Trust is the Basis for Effective Suicide Risk Assessment in Veterans

Trust is the Basis for Effective SuicideRisk Assessment in Veterans Linda Ganzini, Lauren Denneson, Nancy Press, Matt Bair, Drew Helmer, Jennifer Poat Steve Dobscha VA Health Services Research & Development Center to Improve Veteran Involvement in Care (CIVIC), Portland VA Medical Center Oregon Health & Science University Richard Roudebush VA Medical Center, Indianapolis War-related illness and Injury Study Center, VA New Jersey Healthcare System

Presenter Disclosures Steven K. Dobscha MD (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No Relationships to Disclose

VA suicide risk assessment initiative • Suicide risk assessment for patients with depression and PTSD became national performance goal in 2007. • Routine screening for depression and PTSD takes place using PHQ-2 or PHQ-9 and PC-PTSD • Electronic Medical Record (CPRS) triggers a reminder • Administered in primary care by MAs or nurses; mental health clinicians often do their own • Positive depression or PTSD screen activates brief suicidal ideation risk assessment template. • Templated risk assessment tools to be used in conjunction with clinical judgment to assess risk

Picture of screen—CPRS screenshot of pocketcard?

Suicide risk assessment and screening • Limited empiric support for screening O’Connor et al, Annals Int Med 2013 • Veterans who die by suicide may deny suicidal ideation at last clinic appointments Denneson et al, Psychiatric Services, 2011 • Studies of Afghanistan and Iraq Veterans support that only a minority who screen positive for depression or PTSD engage in mental health care Hoge et al, NEJM 2004, Lu Psych Services 2011 • Little is known about factors that promote or discourage honest disclosure of suicidal ideation.

VA HSR&D Study: Outcomes and Correlates of Suicidal Ideation in OEF/OIF Veterans • Mixed methods study • Main research questions: • What are the correlates of positive brief suicide risk assessments among OEF/OIF Veterans? • To what extent are processes of care affected by positive assessments? • What are Veterans’ experiences of the risk assessment process and their perceptions of clinicians’ responses to assessment results?

Qualitative study methods • Participants • OEF/OIF Veterans in Oregon, Indiana, and Texas VAs • Positive screen for PTSD/depression and positive SI risk assessment in non-mental health ambulatory setting • Individual interviews 2 to 6 months after assessment • Patients with psychiatric instability or cognitive impairment excluded by primary care provider • Recruitment was purposive with attempts to enrich with women and ethnically diverse Veterans • Veterans completed phone interviews, which were audiotaped, transcribed and de-identified • Modified grounded theory used to analyze Strauss and Corbin, Basics of Qualitative Research, 1998

Interview guide • Recollections of suicide assessment process • Comfort/discomfort with assessment process • How the care setting influenced their responses • Regarding suicidal ideation— • Hesitance to discuss • Reactions from providers and staff • Positive and negative views and consequences of disclosure • Experiences in the military with mental health and suicide screening/assessment

Results—Demographic Characteristics • 34 Veterans • Mean age 35 years • 91% men • 73% non Hispanic white • 42% had served in the army • Assessment process • Primary care or post-deployment clinics • Multiple disciplines involved in assessments: Physicians (15) nurses (12) psychologists (1), social worker (1) physician assistant (1), multiple providers (4)

Results: Positive views of SI assessment • Straightforward, clear, expected, devoid of ambiguous language “they seemed to be pretty straight and cut and dry questions…. You got the initial standardized questions then, if the solider answered a yes to certain questions, it’s going to pop up with a different standardized question. Then eventually they figure out what going on with Veterans.” (Participant N) “They are standard. They were what I was here for. I kind of expected them….She didn’t sugar coat it. I mean there’s not a delicate way to say, ‘Hey you’re thinking about killing yourself.’ You just have to ask it. …she didn’t pussyfoot around it either. She was as delicate as you can be asking the questions, but direct about it.” (Participant J)

Criticisms of assessment process • Painful and shameful “I’ve gotten used to it and know you guys are going to ask me every time…it is like sticking a needle through your eye sometimes.” (Participant R) • Repetitive, sense of communication gaps, leading to sense of futility about getting mental health needs assessed. “It’s repetitive. Annoying. It feels like I have already answered the questions for you. And you’re in the same damn office, why should I go to somebody else and answer them all over again. It is a massive waste of time to have to spend seven hours at that place answering the same questions over and over again. But apparently these three people cannot talk to each other.” (Participant O) “But I mean that was about the gist of it. So I just, I felt like I gained nothing. I felt like it wasn’t, there was no attempt to figure out what’s going on. It was just, “Uh…yep checking the box, it’s still there, see you later.” (Participant AE)

Criticism—inability to provide context • Questions too simple, no opportunity to clarify their thoughts or give complex answers. “I mean if I were in her shoes I think I would have asked a little bit more questions. I would have made sure the individual understood the questions… I mean it almost seemed like waste of time… it was too short, too simple. I had thoughts that I wanted to share and I did not get the opportunity to share them.” (Participant AF)

Barriers to disclosure of SI • Veterans accustomed to minimizing and suppressing thoughts of suicide. Believed they should cope on their own. “That’s the heartache…I just try to cover it up and faking it to make it. I know I am hurting, physically and mentally, but the thought of trying to get help is a sign of weakness.” (Participant F) • Veterans were sensitive toward feeling lack of respect, particularly on initial interactions “Those that are nice to me and treat me with respect right away, then they will get the respect—they will get all the information that they need from me.” (Participant W)

Barriers to disclosure of SI—experiences in the military • Stigma and concerns admission of SI might delay return home “I finally started accepting that [having suicidal thoughts] was an issue for me, but prior to that there had been several times I filled out those questionnaire…and it was just something you had to go through to get home. You knew pretty much to say no to everything.” (Participant U) “They ask you, “Do you need to talk to mental health?” you say, “no.” It does not matter if you do or not. You say no because if your commander finds out you said yes they give you shit. What, you’re a soldier. You don’t need any fluffy bunny mental health crap.” (Participant J) “The doctor I am seeing is supposed to know everything. Not ‘Oh I am only a doctor for you today’…They are doing their job, I’m just a number, expendable, I‘m a soldier, I don’t complain and stuff, I feel like a weak person being in there talking about it.” (Participant F)

Barriers to disclosure—trust and privacy “If that is the first thing someone were to say to me, I would just say no, because I wouldn’t want to tell them because I don’t know them. I don’t trust them. I don’t know who they are.” (Participant AG) “I wouldn’t feel comfortable. If it was a new doctor or a new nurse, I don’t feel—it wouldn’t feel comfortable—I’d be too afraid of them. I wouldn’t know how to explain it. I’d be too uncomfortable with the strangers.” (Participant H) “I don’t want to mess up my life even more by being honest with somebody. And they are strangers so I don’t really want to talk to strangers about things that are in my head ‘cause they’re my thoughts.” (Participant E) “I mean people don’t really want to be asked, ‘Hey are you trying to kill yourself?” You know that like ‘Hey that none of your business,’ you know, that’s mine—that’s what I’m thinking in my head.” (Participant W)

Barriers to disclosure—consequences • Worry about hospitalization and medication. “It’s difficult for me, one of the reasons I was worried about talking about it is she going to try and lock me up in a straight jacket, I have no ideas what the response if going to be if I talk to someone honestly.” (Participant O) “And to tell someone that you want to admit them, it don’t make them feel at ease. Now I’m scared to tell you something. ‘Cause you’re telling me, I’m telling you my feeling and you want to admit me to the hospital, that sometimes makes a person, especially a soldier clam up. Now we open a can of worms. Who’s going to take care of my kids? My kids is coming home from school at 5:00. I mean when you talk about admitting me you scare the shit out of me.” (Participant AC)

Facilitators of Disclosure • Trust, provider attitudes of genuine concern, questions of SI in context of Veteran-centered goals “Whereas when speaking with (the therapist), it’s ‘Well, you have kids, you gotta make sure that they’re okay, though to make sure they’re okay, you have to be okay.’ So it’s a more looking down the road to ‘help me,’ not checking the blocks, but to help me.” (Participant AB) “Cause I’ve seen people do that on their screen ‘Have you ever attempted suicide,’ click on the screen. He didn’t do that. He actually sat down. He talked to me. He looked at me. He didn’t take his eyes off me. He talked to me and that’s what made me feel a lot better.” (Participant AG) “Of course it was difficult. Not so much being asked, he was fairly gentle and not aggressive. But he was pretty comfortable to talk to. More than anything else I got the impression right off the bat that he was there to be supportive.” (Participant C)

Recommendations • SI risk assessment should be performed by provider who knows the patient best, not by triage personnel • Repetitive assessment should be avoided • Misperceptions about the consequences of disclosure should be explored • Risk assessment should be part of a conversation • The patient should be warned that her/she is likely to be asked about SI in future and rationale for this • Providers should be aware of potential for shame and avoidance around suicidal thoughts.

Trust is the Basis for Effective Suicide Risk Assessment in Veterans