The Self‐Directed Violence Classification System and the Columbia Classification Algorithm for Suicide Assessment: A Crosswalk

The lack of a standardized nomenclature for suicide‐related thoughts and behaviors prompted the Centers for Disease Control and Prevention, with the Veterans Integrated Service Network 19 Mental Illness Research Education and Clinical Center, to create the Self‐Directed Violence Classification System (SDVCS). SDVCS has been adopted by the Department of Veterans Affairs and the Department of Defense. Another classification system, the Columbia Classification Algorithm for Suicide Assessment, has been recommended by the Food and Drug Administration. To facilitate the use of both systems, this article provides a “crosswalk” between the two classification systems.     

Generalizability of Evidence-Based PTSD Psychotherapies to Suicidal Individuals: A Review of the Veterans Administration and Department of Defense Clinical Practice Guidelines

Posttraumatic stress disorder (PTSD) is strongly associated with suicide. The 2010 Department of Veterans Affairs/Department of Defense Clinical Practice Guidelines for PTSD (VA/DoD CPG) endorse cognitive therapy and its variants as empirically supported PTSD treatments. However, we lack an understanding about whether these treatments are generalizable to patients with suicidal ideation and/or behaviors. Randomized controlled trials (RCTs) cited in the VA/DoD CPGs were systematically reviewed for methodology, suicide-related content, and adverse event reporting. Thirty-eight RCTs were reviewed. Twenty-three reported suicide-related exclusion criteria, 15 made no mention of suicide-related inclusion/exclusion criteria. Thirty-six RCTs included depression assessments containing suicide-related items, but no suicide-relevant data were reported. Two RCTs outlined suicide risk monitoring procedures. Suicidal PTSD participants are underrepresented in PTSD RCTs and suicide risk assessment procedures were inconsistently reported. Standardized reporting of RCT methods pertaining to suicide risk to determine generalizability and safety of empirically supported PTSD treatments to this clinical population is needed.     

Evaluating the Effectiveness of Safety Plans for Military Veterans: Do Safety Plans Tailored to Veteran Characteristics Decrease Suicide Risk?

In response to high suicide rates among veterans, the Department of Veterans Affairs (VA) has mandated that veterans at risk for suicide be given Safety Plans (SP). Research on the efficacy of SPs, however, is unclear and no prior study has examined the degree to which more personally relevant (i.e., higher quality) SPs may be associated with better outcomes or evaluate which components of SPs may be most effective at reducing suicidal behavior. The goal of the present study was to examine whether more personally relevant (i.e., higher quality) SPs reduce future suicide-related outcomes (psychiatric hospitalization, self-harm, and suicide attempts), and to determine which components of a SP may be most effective at reducing these outcomes. Participants were 68 individuals enrolled in a longitudinal national registry of returning military veterans receiving care from the VA, and who had at least one suicide-related event in the VA Suicide Prevention Applications Network. Data were collected between December 2009 and September 2016 and were analyzed between March 2016 and February 2017. Scores of SP quality were used to predict suicide-related outcomes. SP quality was low. Higher SP quality scores predicted a decreased likelihood of future suicide behavior reports (note entered into veteran’s chart after a report of any self-harm behavior, including a suicide attempt). Higher scores on Step 3 (people and places that serve as distractions) predicted a decreased likelihood of future suicide behavior reports. More personally relevant SPs may reduce future suicide-related outcomes among veterans. Low SP quality scores highlight the need for training around SP implementation in the VA.     

Characteristics and VA health care utilization of U.S. Veterans who completed suicide in Oregon between 2000 and 2005

Oregon Violent Death Reporting System data were linked with Veterans Affairs (VA) administrative data to identify and describe veterans who completed suicide in Oregon from 2000 to 2005 (n = 968), and to describe their VA health care utilization in the year prior to death. Twenty-two percent had received health care in the VA system. Of these, 57% did not have mental health diagnoses and 58% had not seen mental health professionals. A larger proportion of those who accessed care were VA-enrolled and received service-connected disability benefits. Fifty-five veterans were hospitalized during the year prior to death. Of these, 33% completed suicide within 30 days of a hospitalization. Further development of suicide prevention strategies for veterans in the community, including general medical treatment settings, is indicated.     

Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow‐up (n = 168; 57%). Fifty‐three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.     

VA telemental health: suicide assessment

The Department of Veterans Affairs (VA) encompasses one of the largest telemental health networks in the world, with over 45,000 videoconferencing and over 5,000 home telemental health encounters annually. Recently, the VA designated suicide prevention as a major priority, with telehealth modalities providing opportunities for remote interventions. Suicide risk assessments, using videoconferencing, are now documented in the literature, as are current studies that find telemental health to be equivalent to face-to-face treatment. Remote assessment of suicidality, however, involves complex legal issues: licensing requirements for remote delivery of care, legal procedures for involuntary detainment and commitment of potentially harmful patients, and liability questions related to the remote nature of the mental health service. VA best practices for remote suicide risk assessment include paradigms for establishing procedures in the context of legal challenges (licensing and involuntary detainment/commitment), for utilizing clinical assessment and triage decision protocols, and for contingency planning to optimize patient care and reduce liability.     

Initiation of evidence-based psychotherapies in Veterans with posttraumatic stress disorder

The Department of Veterans Affairs (VA) requires that all VA hospitals and clinics provide access to evidence-based psychotherapies (EBPs). Despite these widespread dissemination efforts, only a minority of Veterans receive EBP services. Reasons for these low rates of EBP utilization are largely unknown. This study examined the characteristics of Veterans with posttraumatic stress disorder (PTSD) who did (Initiation group) and did not (No-Initiation group) initiate a VA-approved EBP after participating in an information session. Veterans chose their preferred treatment from a menu of EBPs. Results demonstrated that Veterans in the No-Initiation group had longer periods of time between their referral and first EBP visit. Among Veterans in the Initiation group, the majority (68%) initiated a trauma-focused EBP as their first or second treatment, suggesting that providing a range of treatment options did not negatively impact their willingness to engage in PTSD treatment. Results are discussed in terms of VA initiatives to improve access to and initiation of mental health care for Veterans.     

The Validity of a Brief Risk Assessment Tool for Predicting Suicidal Behavior in Veterans Utilizing VHA Mental Health Care

Suicide risk among military veterans is an important and ongoing concern. The Veterans Administration (VA) mandates suicide risk screening of all veterans seen for mental health issues, but little is known about the effectiveness of this screening. A retrospective chart review to examine all suicide risk screens at VA San Diego between October and December 2012 (n = 3,365) was conducted to assess whether results were associated with suicidal behavior over the subsequent 12 months. Patients judged to be at increased risk for suicide were 3 to 16 times more likely to attempt suicide and 7 to 25 times more likely to engage in self‐directed violence over the next 12 months compared with others. The screening tool may be a useful addition to clinical practice.     

Chaplains' Engagement with Suicidality among Their Service Users: Findings from the VA/DoD Integrated Mental Health Strategy

Chaplains play an important role in supporting the mental health of current and former military personnel; in this study, the engagement of Department of Veterans Affairs (VA), Army, Navy, and Air Force chaplains with suicidality among their service users were examined. An online survey was used to collect data from 440 VA and 1,723 Department of Defense (DoD) chaplains as part of the VA/DoD Integrated Mental Health Strategy. Differences were noted for demographics, work setting characteristics, encountering suicidality, and self‐perceived preparation for dealing with suicidality. Compared to DoD chaplains, VA chaplains encounter more at‐risk service users, yet feel less prepared for dealing with suicidality.     

Integrating Mental Health and Primary Care Services in the Department of Veterans Affairs Health Care System

Integrating mental health care in the primary care setting has been identified in the literature as a model for increasing access to mental health services and has been associated with enhanced clinical and functional patient outcomes and higher patient satisfaction. The Department of Veterans Affairs (VA), which operates the nation’s largest integrated health care system, has taken a leadership role in creating a health care system in which mental health care is provided in the primary care setting. This article examines VA’s efforts and progress to date in implementing evidence-based models of integrated mental health services nationally in community based outpatient clinics, home based primary care, and outpatient primary clinics at medical facilities. Psychology plays an important role in this progress, as part of an overall interdisciplinary effort, in which all professions are crucially important and work together to promote the overall well-being of patients. This article is based in part on a presentation by the first author at the 3rd National Conference of the Association of Psychologists in Academic Health Centers (APAHC) in May of 2007 in Minneapolis, Minnesota.     

Challenges and Potential Solutions to Implementing Phone Coaching in Dialectical Behavior Therapy

Dialectical Behavioral Therapy (DBT) is an effective treatment for borderline personality disorder (BPD), yet many health care facilities struggle to implement one of the modes of DBT, phone coaching. The aims of this study were to present barriers and reported solutions regarding the implementation of DBT phone coaching. We conducted a sequential mixed methods national program evaluation that included a quantitative self-report survey completed by Department of Veterans Affairs (VA) facilities (N = 59) offering any of the four modes of DBT. Subsequent qualitative interviews using a semistructured interview guide informed by the Promoting Action on Research Implementation in Health Services (PARIHS) were completed with DBT providers and administrators from a subset (n = 16) of these VA sites. Four themes—the lack of tools and policies, compensation for phone coaching, clinician willingness to conduct phone coaching, and consistent program and leadership support—were identified and illustrated in a case study. This study also offered concrete recommendations for those health care organizations, managers, administrators, and clinicians who may be interested in implementing phone coaching at their health care facilities.     

The Infrequency-Posttraumatic Stress Disorder scale (Fptsd) for the MMPI-2: development and initial validation with veterans presenting with combat-related PTSD

Researchers have identified difficulties associated with the use of traditional Minnesota Multiphasic Personality Inventory-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) validity scales with survivors of traumatic events. A new scale, the Infrequency-Posttraumatic Stress Disorder scale (Fptsd), was created from MMPI-2 items that were infrequently endorsed by 940 male combat veterans presenting for treatment at the posttraumatic stress disorder (PTSD) clinics of 2 Veterans Affairs Medical Centers. A variety of statistical methods were implemented that preliminarily established Fptsd's validity with a validation sample of 323 additional PTSD-diagnosed combat veterans. Results indicate that, relative to previously established validity and overreporting scales (F, Fb, and Fp), Fptsd was significantly less related to psychopathology and distress and better at discriminating simulated from genuinely reported PTSD. Clinical implications are discussed concerning the use of Fptsd to assess disability-seeking veterans suspected of overreporting PTSD symptoms.     

Development of a Brief Adjunctive Intervention for Family Members of Veterans in Individual PTSD Treatment

Family involvement in the treatment of posttraumatic stress disorder (PTSD) among veterans has the potential to improve treatment retention and outcomes. Current protocols that incorporate family members into treatment tend to involve at least 15 sessions, and none are designed to complement Cognitive Processing Therapy (CPT) or Prolonged Exposure (PE), the two most widely used and heavily promoted evidence-based PTSD therapies in the Veterans Affairs (VA) healthcare system. The current paper describes the development and initial feasibility and acceptability of a Brief Family Intervention (the BFI) designed to be delivered as an adjunct to veterans’ individual CPT/PE. The BFI focuses on providing psychoeducation about PTSD and treatment, building family member support for treatment, and reducing family symptom accommodation. A detailed review of the treatment structure and activities is provided, and qualitative data from four dyads (veterans and their spouses/significant others) at baseline and post-intervention are presented. Veterans and partners reported positive responses to the program and were enthusiastic about its utility. Larger randomized controlled studies will be needed to determine the protocol’s efficacy and effectiveness.     

Treatment of posttraumatic stress disorder in U.S. combat veterans: a meta-analytic review

Among U.S. veterans who have been exposed to combat-related trauma, significantly elevated rates of posttraumatic stress disorder (PTSD) are reported. Veterans with PTSD are treated for the disorder at Veterans Affairs (VA) hospitals through a variety of psychotherapeutic interventions. Given the significant impairment associated with PTSD, it is imperative to assess the typical treatment response associated with these interventions. 24 studies with a total sample size of 1742 participants were quantitatively reviewed. Overall, analyses showed a medium between-groups effect size for active treatments compared to control conditions. Thus, the average VA-treated patient fared better than 66% of patients in control conditions. VA treatments incorporating exposure-based interventions showed the highest within-group effect size. Effect sizes were not moderated by treatment dose, sample size, or publication year. Findings are encouraging for treatment seekers for combat-related PTSD in VA settings.     

Changes in suicidal ideation following cognitive processing therapy in a VA residential treatment program

ABSTRACT

In 2015, suicide accounted for over 44,000 deaths and was the 10th leading cause of mortality in the US. Although Veterans, in general, are at a high risk for suicide, Veterans with Posttraumatic Stress Disorder (PTSD) are at even greater risk. While evidence suggests that PTSD symptoms are reduced by Cognitive Processing Therapy (CPT), little is known about how this treatment impacts changes in suicidal ideation across residential treatment. Studies with active duty personnel have found reductions in suicidal ideation following CPT treatment; however, only one study to date has examined this question in a Veteran sample. The current study examined (a) changes in suicidal ideation across a residential CPT treatment program and (b) the influence of demographic variables on change in suicidal ideation across treatment. Participants (N = 303) were admitted to a residential PTSD treatment in a VA medical center and completed pre-, mid-, and post-treatment assessments. Multilevel modeling of archival data revealed that suicidal ideation significantly decreased over the course of CPT (B = ?0.153, SE =0.028, 95%CI =[?0.21, ?0.10], t= ?5.40, p< .001); however, this change did not differ based on age, marital status, sex, or race/ethnicity. Clinical and research implications are discussed.     

Development and psychometric properties of the disability application appraisal inventory

This article describes the development and psychometric properties of an inventory to assess cognitive appraisal of the Department of Veterans Affairs (VA) disability application process, the Disability Application Appraisal Inventory (DAAI). Participants were 439 veterans seeking disability status for posttraumatic stress disorder through the VA and subgroups from that sample. The 3 DAAI scales assess (a) understanding of the disability application process (Knowledge scale) (b) expectations specific to the process (Negative Expectations scale) and (c) investment in obtaining disability status (Importance scale). The scales are internally consistent and largely uncorrelated. Test-retest correlations are adequate for the Negative Expectations and Importance scales. Evidence of factorial and construct validity is presented.     

Posttraumatic stress disorder, traumatic brain injury, and suicide attempt history among veterans receiving mental health services

History of posttraumatic stress disorder (PTSD) or traumatic brain injury (TBI) has been found to increase risk of suicidal behavior. The association between suicide attempt history among veterans with PTSD and/or TBI was explored. Cases (N = 81) and 2:1 matched controls (N = 160) were randomly selected from a Veterans Affairs Medical Center clinical database. PTSD history was associated with an increased risk for a suicide attempt (OR = 2.8; 95% CI: 1.5, 5.1). This increased risk was present for those with and without a history of TBI. Results support incorporating PTSD history when assessing suicide risk among veterans with and without TBI.     

The Influence of Service Era: Comparing Personality Assessment Inventory (PAI) Scale Scores Within a Posttraumatic Stress Disorder Treatment Clinic (PCT)

Research is mixed on the role of service era in symptom endorsement among Veterans, with differences emerging depending on the instrument evaluated. This study compares Personality Assessment Inventory (PAI) scale scores of VA test-takers who served during the Vietnam, Desert Storm, or Post-9/11 service eras. The sample was collected at a VA Posttraumatic Stress Disorder Clinical Team. Associations between gender and combat exposure were also examined as covariates. Results suggest that Veterans’ self-report on the PAI is influenced by service era, even after accounting for gender and combat exposure during deployment. The largest differences were between Vietnam or Post-9/11 Veterans and those from the Gulf War era. Symptom differences typically varied across scales commonly associated with symptoms of trauma exposure/posttraumatic stress disorder. Implications for the clinical use of, and research with, the PAI and other broadband personality assessments within the VA healthcare system and trauma treatment settings are discussed.

     

Spirituality and Religion: Neglected Factors in Preventing Veteran Suicide?

The Clay Hunt Suicide Prevention for American Veterans Act, enacted in 2015, aimed to increase access to treatment for U.S. military veterans; however, poor attendance at aftercare and high rates of treatment refusal suggest that, even when treatment is accessible, it may not be acceptable. Often, it is difficult to acknowledge the need for help and to commit to treatment. The stigma of mental illness diminishes the self-respect of individuals with mental health problems and may be especially acute for veterans because of the centrality of resilience in military culture. This stigma also can jeopardize current employment or prospects for future employment. This paper proposes a partial answer to the question, “What more might be done to engage and effectively treat veterans who are at high risk of suicide?” The meaning of spiritual and/or religious expression in human development, well-being, and social functioning has long been of great interest to theorists in disciplines as diverse as sociology, theology, and psychology. Some empirical studies have further suggested that certain religious and/or spiritual beliefs, practices, and/or affiliations may be protective against suicide. This paper (a) summarizes these perspectives, (b) considers how clinical inquiry into the role of religion and/or spirituality in the lives of veterans at high risk of suicide fits into the suicide prevention program of the U.S. Department of Veterans Affairs, and (c) offers specific recommendations to practitioners.     

Providing Pastoral Care Services in a Clinical Setting to Veterans At-Risk of Suicide

The value of enhanced spiritual wellbeing has largely been overlooked as part of suicide prevention efforts in Veterans. The aim of this qualitative study is to examine the clinical pastoral care services provided by VA Chaplains to Veterans at-risk of suicide. This study was conducted using in-depth interviews with five Chaplains affiliated with a medical center located in upstate New York. This study was able to show that some at-risk individuals do actively seek out pastoral care, demonstrating a demand for such services. In conclusion, a pastoral care framework may already exist in some clinical settings, giving at-risk Veterans the opportunity to access spiritual care.