the VA health care system and 39 % of OEI/OEF Veterans [24]. In addition to health disparities, many Veterans in isolated rural communities have difficulty accessing VA services. Disparities in rural residents in the general population have been associated with increased risk for suicide, particularly in isolated rural communities [25–32]. Education and Training in Veteran-specific Suicide Prevention Gatekeeper, consumer, and peer training in suicide prevention are public health strategies used in community and workplace settings for many decades [33]. A federal initiative produced Core Competencies for Assessing and Managing Suicide Risk (AMSR) for Mental Health Professionals [10]. However, few training programs for mental health providers are competency-based or offer intensive training in suicide-specific, evidencebased interventions for Veteran-specific suicide prevention [34]. The VA has continuously increased their mental health workforce over the past few years. These providers need intensive training in evidence-based suicide prevention and interventions. The VA has developed and implemented training sessions for staff on

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suicide prevention, consistent with the VA priorities [35]. Suicide Prevention Coordinators from each VA hospital educate non-clinical staff in orientation and community gatekeepers in suicide prevention [35, 36]. Web-based suicide prevention initiatives are implemented to educate and train professionals and the public. Other targeted trainings (e.g., suicide prevention in women and the elderly) are in development for national e-Learning dissemination by the VA VISN2 Center for Excellence. VISN refers to the 21 Veterans Integrated Service Networks that divide VA health services by geographic area around the country. Inconsistent definitions of suicidality have impaired communication in clinical services, research, and education; however, a VA initiative addresses this gap. In 2010, the VA announced the nationwide roll-out of a nomenclature for Self-Directed Violence (SDV) and an associated clinical tool. This nomenclature is based on the typology by Silverman and colleagues [37, 38]. This SDV initiative was a collaboration between the VISN19 Mental Illness Research, Education, and Clinical Center (MIRECC) and the Centers for Disease Control and Prevention (CDCP) [39]. Although there is a gap in health education research, preliminary results, such as increases in knowledge, confidence, and changes in practice for assessing and managing suicidality, are encouraging [40]. Matthieu and colleagues evaluated a brief standardized gatekeeper program (including scripted behavioral rehearsal practice) with 602 VA staff (50 % were providers) in 14 regional trainings [41]. Using a pre-post study design, the findings demonstrated significant knowledge gain and increased self-efficacy. However, experts have recommended gatekeeper training should also be linked to sensitive and robust outcome measures beyond suicide deaths, such as emergency room utilization. Accordingly, a study involving the Collaborative Assessment and Management of Suicidality (CAMS) is in process in the southeastern VA VISN. Provider adherence and patient outcomes, including health care utilization, are being assessed for one year for mental health providers randomized to in—person, e-learning or no training in an empiricallybased, assessment and management of suicidality system [34, 42]. In summary (Societal Impact), suicide mortality and morbidity is increasing in some sub groups of Veterans. Veteran-specific risk factors for suicide include depression, untreated disorders, combat experience, and psychiatric disorders. These risk factors also include health disparities in Veterans, such as burden due to psychiatric disorders. The VA has increased education and training in suicide prevention at multiple levels, including VA providers, staff members, and community stakeholders. There is a need for additional accessible training for providers in Veteran- and suicide-specific evidence-based interventions. More health education research needs to address gaps in Veterans-specific suicide prevention training and community. Outcomes of training should include provider adherence and patient outcomes.

Research Impact: Research in Suicide Prevention in Veterans Research Impact includes systematic reviews, studies, research funding and centers targeting Veteran-specific suicide prevention [5]. Central to the evaluation of suicide intervention are public health research definitions, such as direct versus indirect outcomes of suicide prevention interventions. Direct outcomes (suicide morbidity and mortality) include suicide ideation, attempts, and completed suicide defined in the revised nomenclature of suicidality [36–39, 42, 43]. Intermediate outcomes—also referred to as indirect outcomes, variables, or proxies—occur in the causal pathway between a determinant and

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the final health outcome [43]. These intermediate outcomes include increases in knowledge, changes in attitudes, skill building, referrals, and decreases in depression, anxiety, and hopelessness in at risk individuals. Research Funding of Veteran Suicide There have been increases in VA and Department of Defense (DOD) funding for research and surveillance in suicidology. The Veteran Suicide Act called for a study of suicide in Veterans since 1997 and a report to Congress [1]. In 2007, the VA established a Center of Excellence (CoE) at Canandaigua, New York. This CoE was organized as a prevention and research center with the goal of reducing the morbidity and mortality in the Veteran population associated with suicide. The Center’s mission is to serve as a national, regional, and local resource on suicide prevention and mental health. The CoE is addressing the problem of suicide in Veterans at various levels of risk through research program evaluation, dissemination of evidence based practice and partnership [44]. The VISN19 Mental Illness Research, Education, and Clinical Center (MIRECC), was also funded and focuses on research and clinical approaches to decrease suicide risk. Systematic Reviews of Interventions Targeting Suicidality Providers have the potential to reduce the risk of suicide and promote resiliency through the delivery of evidence-based, suicide-specific interventions targeting Veterans. Systematic reviews, best practices, toolboxes and individual studies provide the evidence for these interventions. Six significant reviews of suicide prevention interventions are summarized below, some of which are Veteran-specific, whereas other reviews demonstrate Veteran-specific gaps. The VA and other federal agencies funded an Institute of Medicine (IOM) review, based on The National Strategy for Suicide Prevention objectives [26]. A Committee was tasked with completing the following: an assessment of the science base; an evaluation of the status of primary and secondary prevention; identification of strategies for studying suicide; and the development of conclusions regarding gaps in knowledge, research opportunities, and strategies for prevention of suicide [26]. Only a few studies reviewed in this extensive report are Veteran-specific, highlighting the gap in studies at the time of this review. Recommendations of the report relevant to the VA include: (1) funding agencies to include measures of suicidality in all large and long-term studies of health behaviors, mental health interventions, and genetic studies of mental disorders, and (2) testing, expanding, and implementing programs for suicide prevention through funding from appropriate agencies. Exemplars of responses to these recommendations are the VA funded CoE and MIRECC targeting suicidality [36, 44]. In the second systematic review, international suicide experts reviewed the efficacy of 91 studies of suicide prevention interventions [45]; however, none focused on Veteran populations. The review team concluded physician education in depression recognition and treatment, and restriction of access to lethal methods (both are VA practices) reduced suicide rates, whereas three other methods (including clinical practices of screening and treatment used in the VA) required further study. The American Foundation for Suicide Prevention (AFSP) and the SPRC conducted a federally funded systematic review [based on the National Registry of Evidence-Based Programs and Practices (NREPP) criteria] of suicide prevention programs and developed the Best Practices Registry (BPR) [46]. The BPR does not include any Veteran-specific

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interventions but includes several best practices used within the VA [Dialectical Behavior Therapy, Prevention of Suicide in Primary Care Elderly (PROSPECT), and Reducing Analgesic Packaging]. Pertinent to the evaluation of VA systems level suicide interventions is the exemplar evaluation of the Air Force Suicide Prevention Program. This evaluation design was rated as methodologically strong, based on the inclusion of a large population, explicit component description, linear time-trend analysis, and consideration of potential confounds [46–49]. In a Veteran-specific (including military personnel) systematic review of suicide prevention interventions, 74 studies published between 2005 and 2008 were reviewed [50]. The studies included randomized controlled trials (RCT), controlled clinical trials (CCT), observational studies, cohort studies, and interrupted time series studies. The findings included the following: (1) Multicomponent interventions are more likely to reduce the risk of suicide but there are insufficient studies of interactive effects and multicomponent programs to draw conclusions about effectiveness; (2) Psychosocial interventions following a suicide attempt were only minimally effective and the quality of evidence (face validity) was moderate; (3) No studies assessed the specific effectiveness of any hotlines, outreach programs, peer counseling, treatment coordination programs, and new counseling programs; (4) Although restriction of access to lethal means likely has a cause-specific effect on suicides, its effect on total suicides is less clear; (5) There is a gap in randomized controlled trials and high-quality observational studies; and (6) Few studies focus on therapeutic relationships. Bagley and colleagues conducted a systematic review of seven intervention studies targeting military personnel (n = 4 studies) and Veterans [47]. The researchers assessed the quality of evidence for outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification system. The three Veteran studies included a pilot RCT of Dialectical Behavior Therapy with 20 Women Veterans, a comparison study of the suicide attempt rate in 3,733 substance abusing persons, and a study of antidepressant treatment and suicidality in 226,000 patients with new depressive disorder. Studies were rated as very low on quality of evidence due to being observational, including disparate populations, and failing to reach statistical significance [47]. A federal review of Civilian Best Practices identifies clinical practices to reduce suicidality and enhance mental health care [51]. This review was requested by the Army but has the potential to inform both military and VA adoption of programs to reduce suicidality through improving the chain of completed care (in inpatient psychiatric units, outpatient behavioral health, primary care for mental health, gatekeeper and informal levels of care) [51]. Additional Studies of Veteran Suicide and Prevention Valenstein and colleagues (study described above) demonstrated that VA patients in depression treatment are at high risk for suicide within 12 weeks of initiation of antidepressant treatment and dosage changes and discharge from the psychiatric unit [20]. This risk may be significantly reduced by providing intensive monitoring (mental health and primary care visits) for VA patients in depression treatment [52]. Further research is needed on the frequency, nature, duration, and content of monitoring visits. Valenstein and colleagues randomly selected 100,000 depressed patients (92 % male) from the VA National Registry for Depression (NARDEP) between 1999 and 2004. The authors identified relevant systems changes for various monitoring approaches and estimated costs [52].

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The Collaborative Assessment and Management of Suicidality (CAMS) is a structured, suicide-specific process of clinical assessment, monitoring, and management recommended for VA populations [42, 47, 51]. CAMS has already undergone rigorous evaluation and other studies are in progress in Veteran populations [42, 53–56]. CAMS was tested in a retrospective study of medical record archives (comparison of patient-practitioner dyads in Air Force outpatient clinics in CAMS versus treatment as usual care). This study demonstrated significantly more rapid resolution of suicidality (approximately one month) and fewer emergency department and primary care visits suggestive of possible cost savings [56]. In summary (Research Impact), the scientific body for the evidence to address suicidality in Veterans is expanding. In several systematic reviews, researchers have identified gaps in research and suggested that multicomponent interventions are promising. Research funding has increased; however, more research is needed on suicide prevention in Veterans and telemedicine, primary care mental health, monitoring of high risk periods, genderspecific approaches, psychosocial programs, therapeutic relationships, cost effectiveness, and health disparities. Systematic reviews, such as the Best Practices Registry need to target Veteran-specific programs.

Policy Impact: Suicide in Rural Veterans Policy Impact focuses on the type, level, and nature of policy activities, and networks related to suicide prevention policy targeting Veterans in the VA [5]. Federal Activities Targeting Suicide in Veterans Suicide prevention in Veterans and the military is a national priority [35, 57]. The VA, DOD, and several Federal entities are committed to decreasing the burden of suicide among Veterans. This commitment is evidenced by the VA Suicide Prevention Strategy, Congressional bills and testimonies, and funding priorities [35]. The Omvig Suicide Prevention Act P.L. 110-110 addressed comprehensive programs for suicide prevention. The Department of Health and Human Services (DHHS) Substance Abuse and Mental Health Services Administration (SAMHSA) established returning Veterans and their families as both a priority program area [58] and the national suicide Prevention Strategy is being updated [59]. Two special VA panels, the Blue Ribbon Work Group and Expert Panel, were appointed in 2008 to provide recommendations of how the VA could improve its programs in suicide prevention, research, and education. Dr. Peake asserted in announcing the appointments, ‘‘the VA is committed to doing all we can to improve our understanding of a complicated issue that is also a national concern’’ [60]. The Blue Ribbon Work Panel released their findings and recommendations, many of which have already implemented (see Table 2) [61]. In addition to these recommendations, the Blue Ribbon Work Panel identified 14 additional areas for possible action including: adopting a standard definition for suicide and suicide attempts, implementing a gun safety program targeting children of Veterans, working with community partners, consolidating suicide prevention activities into a comprehensive strategic plan, and prioritizing research activities [60]. More recently, the VA has been recognized as providing national leadership in suicide prevention, such as creating a culture of safety [62, 63].

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Psychiatr Q Table 2 Report of DVA blue ribbon work panel on suicide prevention Findings

Recommendations

1. Conflicting and inconsistent reporting of Veteran suicide rates were observed across various studies

1. VHA should establish an analysis and research plan in collaboration with other federal agencies to resolve conflicting study results in order to ensure that there is a consistent approach to describing the rates of suicide and suicide attempts in Veterans

2. Suicide screening processes being implemented in VHA primary care clinics go beyond the current evidence and may have unintended effects.

2. The VA should revise and reevaluate the current policies regarding mandatory suicide screening assessments

3. VA is attempting to systematically provide coordinated, intensive, enhanced care to Veterans identified as being at high risk for suicide. However, the criteria for being flagged as high risk are not clearly delineated; nor are criteria for being removed from the high risk list

3. Proceed with the planned implementation of the Category II flag, with consideration given to pilot testing the flag in one or more regions before full national implementation

4. The root cause analyses presented to the Work Group did not distinguish between suicide deaths, suicide attempts, and self-harming behavior without intent to die

4. Ensure that suicides and suicide attempts that are reported from root cause analyses use definitions consistent with broader VHA surveillance efforts

5. The emphasis of VHA leadership on the use of clozapine and lithium does not appear to be sufficiently evidence-based

5. VHA should ensure that specific pharmacotherapy recommendations related to suicide or suicide behaviors are evidence-based

6. Efforts to improve accurate media coverage and disseminate universal messages to shift normative behaviors to reduce population suicide risk behavior are not being fully pursued

6. The VA should continue to pursue opportunities for outreach to enrolled and eligible Veterans, and to disseminate messages to reduce risk behavior associated with suicidality

7. Concerns about confidentiality for OIF/OEF service members treated at VHA facilities may represent a barrier to mental health care

7. The issue of confidentiality of health records of OIF/OEF service members who receive care through the VHA should be clarified both for patient consent-to-care and for general dissemination to Reserve and Guard service members contemplating utilizing VHA medical system services to which they are entitled

8. The introduction of Suicide Prevention Coordinators (SPCs) at each VA medical center is a major innovation that holds great promise for preventing suicide among Veterans; however, there is insufficient information on optimal staffing levels of SPCs

8. In order to maximize the effectiveness of the Suicide Prevention Coordinators program, it is recommended that there be ongoing evaluation of the roles and workloads of the SPC positions

There are overlaps (such as research questions, population, and recommendations) in VA and DOD prevention programs and reports. The Rand National Defense Research Institute used an epidemiological approach to examine data on military suicides, scientific literature, consensus on the best prevention strategies, and branch interviews assessing comprehensive suicide prevention programs [6]. Many of the recommendations in the Rand report are also applicable to Veterans and overlap with the report of the Blue Ribbon Panel specific to suicide prevention in Veterans [61]. The VA priority on rural disparities in Veterans is informed by federal priorities: to eliminate disparities, to improve access to quality care in rural and geographically remote areas, to improve rural behavioral health services, to address behavioral health workforce crises, and to provide public information to increase rural residents’ understanding of mental illnesses and best practices in treatment [25]. Barriers to mental health care in rural

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areas can increase risk for suicide. Depression is less likely to be diagnosed in rural primary care and untreated psychiatric disorders are potent risk factors for suicide in Veterans. Despite advances in VA policies to reduce health disparities for rural Veterans, the results of current VA policy initiatives to decrease suicide in rural Veterans need to be evaluated [24]. In summary (Policy Impact), multiple policy activities have focused on suicide prevention in Veterans and underscored this as a priority area across federal institutions. Multiple activities within the VA have been initiated and are consistent with recommendations in these policy reports. There is overlap in policy reports on Veterans and military personnel. Additional policy activities need to address the reduction of suicide risk and health disparities in rural Veterans. There is a need for an updated, comprehensive strategic plan for Veteran-specific suicide prevention, including prioritizing research activities.

Service Impact: System and Individual Level Interventions Service Impact includes both systems level and individual level programs [5]. The VA has implemented multiple systems-wide programs. Universal programs, which broadly blanket a community, such as the Air Force Suicide Prevention Program (AFSPP), have proven to be effective in reducing suicide [46]. Suicidality is the most common emergency and challenging problem encountered by mental health professionals. Systems Level Programs for Suicide Prevention The VA suicide prevention strategy uses a public health approach consisting of multiple strategies to address the needs of Veterans in crisis [35]. The strategy requires ready access to high quality mental health and primary care services. Suicide Prevention Coordinators (SPCs) were funded for each VAMC in early 2007 [36]. The VHA National Suicide Hotline (now the Veteran Crisis Line) opened at the Canandaigua VA in mid 2007. Through a partnership with SAMHSA and Lifeline, 24/7 trained professionals serve Veterans and their families in crisis. Inpatient suicides have led the list of events resulting in patient death voluntarily reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [64]. In a root cause analysis study of 350 inpatient attempts and completed suicides occurring in VA hospitals from 1999 through 2009, 177 occurred on inpatient psychiatry units and 149 of the total 350 were classified as attempts. Hanging was the most common methods for both completed and attempted suicide and cutting was the second most common method [65]. Emergency Department’s (ED) were the second most common VA setting for these suicides [66]. Ten percent (35 cases) of the total 350 suicides occurred in the ED with 34 cases classified as attempts. The VA is an exemplar in monitoring hazards as evidenced by the quality assurance study by Mills and colleagues [67]. A Mental Health Environment of Care Checklist was developed and tested in 113 VA facilities. A total of 7,642 hazards were identified, most commonly anchor points for hanging, followed by material that could be used as a weapon against staff or other patients. At the end of one year, 76.3 % of the hazards were abated. This Checklist is used across units by safety committees in VA inpatient units to monitor and abate hazards. The VA has also increased resources in telemedicine, access points between mental health and primary care, and opportunities for early identification and intervention in suicidality [68–70]. The Safe Vet project is being implemented by the VA CoE at selected

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facilities to respond to Veterans seen in the emergency department, using Coordinators, intensive behavioral evaluation, and follow up for one year [71]. Several reports have recommended adapting new tools in screening and tracking suicidality in electronic medical records [47, 61]. Templates for assessment of suicide risk and suicide attempts are currently included in the computerized patient medical records. The VA is in the process of operationalizing the CAMS monitoring system (Suicide Status Forms templates) in the medical records [42]. Individual Level Programs for Suicide Prevention Veterans of Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) are eligible for five years of free VA health care. There is a critical need to provide Veterans at risk for suicide with the safest and highest quality of care as recommended by the Institute of Medicine and the VA suicide prevention strategy [26, 35]. The basic assumption of the VA is that suicide prevention requires access to a high quality mental health care system and activities that specifically target suicide [35]. Within the VA, evidence-based practice in suicide prevention interventions are led by providers, SPC’s, clinical researchers, the QUERI Center on Mental Health and the CoE and MIRECC centers. These practices are informed by clinical research, clinical guidelines and The Joint Commission suicide safety protocol, but these interventions are not systematically disseminated or adopted [26, 35, 36, 39, 41, 42, 45–47, 50, 51, 61–63, 67, 68, 72–76, 89]. Monitoring of patients at risk for suicide is an evidence-based practice. A Category II Patient Record Flag (PRF) is placed on Veterans at risk for suicide, by either mental health provider request or mandatory placement due to an attempt [35]. The flags are often initiated during an inpatient stay to alert mental health and primary care providers that a Veteran needs additional monitoring such as: weekly high-risk inpatient meetings, suicidespecific discharge planning, medication reconciliation, prescription modifications, and weekly mental health visits over the 30 days post inpatient discharge. The VA has developed several tools for reducing risk for suicide. Stanley and Brown developed a manual for VA providers on collaboratively constructing a safety plan [75]. This model has been incorporated into a template in the VA computerized patient record system and a copy is printed for the patient, devoid of personal identifying information and provider cues. Safety plans are reviewed with patients during the discharge meeting, incorporated into the outpatient treatment protocol, and reviewed and modified at each outpatient session. Telecommunication is proving to be a promising approach to suicide prevention and a strategy that addresses health disparities in Veterans. Authors have developed guidelines and best practices to address the legal challenges of telecommunication and provided research evidence of equivalency with face-to face interventions [77, 78]. The VA is the largest telemental health network in the world and has demonstrated effectiveness of telemental health targeting multiple diagnoses [68–70]. VA suicide-specific telecommunication applications include videophones in homeless shelters and halfway houses, in-home messaging devices, videoconferencing suicide assessments between facilities, and treatment protocols for depressed persons [68, 79]. Crilly and Lewis emphasized the critical need for research in the area of telemedicine and suicide reduction in rural Veterans [68]. An exemplar in telecommunication is the Veterans Crisis Line, which provides not only hotline access, but also access to a website, Internet, and social network links [79]. In summary, suicide-specific interventions can be systems or individual level, and evidence exists for effective individual level interventions. The VA is a leading institution

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in systems level interventions and has adopted evidence-based suicide-specific interventions. There are multiple reviews and studies which need to continue to inform suicidespecific interventions with Veterans. Telecommunication is widely used in the VA and is a promising strategy for suicide prevention, though the need continues for expanded evaluation of systems level interventions, combined strategies, and suicide-specific telemental health interventions. A strategic plan needs to prioritize the dissemination and adoption of suicide-specific, evidence-based practice for providers.

Potential Strategies for Suicide Prevention in Veterans In addition to the exemplars described in each Impact area, we offer several examples of innovative strategies to address suicide-specific prevention and intervention in Veterans. In regards to training and education (service impact), most mental health providers have not been trained in empirically-based systems for assessment or management of suicide. It is imperative that VA mental health providers develop and maintain competencies in suicidespecific practice, such as the national Assessing and Managing Suicide Risk (AMSR) competencies which have been used to train active duty Air Force, Navy and Marine mental health providers [10]. There is a need for interdisciplinary, innovative, easily accessible, interactive, and up to date training in suicide prevention [34]. Professional schools and organizations need to develop innovative curriculum, practicums, and continuing education focused on Veteran-specific, evidence-based practice in suicide prevention. Federally-funded training programs for graduate programs, student tuition or loan forgiveness, and clinical training sites specific to Veteran mental health are needed. Recruiting active duty and retired military persons for graduate training in Veteran-specific behavioral health could potentially increase the workforce within this specialty [81]. The SAMSHA Recovery to Practice initiative funding discipline-specific recovery curriculums could serve as a funding model for continuing education dissemination. The Clinical Prevention and Population Health Curriculum provides a framework to structure a Veteran-specific suicide prevention curriculum [82]. The curriculum framework focuses on the Healthy People 2010 objective to increase health promotion and disease prevention content in health professional education, consistent with the VA public health approach to suicide prevention [44]. The modules could be easily adopted to target Veteran-specific suicide prevention including: (1) Evidence-Based Practice in, (2) Clinical Preventive Services and Health Promotion, (3) Health Systems and Policy and Advocacy, and (4) Population and Community Aspects of Practice [82]. An e-Learning version could include podcasts, videos, and interactive segments. The modules could be segmented to deliver training programs specific to the targeted professionals, gatekeepers, consumers, organizations, and policy makers. Intensive training in effective programs, such as CAMS, can serve as prototypes for sound clinical training for psychotherapists. Regarding prevention, Veteran-specific suicide prevention educational and outreach campaigns should be developed to target subgroups, such as the elderly, women, and rural Veterans [60]. Public education initiatives including the National Institute of Mental Health Real Men Real Depression and the National Alliance for the Mentally Ill Fight Stigma: Become a Stigma-Buster campaigns serve as models for such efforts. Suicidespecific prevention efforts should be linked to other federal health education campaigns. For example, hope is a key construct in suicide prevention and is one of the 10 fundamental concepts of recovery in the National Consensus Statement [83]. Another model is the film

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series Unnatural Causes, which focuses on social determinants of health that associates suicide with unemployment and economic conditions [84]. A film series addressing suicide risk in Veterans, Veteran consumer stories of seeking help, and VA suicide prevention activities could potentially contribute to awareness in professionals, communities, and consumers. Specific to research impact, strategies need to address research gaps in gender, culture, multicomponent approaches, provider training, and system adoption of best practices. Consistent with the VA Women’s Health Agenda, studies should compare clinical outcomes of suicide-specific interventions between genders and test gender-specific interventions [85]. For instance, crisis telehealth interventions have been found to be effective for young females and could be tested for young suicidal female Veterans [86]. The VA QUERI is a leader in implementation science and has the potential to apply sophisticated methodologies to address gaps in research. There is a gap in inpatient-specific psychotherapy to reduce suicidality [62]. Interventions should be tested to address suicidality in homeless Veterans with ongoing inpatient admissions, such as integrative programs to reduce suicidality [e.g., CAMS and Illness Management and Recovery (IMR) [42, 87, 88]]. Multicomponent interventions have been recommended, but not evaluated [47]. Additional evaluation of suicide-specific telepsychiatry with Veterans is warranted [70, 89]. The expanding body of trauma intervention science within the VA provides a model for expanding research in suicide-specific intervention science, as well as partnerships between academic research centers in suicide research and VA [44]. There is also a need for health education research targeting suicide prevention in Veterans including randomized trials and observational studies of provider behavioral change, evaluation of competency-based approaches, measures of direct patient outcomes, and dissemination and adoption of suicide prevention strategies [31, 34, 90]. Culture is a social determinant of health, which affects Veterans’ views of suicide and utilization of suicide intervention. Colucci encourages moving from an academic interpretation of what the culture consists of to an individual’s interpretation of how their culture views suicide [91]. There is a gap in methodological approaches targeting culturespecific norms, variations in meanings, social representations, impact of experiences, such as guilt, burden, and shame, and attitudes associated with suicide within various Veteran subcultures (military branch, theater, age, gender, ethnicity, disability, and chronic illness). Beyond hotlines and VA outreach services, there are few studies of community-based interventions that reach Veterans at risk for suicide who are not receiving VA services. Suicide-specific interventions tailored to address Veteran disparities, such as homelessness, need to be developed and tested. Specific to policies, strategies need to address policy gaps in VA reports and the application of strategies addressed in federal suicide-specific strategies. A VA policy report, similar to the Rand Report, is needed to summarize the multiple documents (systematic reviews, policy reports, etc.) and update the progress in order to identify recommendations and actions for specific sectors. The document could provide a logic model for the improvement of Veteran-specific suicide prevention within VA, state and county services. There is also a need for a comprehensive review of suicide in Veterans and the impact of social determinants of health [92]. Policy activities targeting subgroups of high risk Veterans overlap with those of other federal agencies targeting groups with elevated risk for suicide in other age cohorts (15–24 year olds). For example, the Suicide Prevention Resource Center (SPRC) has offered recommendations in key areas for preventing suicide in rural youth: promotion of help-seeking behaviors, data and surveillance, services, screening and identification, bereavement, gatekeeper training, and survivor issues [93].

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These recommendations could be easily adapted to suicide prevention targeting rural Veterans who experience health disparities. These overlaps and intersects may be addressed in the update of the national Suicide Prevention Strategy currently in process [94]. Specific to service impact, the Civilian Best Practices review on reducing suicidality can inform dissemination, training, and evaluation of best practices [51]. This report underscores consumer approaches, targeting needs defined by Veterans and their families/ significant others and situating programs in community Veteran organizations. Suicidespecific interventions shown to be effective such as means restriction, culturally-tailored emergency department interventions, follow-up letters to suicidal persons evaluated in emergency rooms, and problem-solving cognitive behavioral interventions (CBT) are also relevant to suicide prevention for Veterans and their families [21, 26, 74]. The VA study of 112 Veterans who died in Oregon (2000–2005) and had VA contact underscored the complexity of assessing suicidal risk in Veterans who died by suicide. Mental health providers were more likely to assess for suicide than primary care providers, yet 75 % of those Veterans who were asked about suicidal ideation denied it. Enhanced communication strategies are indicated to address this gap [95]. The IOM has recently addressed principles of provider and patient communication that could be applicable to enhanced communication with Veterans at risk for suicide in multiple settings [96]. Past descriptive and observational studies identify patient concerns and psychosocial cues are frequently dropped in primary care provider-patient communication, suggesting an area for communication skills training [97]. Programs targeting depression and trauma, Mental Health Intensive Case Management (MHICM) programs and telemedicine services need suicidality reducing components [68, 69, 78, 98]. Trauma-specific telemental health provides a model for Veteran suicidespecific telepsychiatry development [99]. Manualized evidence-based programs, such as the CAMS Suicide Status Forms, could also be easily adapted to telemental health for rural Veterans and could address the legal challenges of this intervention [78]. Monitoring Veterans during high-risk periods for suicide can be implemented through telephone (TeleCheck) visits [78]. Although rural VA Community Based Outpatient Clinics (CBOCs) are exemplars in increasing access and utilization of mental health services, VA-funded dissemination of evidence-based interventions (other than telemedicine), tends to be urban-based. Telecommunication can deliver provider suicide-specific training and consultation in remote rural communities [99]. The Suicide Prevention Toolkit for Rural Primary Care, disseminated by the SPRC, is currently being evaluated and has the potential to be adopted in CBOCs [100]. The Toolkit contains information and tools to implement evidence-based suicide prevention practices, which could be tested in CBOCs. In addition, strategies recommended for rural suicide prevention with youth serve as a template and can be adapted to target rural Veterans [101]. Minority, rural Veterans may not be able or willing to access services from persons of the same ethnic group or persons with rural expertise [25, 27, 28]. Engaging ethnic, rural Veteran populations in mental health treatment calls for culturally-specific outreach: partnering with ethnic community leaders, employing diverse Veteran mental health professionals and clinic staff, and building coalitions and grass root advocacy with Veteran consumers and groups. Comparisons of outcomes (e.g., responses to care) of specific suicide prevention strategies have begun to look within cultural subgroups in order to develop culturally sensitive prevention strategies. An exemplar in this area is

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gender-specific research in Women Veterans’ health and trauma, as female gender is a source of health disparity in Veteran populations [102].

Implications for Behavioral Health There have been great efforts to address suicide in Veterans over the last decade and the VA has demonstrated a strong and systematic leadership. Though not a systematic review and descriptive in nature, this RIM impact narrative provides those involved in Veteranspecific suicide prevention a way to frame their impact and develop new areas of impact. This narrative illustrates a systems approach to suicide prevention through activities in all areas of impact driven by research and evidence-based practice. There are overlaps in the activities between RIM areas and fluidity in the rapidly evolving field of suicide prevention targeting Veterans. This Research Impact narrative also provides a summary of Veteranspecific activities to educate professional students and trainees and mental health providers within the VA and outside the VA, as non-VA systems serve a large numbers of Veterans. It can serve to promote a dialogue with funders, government agencies, potential collaborators, and Veterans and their families. No movement has been more convincing than the suicide survivors’ grass root advocacy movement (led by SPAN USA) in demonstrating the power of partnerships encompassing consumers, survivors, scientists, health professionals, scholars, and policy makers in saving lives. Acknowledgments This review was supported by resources from the VA Nursing Academy, College of Nursing, Medical University of SC and the Center for Disease Prevention and Health Interventions for Diverse Populations, Ralph H. Johnson Veterans Medical Center.

References 1. Sundararaman R, Panangala S, Lister S: Suicide Prevention Among Veterans—CRS Report to Congress Report for Congress. Washington, DC, Congressional Research Services, Domestic Social Policy Division, 2008. 2. Kang H, Bullman T: Risk of suicide among US Veterans after returning from the Iraq or Afghanistan war zones. Journal of the American Medical Association 300:652–653, 2008 3. Kaplan MS, Huguet N, McFarland BH et al.: Suicide among male Veterans: a prospective populationbased study. Journal of Epidemiology and Community Health 6:619–624, 2007 4. Seal K, Bertenthal D, Miner C et al.: Bringing the war back home: mental health disorders among 103,788 US Veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs Facilities. Archives of Internal Medicine 167:476–482, 2007 5. Kuruvilla S, Mays N, Pleasant A et al.: Describing the impact of health research: a research impact framework. BMC Health Services Research 6:134, 2006 6. RAND Center for Military Policy Research: In: Ramchand R, Acosta J, Burns R, Jaycox L, Pernin C (Eds) The War Within: Suicide Prevention in the US Military. Santa Monica, RAND Corporation, 2011 7. Department of Veterans Affairs, Health Services Research and Development Service: Racial and Ethnic Disparities in the VA Healthcare System: A Systematic Review. Washington DC, Same, 2007. 8. Quin˜ones AR, O’Neil M, Saha S, et al.: Interventions to Reduce Racial and Ethnic Disparities. VA-ESP Project #05-225; 2011. 9. Egede L: Race, ethnicity, culture, and disparities in health care. Journal of General Internal Medicine 21:667–669, 2006 10. Suicide Prevention Resource Center: Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals. http://www.sprc.org. Accessed March 30, 2009. 11. McCarthy J, Valenstein M, Kim H et al.: Suicide mortality among patients receiving care in the Veterans Health Administration health care. American Journal Epidemiology 169:1033–1038, 2009

123

Psychiatr Q 12. Bossarte R, Claassen C, Knox K: Veteran suicide prevention: emerging priorities and opportunities for intervention. Military Medicine 175:461462, 2010 13. Bossarte R, Knox K, Piegari R: Prevalence and characteristics of suicide ideation and attempts among active military and Veteran participation in a National Health Study. American Journal of Public Health Study. American Journal of Public Health 102(S1):S38–S40, 2012 14. Gibbons R, Hendricks B, Hur K et al.: Relationship between antidepressants and suicide attempts: an analysis of the Veterans Health Administration data sets. America Journal of Psychiatry 164:1044, 2007 15. Tomich N: Roundtable Discussion: Health Issues Affecting Women in Military Services. World Medical and Health Policy 2:Art 8, 2010. 16. Valenstein M, Kim H, Ganoczy D et al.: Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts. Journal of Affective Disorders 112:50– 58, 2009 17. Zivin K, Kim H, McCarthy J et al.: Suicide mortality among individuals receiving treatment for depression in the Veterans’ affairs health system: association with patient and treatment setting characteristics. American Journal of Public Health 97:2193–2198, 2007 18. McIntosh J (for the American Association of Suicidology): USA suicide 2009 Official Final Data. Washington, DC, American Association of Suicidology. http://www.suicidology.org. Accessed January 12, 2012. 19. McFarland B, Kaplan M, Huguet N: Self-inflicted deaths among women with US military service: a hidden epidemic. Psychiatric Services 61(12):1177, 2010 20. Thompson R, Kane V, Sayers S et al.: An assessment of suicide in an urban VA medical center. Psychiatry. Interpersonal Biological Processes 65:326–337, 2002 21. Kleespies P, AhnAllen C, Knight J et al.: A study of self-injurious and suicidal behavior in a Veteran population. Psychological Services 8(3):236–250, 2011 22. Weeks W, Kazis LE, Shen Y et al.: Difference of health-related quality of life in urban and rural Veterans. American Journal of Public Health 94:1962–1967, 2004 23. Wallace A, Weeks W, Wang S et al.: Rural and urban disparities in health-related quality of life among Veterans with psychiatric disorders. Psychiatric Services 57:851–856, 2006 24. VHA Office of Rural Health: http://www.ruralhealth.va.gov/index.asp. Accessed Nov 8, 2011. 25. US Department of Health and Human Services: Mental Health and Rural America: 1994–2005. Rockville, MD, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2006. 26. Institute of Medicine of the National Academies: Reducing Suicide: A National Imperative. The National Academies Press, Washington, DC, 2002 27. Bird D, Dempsey P, Hartley D: Addressing Mental Health Workforce Needs in Underserved Rural Areas: Accomplishments and challenges. Portland, ME: Maine Rural Health Research Center, Muskie Institute, University of Southern Maine, 2001. 28. US Department of Health and Human Services: Mental Health: Culture, Race, and Ethnicity: A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD, US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2001. 29. The Annapolis Coalition on the Behavioral Health Workforce: An Action Plan for Behavioral Health Workforce Development: A Framework for Discussion. Washington, DC. Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, 2007. 30. New Freedom Commission on Mental Health, Subcommittee on Rural Issues: Background Paper. DHHS ooPub. No. SMA-04-3890. Rockville, MD, 2004. 31. Institute of Medicine of the National Academies: Health Professions Education: A Bridge to Quality. The National Academies Press, Washington, DC, 2003 32. Larson M, Beeson P, Mohatt D: Taking Rural into Account: A Report of the National Public Hearing on Rural Mental Health. National Association for Rural Mental Health and the Federal Center for Mental Health Services, St. Cloud, 1993 33. Clark T, Matthieu M, Ross A et al.: Training outcomes from the Samaritans of New York suicide awareness and prevention programme among community-and school-based staff. British Journal of Social Work 40:2223–2238, 2010 34. Magruder K, York J, Jobes D, et al.: Patient and Provider Outcomes of e-Learning Training in CAMS. EDU 08-424. Health Services Research &Development, Department of Veterans Affairs. 8/1/09–7/31/ 12. 35. Department of Veterans Affairs: Office of Inspector General Implementing VHA’s Mental Health Strategic Plan Initiatives for Suicide Prevention. 2009. http://www.va.gov/oig/publications/reportslist.asp. Accessed July 29, 2010.

123

Psychiatr Q 36. Kemp J. The VISN 2 Center of Excellence at Canandaigua. 2010. 37. Silverman M, Berman A, Sanddal N et al.: Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 1: background, rationale, and methodology. Suicide and Life-Threatening Behavior 37:248–262, 2007 38. Silverman M, Berman A, Sanddal N et al.: Rebuilding the tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors. Part 2: suicide-related ideations, communications, and behaviors. Suicide and Life-Threatening Behavior 37:264–277, 2007 39. Brenner L: Department of Veterans Affairs. Centers for Disease Control and Prevention, Self-directed Violence (SDV) Classsification System, 2010 40. Oordt M, Jobes D, Fonseca V et al.: Training mental health professionals to assess and manage suicidal behavior: can provider confidence and practice behaviors be altered? Suicide and LifeThreatening Behavior 39:21–32, 2009 41. Matthieu M, Cross W, Batres A et al.: Evaluation of gatekeeper training for suicide prevention in Veterans. Archives of Suicide Research 12:148–154, 2008 42. Jobes D: Managing Suicidal Risk: A Collaborative Approach. Guilford Press, New York, 2006 43. Truman B, Smith-Atkin C, Hinman A et al.: Developing the guide to community preventive servicesoverview and rationale. American Journal of Preventive Medicine 18:18–26, 2000 44. VISN 2: Center of Excellence at Canandaigua Information Sheet. 2010. 45. Mann J, Apter A, Bertolote J et al.: Suicide prevention strategies: a systematic review. Journal of American Medical Association 294:2064–2074, 2005 46. Suicide Prevention Resource Center: National Registry of Evidence-Based Suicide Prevention Program (NREEP). http://www.sprc.org. Accessed January 30, 2009. 47. Bagley S, Munjas B, Shekelle P: A systematic review of suicide prevention programs for military or Veterans. Suicide and Life-Threatening Behavior 40:257–265, 2010 48. Knox K, Litts D, Talcott G et al.: British Medical Journal 327:1376, 2003 49. Knox K, Pflanz S, Talcott G: The US air force suicide prevention program: implications for public health policy. American Journal of Public Health 100:2457–2463, 2010 50. Department of Veterans Affairs: Health Services Research and Development Services. Strategies for Suicide Prevention in Veterans. Department of Veterans Affairs, Washington DC, 2009 51. Shoenbaum M, Heissen R, Pearson J: Opportunities to Improve Interventions to Reduce Suicidality: Civilian ‘‘Best Practices’’ for Army Consideration. DHHS, National Institute of Health, National Institute of Mental Health, Washington DC, 2009 52. Valenstein M, Eisenberg D, McCarthy J et al.: Service implication for providing intensive monitoring during high risk periods for suicide among VA patients with depression. Psychiatric Services 60:439–444, 2009 53. Comtois KA, Jobes DA, O’Connor S, et al.: Collaborative assessment and management of suicidality (CAMS): Feasibility trial for next-day appointment services. Depression and Anxiety 0:1–10, 2011. 54. Jobes DA,Comtois K, Brenner L, Gutierrez P.: Clinical trial feasibility studies of the Collaborative Assessment and Management of Suicidality (CAMS). In O’Connor R, Platt S, Gordon J (Eds) International Handbook of Suicide Prevention: Research, Policy & Practice. Chichester, UK, Wiley, 2011. 55. Jobes D, Wong S, Conrad A et al.: The collaborative assessment and management of suicidality versus treatment as usual: a retrospective study with suicidal outpatients. Suicide and Life Threatening Behavior 35:483–497, 2005 56. Drozd JF, Jobes DA, Luoma JB: The collaborative assessment and management of suicidality in air force mental health clinics. The Air Force Psychologist 18:6–11, 2000 57. Katz I: Lessons learned from mental health enhancement and suicide prevention activities in the Veterans Health Administration (Editorial). American Journal of Public Health 102(S1):S14–S16, 2012. 58. US Department of Health and Human Services. Veterans and Their Families: A SAMSHA priority. Rockville, MD, U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2008. 59. US Department of Health and Human Services: National Strategy for Suicide Prevention: Goals and Objectives for Action. (SAMSHA Publication No. SMA01-3518). Rockville, MD, US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2001. 60. US Department of Veterans Affairs: VA Secretary Appoints Panel of National Suicide Experts Press Release]. http://www1.va.gov/opa/pressrel/pressrelease.cfm?id=1506. Accessed May 21, 2008. 61. Report of the Blue Ribbon Work Group on Suicide Prevention in the Veteran Population. http://www.mentalhealth.va.gov/suicide_prevention/Blue_Ribbon_Report_FINAL_June30_08.pdf.

123

Psychiatr Q 62. Knesper DJ, American Association of Suicidology, Suicide Prevention Resource Center: Continuity of care for suicide prevention and research: Suicide attempts and suicide deaths subsequent to discharge from the emergency department or psychiatry inpatient unit. Newton, MA, Education Development Center, Inc., 2010 63. National Action Alliance: Care and Critical Intervention Task Force. Suicide Care in Systems Framework, 2011 64. The Joint Commission Accreditation Behavioral Health Care Behavioral Health Care National Patient Safety Goals; 2011. www.jointcommission.org, Retrieved on September 9, 2011. 65. Mills P, Derosier JM, Ballot BA: Inpatient suicide and suicide attempts in Veterans Affairs Hospitals. The Joint Commission Journal on Quality and Patient Safety 34(8):482–488, 2008 66. Mills PD, Watts BV, Derosier JM et al.: Suicide attempts and completions in the emergency department in VA Affairs Hospitals. Emergency Medical Journal 29(5):399-403, 2012 67. Mills PD, Watts BV, Miller S et al.: A checklist to identify inpatient suicide hazards in Veterans affairs hospitals. Joint Commission Journal of Quality and Patient Safety 36:87–93, 2010 68. Crilly J, Lewis J: Internet-based psychiatric interventions: Application for rural Veterans at risk for suicide. Proceedings of the International Conference on Society and Information Technology (ICSIT), April, Orlando, Florida, 2010. 69. Frueh BC, Monnier J, Yim E et al.: A randomized trial of telepsychiatry for post-traumatic stress disorder 2007. Journal of Telmedicine and Telecare 13:142–147, 2007 70. Tuerk PW, Fortney J, Bosworth H et al.: Toward the development of national telehealth services: the role of the Veteran’s Health Administration and future directions for research. Telemedicine and e-Health Journal 16:115–117, 2010 71. Sherwood J. Canandaigua VA Center programs go national. Daily Messenger 2009 May 3. 72. Alexopoulos G, Reynolds C, Ten Have T et al.: Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT Study. American Journal of Psychiatry 166:882–890, 2009 73. Fortney JC, Pyne JM, Edlund MJ et al.: A randomized trial of telemedicine-based Collaborative Care for Depression. Journal of Internal Medicine 22:1086–1093, 2007 74. Rudd M, Joiner T, Rajab M: Treating Suicidal Behavior: An effective, Time-Limited Approach. Guilford Publishers, New York, 2011 75. Work Group on Suicidal Behaviors. Practice guidelines for the assessment and treatment of patients with suicidal behavior. American Journal of Psychiatry 160(Suppl):11, 2003. 76. Stanley B, Brown G. The Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version. New York Suicide Prevention Center, Department of Psychiatry: Columbia University & New York State Psychiatric Institute; 2008, August. 77. American Telemedicine Association. ATA Telemental Health Guidelines. October 2009. 78. Godleski L, Nieves E, Darkins A et al.: VA Telemental health: suicide assessment. Behavioral Sciences and the Law 26:271–286, 2008 79. Krysinska K, De Leo D: Telecommunication and suicide prevention: hopes and challenges for the new century. Omega 55:237–253, 2007 80. News and Notes. Psychiatric Services 61:732, 2010. 81. Hudson L: The treatment of PTSD: a student’s perspective by CPT Laura Hudson. The Army Nurse Corps Newsletter 5:14–15, 2005 82. Association for Prevention Teaching and Research (APTR): Clinical Prevention and Population Health Curriculum Framework, 2009. http://www. APTR. Accessed July 1, 2009. 83. Substance Abuse and Mental Health Services Administration: National Consensus Statement on Mental Health Recovery. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, 2004. Accessed August 9, 2010 http://mentalhealth.samhsa.gov/publications/allpubs/sma05-4129/. 84. The National Minority Council of Public Television: Unnatural causes: Is inequality making us sick? California Newsreel. 2008. 85. Yano EM, Bastian LA, Frayne SM et al.: Toward VA women’s health research agenda: setting evidence-based priorities to improve the health and health care of women Veterans. Journal of General Internal Medicine 21:S93–S101, 2006 86. Sareen J, Belik S: The need for outreach in preventing suicide among young veterans. PLoS Medicine 6(3):e35–e36, 2009 87. Substance Abuse and Mental Health Services Administration: Illness Management and Recovery: Getting Started with Evidence-Based Practices. HHS Pub. No. SMA-09-4462, Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, U.S.

123

Psychiatr Q

88. 89. 90. 91. 92. 93.

94.

95. 96. 97. 98. 99. 100.

101. 102.

Department of Health and Human Services, 2009b. Retrieved August 9, 2010, from http://download. ncadi.samhsa.gov/ken/pdf/toolkits/illness/IMR_GettingStarted.pdf. York J: Hope Kits and CAMS. Recovery to Practice Weekly Highlight, 3, 21. US DHHS, Substance Abuse and Mental Health Services Administration, June 7, 2012. Gros D, Veronee K, Strachan M et al.: Managing suicidality in home-based telehealth. Journal of Telemedicine and Telecare 17:332–335, 2011 Hawks S, Smith T, Thomas H et al.: The forgotten dimensions in health education research. Health Education Research 23:319–324, 2008 Colucci E: The cultural facet of suicidal behavior: its importance and neglect. Australian E-Journal for the Advancement of Mental Health 5:1446–7984, 2006 York J, Lamis D, Garfinkel P et al.: Family drug treatment courts and social determinants of health. Family Law Review 50(1):137–149, 2012 STIPDA Rural Youth Suicide Prevention Workgroup: Recommendations to States. Preventing Youth Suicide in Rural America. State and Territorial Prevention Directors Association. Atlanta, GA and Suicide Prevention Resource Center. Newton MA. April 2008. Available at www.sprc.org. Suicide Prevention Resource Center, SPAN USA, Litts D ed. Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead. 2010. Newton, MA: Education Development Center, Inc. Available at: www.sprc.org. Denneson L, Basham C, Dickinson K et al.: Suicide risk assessment and content of VA health care contacts before suicide completion by Veterans in Oregon. Psychiatric Services 61:1192–1197, 2010 Paget L, Han P, Nedza S, et al.: Patient Clinician Communication: Basic Principles and Expectations. Discussion Paper; Institute of Medicine of the National Academies: 2011 June. Zimmermann C, Kim H, Ganoczy D et al.: Cues and concerns by patients in medical consultations: a literature review. Psychological Bulletin 133:438–463, 2007 Mohamed S, Neale M, Rosenheck R: VA intensive mental health case management in urban and rural areas: veteran characteristic and service delivery. Psychiatric Services 60:914–921, 2009 Shore J, Manson S: A developmental model for rural telepsychiatry. Psychiatric Services 56:976–980, 2005 Western Interstate Commission on Higher Education (WICHE) and Suicide Prevention Resource Center (SPRC): Suicide Prevention Toolkit for Rural Primary Care: A Primer for Primary Care Providers. Boulder, Colorado: Western Interstate Commission on Higher Education, 2009. Suicide Prevention Resource Center: Preventing Youth Suicide in Rural America. www.sprc.org. Accessed January 21, 2009. Goldzweig C, Balekian TM, Rolon C et al.: The state of women Veterans’ health research. Results of a systematic literature review. Journal of General Internal Medicine 21:S82–S92, 2006

Author Biographies Janet A. York, PhD, PMHCS, BC, FAAN PMHCS-BC, FAAN is a Professor of Nursing, Medical University of South Carolina and a nurse research, VA Nursing Academy, Ralph H Johnson VAMC, Charleston, SC. She is an expert in research, intervention and advocacy in suicidology. She has collaborated in the development of therapeutic courts and the dissemination of evidence-based practices in these programs. Dorian A. Lamis, MA is a predoctoral psychology intern at the Emory School of Medicine, Grady Health System in Atlanta GA. He completed his doctoral work in Clinical Psychology at the University of South Carolina. He received his MA in Clinical Psychology from East Tennessee State University. His research focuses on suicidal behaviors and alcohol use in adolescents and young adults, with a particular emphasis on college students. He has published on these topics as well as on other risk and protective factors for suicide. Charlene A. Pope, PhD, MPH was trained as a health service researcher and a sociolinguist who studies variations in how people, particularly patients and health providers, speak with one another and the relationship of speaking practices to clinical and health service outcomes as mechanisms of potential disparities. Over the last decade, she has collected spoken data for a variety of types of discourse analysis, participated and led teams coding sound and transcription data, screened for and conducted linguistic analysis of health literacy practices, and has collaborated with multidisciplinary health and social science teams in studies of health service disparities. Her current interest is microanalysis of social interaction in health care encounters and the use of findings to improve clinical communication and eliminate disparities.

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Psychiatr Q In her role as a VA researcher, she studies rural and racial health service disparities and interventions to promote equity for Veterans. Leonard E. Egede, MD, MS is a Professor of Medicine in the Division of General of Internal Medicine and Geriatrics. He is the Director of the MUSC Center for Health Disparities Research and the Director of the Charleston VA REAP—Center for Disease Prevention and Health Interventions for Diverse Populations. Dr. Egede has a Master’s degree in clinical research and a fellowship in health services research. Dr. Egede has participated and led research projects designed to understand racial/ethnic variations in health care. His expertise is in the interplay among psychosocial factors, race/ethnicity, and health outcomes for chronic diseases. He has authored over 60 original peer reviewed publications related to psychosocial influences on health and racial/ethnic differences in health outcomes in a variety of peer-reviewed journals including the Archives of Internal Medicine, Diabetes Care, American Journal of Medicine, and American Journal of Public Health. He is a member of NIH and VA study sections. Dr. Egede is on the National Advisory Council of the Physician Faculty Scholars Program of the Robert Wood Johnson Foundation. He currently serves as a Deputy Editor for the Journal of General Internal Medicine and is on the editorial board of Current Diabetes Reviews.

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