In February 2016, The United States Veteran Affairs (VA) Department convened a Summit to discuss recommendations for improving suicide prevention, highlighting the urgency of addressing the unique needs of suicidal veterans.1
This population is vulnerable due to a variety of factors including posttraumatic stress syndrome (PTSD) and/or traumatic brain injuries (TBI) sustained in combat. However, “it is important not to assume that all veterans are damaged and suicidal,” according to Peter Gutierrez, Associate Professor, Department of Psychiatry, University of Colorado Denver School of Medicine. What is important is identifying those at risk and engaging in prevention and ongoing interventions, he told Psychiatry Advisor.
Assessing risk involves understanding “where the person served and the nature of the service, as a starting point,” said Gutierrez, who is also Clinical Research Psychologist, Denver VA Medical Center. This can provide clues to inform the assessment and place it in broader context.
TBI vs PTSD
An estimated 22% of all combat casualties from recent conflicts in Afghanistan and Iraq are brain injuries, and 60% to 80% of soldiers who have other blast injuries may also have TBIs.2 These are classified as mild, moderate, or severe, based on the nature of the injury (Table 1). Importantly, TBI and PTSD can present with similar symptoms, which can be confusing, Gutierrez noted.
Table 1: Classification of Traumatic Brain Injury (TBI)
|Level of Severity||Definition|
Bryant R. Dialogues Clin Neurosci. 2011;13(3):251-262.
“If you know a veteran was exposed to multiple blast traumas, for example, you want to be thinking of TBI and appropriately assessing that.” Depending on the nature and extent of the damage, and its impact on executive functioning, the patient may have less ability “to carefully think things through in times of crisis and may be at greater risk of resorting to intentional self-harm.”
Both TBI and PTSD present with impairments in problem solving and stress tolerance.3 “When depression is introduced into the picture, sorting these out can become incredibly difficult,” Gutierrez commented. Chronic pain, which can affect veterans who have been injured, also results in symptoms that can overlap with each of these conditions.3
It was once thought that PTSD could not result from TBI because the impaired consciousness at the time of trauma precluded encoding the traumatic experience.3 However, recent evidence indicates that PTSD can follow mild and even severe TBI, although individuals may suffer periods of retrograde and anterograde amnesia, which may limit their ability to recall episodes of the traumatic experience.3 A survey of 2525 U.S. soldiers found that only 16% of troops who sustained a physical injury reported symptoms of PTSD, as compared to 33% of those with mild TBI.4
PTSD might follow TBI as a result of several possible mechanisms, including fear conditioning, memory reconstruction, and post-amnesia resolution.3 Moreover, mild TBI increases the risk of PTSD, possibly by depleting the cognitive resources and working memory required to navigate ongoing stressors in one’s environment that may affect veterans—eg, pain, medical procedures, loss of employment, and interpersonal conflicts.3
Gutierrez refers patients for a neurological or neuropsychiatric consultation if he is concerned about multiple TBIs or evidence of a moderate-to-severe TBI. “I include this information in the assessment to help me understand where the brain is and is not functioning.”
Ultimately, however, “it may actually be less important to know exactly what is responsible for the veteran’s executive dysfunction than to assess its extent and tailor treatment approaches accordingly, based on ability to process information and make decisions that require thoughtful planning,” he said.
Age and Exposure to Habitual Pain
Older veterans are at greater risk of suicide than are younger veterans, Gutierrez stated. “Elderly people have had different life experiences, both resulting from and independent of military service. Therefore, they might have increased tolerance of pain that can, in turn, increase the likelihood that they might engage in lethal self-harm.”
The mechanism can be understood according to opponent-process theory, which predicates that repeated exposure to an affective stimulus over time causes the stimulus to lose its ability to elicit the original response, thereby strengthening the opposite response.5 Consequently, the longer a veteran has lived, the greater the likelihood that s/he has become inured to the protective mechanisms of pain and fear that typically prevent people from ending their lives, Gutierrez explained.
The Role of Firearms
Veterans are far more likely to use firearms for suicidal purposes than are nonveterans.6,7 In the general population, women tend use non-firearm methods to end their lives, but among veterans, women actually outnumber their male counterparts in choosing firearms.6
“Veterans are familiar and comfortable with guns, and with using guns to kill,” Gutierrez observed. Moreover, “many own guns, increasing the risk even more.” He urged clinicians “not to ask suicidal veterans whether they own weapons, but how many they own, whether they have easy access, and how they are stored.”
Make sure the veteran understands that you are not there to confiscate the weapons, he added. “I say gently as many times and in as many ways as possible, ‘I am not talking about taking your gun away, but helping you keep safe during a time of crisis.’”
For example, some veterans keep their guns under their pillow because that is the only way they feel safe. So begin by asking whether they are willing to move it elsewhere in the bedroom, such as a night table or dresser drawer. “I work with them to create more and more physical distance between them and their weapon.”
In the case of imminent risk, Gutierrez involves family members or friends who agree to take temporary charge of the weapon. “For example, the spouse or partner agrees to lock it up, but the veteran knows that it is still in the house. Or perhaps a relative agrees to hold it for two weeks.” He added that state laws differ and it is important to be informed whether it is legal to give a firearm to someone else.
To Hospitalize or Not to Hospitalize?
“I regard hospitalization as a last resort,” Gutierrez said. Avoiding hospitalization might mean seeing the patient multiple times weekly, arranging telephone check-ins, and involving family and friends in a safety plan.
Gutierrez asks patients at imminent risk of suicide, “Do you think hospitalizing you will keep you safe?” He explained, “I always prefer hospitalization to be voluntary rather than involuntary. If you engage patients in the discussion, they feel they have participated in the decision-making process.”
He noted that past behavior tends to predict future behavior. For example, an individual who has previously slashed his wrists is likely choose this method and should be taken seriously if he or she threatens to do so again. “Patients do a better job than clinicians in predicting their suicidal risk.”
The Role of Assessment Tools
Gutierrez noted that the Beck Scale for Suicidal Ideation and the Beck Hopelessness Scales8,9 have been found reliable and valid in this population. His own preference, however, is the Self Harm Behavior Questionnaire, which—although initially developed for adolescents—has been used extensively in research on veteran suicide.10-12
Individuals who have been part of the military have a unique culture.13,14 “To be culturally competent, you have to honestly own what you do not know,” Gutierrez stated. “You can say, ‘I have never been in the military. I would like to learn from you so I can provide the best possible care.’”
Suicide Assessment in Homeless Veterans
According to the US Department of Housing and Urban Development, in 2015, 11% of homeless people were veterans and 34% of homeless veterans were in unsheltered locations, compared with 28% of all homeless adults.15
“When a suicidal veteran is homeless, it is impossible to involve family or friends in a safety plan, and there is no stable home environment in which they can be safely maintained,” Gutierrez observed. “An inpatient hospital stay—if it is long enough—can be the beginning of a process that might connect them to available services.”
He added that when homeless people present to an emergency department claiming to be suicidal, “there is often an assumption that they are only looking for a warm place to sleep and some hot meals.” This makes assessment more complex. However, he said, he would not change his overall assessment approach. “You always want to determine the level of intent to kill themselves. Do they really want to die? Do they have access to lethal means? Have they attempted suicide in the past and, if so, what means did they use?” Ultimately, the threat must be taken seriously. “You do not want to turn away someone who is at imminent risk of suicide.”
Gutierrez encouraged the use of suicide-specific interventions. “Treat the suicidality directly, not just as a symptom of something else,” he advised.
Cognitive behavioral therapy (CBT) has been used effectively with veterans in active duty populations and after discharge.17,18 Collaborative Assessment and Management of Suicidality (CAMS) is a group intervention being researched in military and veteran populations.19,20 CAMS is not a “specific intervention, but rather a therapeutic framework to help clinicians organize how they treat suicidal individuals,” Gutierrez said. Mindfulness-based approaches can also be helpful.21
“Veterans are not a homogeneous group, and many actually thrive when they leave the military,” Gutierrez observed. Remaining cognizant of those who are vulnerable and choosing appropriate assessments and interventions are key to reducing the incidence of suicide in this population.
1. US Department of Veterans Affairs (VA). VA announces additional steps to reduce veteran suicide. Available at: http://www.va.gov/opa/pressrel/includes/viewPDF.cfm?id=2761. Accessed: June 18, 2016.
2. Summerall EL. Traumatic brain injury and PTSD. US Department of Veterans Affairs. Available at: http://www.ptsd.va.gov/professional/co-occurring/traumatic-brain-injury-ptsd.asp. Accessed: June 6, 2016.
3. Bryant R. Post-traumatic stress disorder vs traumatic brain injury. Dialogues Clin Neurosci. 2011;13(3):251-262.
4. Hoge CW, McGurk D, Thomas JL, et al. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med. 2008 Jan 31;358(5):453-63.
5. Joiner T. The Interpersonal-Psychological Theory of Suicidal Behavior: Current Empirical Status. American Psychological Association. Psychological Science Agenda. June, 2009. Available at: http://www.apa.org/science/about/psa/2009/06/sci-brief.aspx. Accessed: June 14, 2016.
6. Hoffmire CA, Bossarte RM. A reconsideration of the correlation between veteran status and firearm suicide in the general population. Inj Prev. 2014 Oct;20(5):317-21.
7. Kaplan MS, McFarland BH, Huguet N. Firearm suicide among veterans in the general population: findings from the national violent death reporting system. J Trauma. 2009 Sep;67(3):503-7.
8. Beck Scale for Suicidal Ideation. Available at: http://www.pearsonclinical.com/psychology/products/100000157/beck-scale-for-suicide-ideation-bss.html. Accessed: June 18, 2016.
9. Beck Hopelessness Scale. Available at: http://www.pearsonclinical.com/psychology/products/100000105/beck-hopelessness-scale-bhs.html. Accessed: June 18, 2016.
10. Muehlenkamp JJ, Cowles ML, Gutierrez PM. Validity of the Self-Harm Behavior Questionnaire with diverse adolescents. Journal of Psychopathology and Behavioral Assessment. 2010;32:236-245.
11. Gutierrez, PM, Osman A., Barrios FX, Kopper BA. Development and initial validation of the Self-Harm Behavior Questionnaire. Journal of Personality Assessment. 2001;77(3):475-490.
12. Gutierrez PM, Osman A. Adolescent Suicide: An Integrated Approach to the Assessment of Risk and Protective Factors. DeKalb, IL: Northern Illinois University Press, 2008.
13. Hobbs K. Reflections on the culture of veterans. AAOHN J. 2008 Aug;56(8):337-41.
14. Boudiab LD. Veteran Culture and Veteran-Centric Care. VA Nursing Academy. Available at: http://www.aacn.nche.edu/downloads/joining-forces-tool-kit/educational-resources/INTRO_to_VANA_and_Veteran_health_care_needs.pdf. Accessed: June 16, 2016.
15. US Department of Housing and Urban Development. 2015 Annual Homeless Assessment Report (AHAR) to Congress. Available at: https://www.hudexchange.info/resources/documents/2015-AHAR-Part-1.pdf. Accessed: June 18, 2016.
16. Wenzel A, Brown GK, Karlin BE. (2011) Cognitive Behavioral Therapy for Depression in Veterans and Military Servicemembers: Therapist Manual. Washington, DC: U.S. Department of Veterans Affairs. Available at: http://www.mirecc.va.gov/docs/CBT-D_Manual_Depression.pdf. Accessed: June 20, 2016.
17. Brown GK, Karlin BE, Trockel M, et al. Effectiveness of Cognitive Behavioral Therapy for Veterans with Depression and Suicidal Ideation. Arch Suicide Res. 2016 Mar 16:1-6. [Epub ahead of print]
18. Trockel M, Karlin BE, Taylor CB, et al. Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep. 2015 Feb 1;38(2):259-65.
19. Jobes DA. The Collaborative Assessment and Management of Suicidality (CAMS): an evolving evidence-based clinical approach to suicidal risk. Suicide Life Threat Behav. 2012 Dec;42(6):640-53.
20. Johnson LL, O’Connor SS, Kaminer B, et al. Suicide-focused group therapy for veterans. Military Behavior Health. 2014;2:327-336.
21. Serpa JG, Taylor SL, Tillisch K. Mindfulness-based stress reduction (MBSR) reduces anxiety, depression, and suicidal ideation in veterans. Med Care. 2014 Dec;52(12 Suppl 5):S19-24.