Contributed by Stephen E. Dannenbaum, Ph.D., Vice President, Behavioral Health, United Healthcare Military & Veterans
In September, PMCN helped to plan and sponsor the VA Mental Health Conference here in Colorado Springs. The following report is based on a presentation by Stephen Dannenbaum, PhD, Vice President Behavioral Health, UnitedHealthcare Military & Veterans. The report provides data and clinical insight into suicide rates, causes, and prevention steps in active service member and veteran populations.
Today we see over 46,000 suicides per year in the general population; a number that increases by around 10 percent year over year, dwarfing the homicide rate of just over 20,000. This translates into one suicide every 15 minutes or 95 per day. Suicide is much more likely in the Western half of the United States with these states occupying eight of the top 10 states (Alaska being number one). While men are four times more likely than women to die from suicide, women are three times more likely to make a suicide attempt. And while suicide generally increases with age, in the typical high school classroom one male and two females have probably attempted suicide in the past year. “Attempts” are a key factor in understanding suicide risk.
With respect to current service members and veterans, rates have steadily increased over the past decade with rates per 100,000 as high as 17-20, whereas the national average is 11.5 for young adult males. Post-Traumatic Stress Disorder (PTSD) can increase this rate six-fold. While the Military Health System has implemented a variety of prevention initiatives, in many cases the results have not kept pace with the increasing rates. Moreover, it appears that veterans are particularly susceptible to an increased risk due to the use of alcohol and prescription drugs.
Finally, suicide risk is high for 30 days after an acute psychiatric hospital discharge and while for post-discharge from an inpatient acute psychiatric facility suicide is most frequent in the first two weeks, most suicides occur on the first day after discharge. These facts speak to the critical importance of post-discharge planning as a central part of inpatient treatment. Inpatient suicide risk factors include, but are not limited to: high lengths of stay and multiple prior admissions, prior suicide attempts, depression, family history of suicide, recent bereavement, being single and living alone.
Approaches and Theories of Suicide
For many years, most behavioral health care professionals have been trained in what we might call the “Classical” approach to suicide. This includes key predictive markers of Intent (how clear and imminent are suicidal thoughts?), Means (how lethal and available are the methods for suicide?), and the Plan (how specific and well thought are the plans?). This is a very reactive approach, not that dissimilar from calling the Fire Department after flames are seen.
A more recent theory has been researched and put forth by Dr. Thomas Joiner (2005) and featured in his book, “Why People Die by Suicide.” Dr. Joiner’s work has strong research support and puts forth the Interpersonal Theory of Suicide which is more akin to detecting smoke signals rather than reacting to flames. The theory posits that there are two key factors to consider; the acquired ability to inflict self-harm, and the desire for suicide. Within the desire component are the components of Perceived Burdensomeness and Thwarted Belongingness. Where these components or factors overlap exists the greatest risk for suicide. The graphic below best illustrates this model:
The first component, Acquired Ability (for self-harm) is learned by direct and vicarious exposure to pain, danger, and training such as might be received in the military. This explains which veterans, first responders, physicians, victims of physical abuse and other harm-related individuals are at higher risk. It also explains why those with previous, unsuccessful suicide attempts are at greater risk.
Unfortunately, we cannot unlearn capability. Once acquired it cannot be un-acquired.
However, the Desire for Suicide and its component parts, Perceived Burdensomeness and Thwarted Belongingness are perceptual or cognitive in nature and can be addressed through therapy such as Cognitive Behavioral Therapy which confronts irrational and erroneous beliefs. It is easy to understand by a service member returning from a deployment might feel like a burden on their family or support system, or why they might feel they just don’t belong. The good news is the perception of being a burden is just that—“a perception” and is more often than not, wrong. Similarly, the perception of belongingness is a cluster of thoughts that can be challenged and modified through Cognitive Therapy, as well as behavioral interventions such as expanding the individual’s support system.
In sum, the Interpersonal Theory offers many more opportunities to prevent suicide by looking at these early predictive factors, rather than waiting for the situation to “erupt into flames.”
Finally, when working with an individual suffering from suicidal ideation and desire there are some very specific and concrete steps that can be taken. While there have been mixed perspectives on the effectiveness of suicide contracts, there is greater consensus that detailed alternative-to-suicide plans can be very effective. A Coping Card simply involves the development of a straightforward crisis plan that can be written down on the back of a business card, a 3×5-inch index card, or a sheet of paper. An example would be, “When I’m upset and thinking of suicide, I’ll take the following steps: 1) Call a Friend, 2) Exercise, 3) Listen to music,” and additional very specific interventions. Contact numbers for suicide hotlines, close friends, and mental health professionals must be included as well. It is very important to have the individual sign the Coping Card as there is research to indicate that people are almost twice as likely to follow through on a commitment if they sign their name to it.
In summary, suicide is still an ever-growing, very serious problem, particularly for service members and veterans. Fortunately, there are new and promising models of suicide prevention that offer both mental health professionals, family members and others new ways to address individuals who are suffering from thoughts of self-harm, at an earlier stage in the process, well before a crisis emerges.
This article originated from the United Healthcare “TRICARE West Region Military & Veterans Monthly”