Behavioral Health Playbook - AMSUS · Behavioral Health Playbook CDR Julie A Chodacki, MPH, PsyD,...
Transcript of Behavioral Health Playbook - AMSUS · Behavioral Health Playbook CDR Julie A Chodacki, MPH, PsyD,...
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AMSUS The Society of Federal Health Professionals Annual MeetingNational Harbor, MD | November 26-30, 2018
Behavioral Health Playbook
CDR Julie A Chodacki, MPH, PsyD, ABPP
Branch Chief, Clinical Care
Psychological Health Center of Excellence
Disclosure
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∎ The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, nor the U.S. Government
∎ CDR Chodacki and the Psychological Health Center of Excellence (PHCoE) staff have no financial interest to disclose. Commercial support was not received for this activity
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Agenda
∎ Behavioral Health Playbook
• Initial plan
• Built-in adaptability
∎ Courses
• Customer-driven
• Discussion/scenario-based
• Culturally curious
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I. Psychological First Aid: Prevention and Early Intervention Principles
Behavioral health capability
III. Combat Operational Stress Control (COSC)
II. Military Mental Health Framework
Behavioral Health EngagementYe
ar
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Behavioral Health SMEE Course Overview
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Behavioral Health Risk Prevention, Assessment and Mitigation SMEE
Task: To conduct a “Behavioral Health Risk Prevention, Assessment, and Mitigation” Subject Matter Expert
Exchange (SMEE)
Purpose: To exchange information and ideas with attendees in order to build U.S. and partner nation (PN) capacity
to mitigate behavioral health risks associated with experience of severe stressors or trauma.
Description: This exchange leverages didactic, structured, scenario-based practical exercises, facilitated
discussions, and clinical and operational case presentation to cover: psychological first aid, the military mental
health framework, and combat operational stress control. The SMEE is designed to develop and enhance clinical
and non-clinical skills to enable participants to gain expertise in how to scan the environment to prevent or identify
potential stressors or traumatic events, recognize signs and symptoms of stress and mental disorders, and to be
able to appropriate intervene or refer individuals who need assistance with stress or behavioral health concerns.
Participants in the course will be able to provide commanders, planners and decision-makers with realistic and
practical risk prevention and mitigation recommendations to reduce behavioral health risks within troop
operations.
Learning objectives for U.S. participants:
1) Compare and contrast fundamental behavioral health knowledge, practices, and services provided to
troop operations used by PN and U.S. militaries
2) Describe the PN’s local, national, and/or regional behavioral health prevention and care standards and
regulations
3) Describe the perspective towards behavioral health in the PN, and whether there are behavioral health
disorders of concern in PN
End-state outcomes for U.S. military:
1) Increased readiness to perform behavioral health prevention and intervention mission
2) Increased interoperability and professional relationships with the PN
Learning objectives for PN participants:
1) Apply the basic principles of Psychological First Aid and COSC
2) Identify, assess, mitigate, signs and symptoms of stress and mental health concerns; be able to expertly
communicate these concepts to troops at all levels of leadership
3) Develop a behavioral health program to mitigate risk for troops at all levels
End-state outcomes for the PN military:
1) Trained clinicians and non-clinicians capable of training others to execute behavioral health program
2) Increased Force Health Protection and increased military readiness
Lesson Plan (two separate modules for each main building block, for clinicians and for non-clinicians)
A: Psychological First Aid
Section I: Chapter 1: Overview
Chapter 2: Preparing to Deliver Psychological First Aid
Chapter 3: Core Actions
B: Military Mental Health Framework
Section I: Intro to Basic Psychological Health/Substance Misuse Concepts
Section II. Behavioral Health Operational Readiness
Section III. Intro to Military Mental Health Policies and Procedures
Section IV. Behavioral Health Clinical Practice Guidelines
C: Combat Operational Stress Control
Section I: Psychological Health Effects of Deployment
Section II: Deployment-Related Exposures
Section III: Deployment Resources
Section IV: Health Assessment Programs
Handouts
1) Draft behavioral health program workbook
2) Scoring case scenario worksheets
3) Assessment checklist
4) Concepts summary handout
Culminating Activity
1) Review of draft behavioral health program, facility walk through if available
2) Clinical and operational case scenarios scored
3) Command Brief
Potential topics for the PN to exchange with the U.S. military
1) Behavioral health prevention or intervention plans and policies
2) Local, military, regional, or national behavioral health care standards
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Capability None Minimal Moderate Significant End State
Doctrine No doctrine of any kind
No local, state, national standards,
SOP’s
Developing standards and doctrine
(SOP) 25%
Developing standards and doctrine
(SOP) 50%
Specific documented standards
(SOP) 75%
Compliance with local, state and national
standards WHO standards
SOPs100% implemented
Organization Organization is not familiar with
mental health literacy or not
interested
No structure to address
psychological threat
Limited Command interest in mental
health literacy
Limited development of prevention and
early intervention structure
Command interest in mental health
developing
Development of action towards enhancing
protective factors and minimizing risk factors
Command interest in mental health
literacy
Developed structure & services focusing on
primary prevention and early intervention
Command interest in mental health literacy
as a core function
Fully functional primary prevention programs
Early intervention/referral
processes/procedures in place
Training No psych first aid, prevention, and early
intervention training program
No standardized training programs
for leaders, service members, and
families. Minimal trainers
Developing standardized training
programs
Developing trainers
Have a standardized training program
Have qualified trainers
Training program at regional level with cadre of
trainers
Program in place to sustain “bench” of trainers
Material No functional documentation
No PT privacy standards
No ability to respond to R & R needs
Minimal documentation process
Minimal member and family support
materials
Documentation under development
Developing information guides for members
and families
Fully implemented documentation
Fully implemented information dissemination
Fully implemented support system
Planning and budgeting to anticipate support of
psychological health of members and families,
including information systems
Leadership &
Education
No education for leadership
Leadership unequipped to address
mental health literacy issues
No psychological first aid
Programs and actions to develop mental
health literacy in units 25% implemented
Programs and actions in place develop
mental health literacy in units 50%
implemented
Programs and actions in place to develop
mental health literacy in units 75%
implemented
Programs and actions in place to develop mental
health literacy in units 100% implemented.
Self-sustaining/self-generating
PersonnelPersonnel is over-worked, sleep
deprived, malnourished
No trained personnel
25% of personnel is performing
optimally, recovering optimally,
eating, sleeping, exercising for
energy enhancement
50 % of personnel is performing optimally,
recovering optimally, eating, sleeping,
exercising for energy enhancement
75% of personnel is performing optimally,
recovering optimally, eating, sleeping,
exercising for energy enhancement
100% of personnel is performing optimally,
recovering optimally, eating, sleeping,
exercising for energy enhancement
Facilities No facilities to promote primary
prevention, rest, exercise, and
positive coping
Very few facilities are allocated to
promote primary prevention, rest,
exercise, and positive coping
Some facilities are allocated to promote
primary prevention, exercise, rest, and
positive coping
Most members and families have access
to facilities that promote primary
prevention, rest, exercise, and positive
coping
100% of members and families have access to
facilities that promote primary prevention, rest,
exercise, and positive coping
Psychological First Aid: Prevention and Early Intervention Principles
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Capability None Minimal Moderate Significant End State
Doctrine No behavioral health (BH) doctrine of any
kind
No local, state, national Standards,
SOP’s
Developing standards and doctrine
(SOP) 25%
Developing standards and doctrine (SOP)
50%
Specific documented standards (SOP) 75% SOPs in place, monitored
Compliance with local, state, national, and
WHO standards
Clinical Practice Guidelines (CPGs) are
evidence based
Organization Organization unaware of BH
problems/issues or not interested
No BH structure, or liaison services to
address BH threat
Limited Command interest in BH
minimal
Limited development of BH structure,
liaison services to address BH threat
Command interest in BH developing
Partial development of BH command structure,
liaison services on BH threat
BH screen prior to service
Command interest in BH developed
Developed BH structure & liaison services
to address BH threat
Standardize BH fitness/suitability for duty
processing
Command interest in BH as a core
leadership function
Fully functional BH team
BH liaison services avail able to address
needs of community
Training No training program for BH staff or support
personnel
No training cadre
No standardized training programs
for BH
Limited BH trainers
Developing standardized BH training
programs
Developing BH trainers
Standardized BH training program
developed
Qualified BH trainer cadre 100%
Training program standardized at regional
level, easily accessible Trainers available
for consultation
Material No functional medical record (MR)
documentation
No patient privacy standards
Minimal MR documentation process
Minimal patient privacy
MR documentation not shared
Developing Electronic Health Record (EHR)
system
Privacy standards developed
Fully implemented MR documentation
process/EHR system developing 75%
Privacy standards developed and monitored
EHR fully implemented/utilized
Privacy Standards (HIPPA) in place and
monitored 100%
Leadership &
Education
No leadership BH education
Leadership doesn’t know how to
handle/identify BH problems
No BH promotion of educational
services for patients
Programs and actions in place to
prevent, identify, and manage adverse
Behavioral Health issues in units 25%
implemented
Leadership aware of BH problems
Programs and actions in place to prevent,
identify, and manage adverse Behavioral
Health issues in units 50% implemented
Leadership trained in BH issues
Programs and actions in place to prevent,
identify, and manage adverse Behavioral
Health issues in units 75% implemented
Leadership proactive about BH issues
Programs and actions in place to prevent,
identify, and manage adverse Behavioral
Health issues in units 100% implemented
Educational services/specific briefs for all
personnel In AO 100%
Leadership vocal, supportive of BH
PersonnelBH workforce unable to support
population
BH staff report high work stress and
poor work/life balance (WLB)
BH workforce staffing is able to
support the
BH staff report high work stress and
WLB difficulties
BH workforce staffing is able to support the
population -50%
BH staff report moderate stress and
moderate WLB difficulties
BH workforce staffing is able to support
the population -75%
BH staff report some work stress and
some WLB difficulties
BH workforce staffing is able to support
the population-100%
BH staff report minimal to no work
stress and minimal to no WLB difficulties
Facilities No inpatient & residential facilities.
No outpatient clinical or embedded
services that allow BH assessment,
engagement, treatment
25% fully capable medical facilities to
handle all BH needs In primary care,
embedded, and in/out patient care
50% fully capable medical facilities to
handle all BH needs
75% fully capable medical facilities to
handle all BH needs
100% fully capable medical facilities to
handle all BH needs
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Military Mental Health Framework
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Capability None Minimal Moderate Significant End State
Doctrine No standardized
framework
No SOP’s
No COSC doctrine
No stress continuum model
SOP’s being developed
Stress continuum model developing
SOP’s developed 50%
COSC doctrine being dev.
Stress continuum model developing 50%
Specific COSC doctrine &
SOP’s and stress continuum model 100%
Ability to create & preserve ready
force, long term MH promotion
developing
SOP’s & COSC doctrine 100%
implemented
Stress continuum model 100%
implemented
Ready force, long term mental health
promotion developed, fully implemented
Organization No systematic efforts to preserve
a psychologically ready force, or
long term mental health
promotion
No concept of operations
Limited development of CONOPS for
COSC
Develop organic COSC team 25%
Partial development of CONOPS for
COSC 50%
Organic COSC team 50%
Partial development CONOPS for COSC
75%
Organic COSC team 75%
100% developed and implemented COSC
CONOPS
Developed and integrated organic COSC
team
Training No training program focused
on COSC
COSC training program 25% COSC training program 50% to include train
the trainer
COSC training program 100% to include train
the trainer
Training cadre recruited and 50% trained
Training program implemented at regional
level with training providers
Material No medical information system Medical information (MI) system
access developing 25%
COSC specific FMs under
development
Access to MI systems50%
COSC specific FMscomplete
Access to MI systems 100%
EHR’s, computer networking, equipment to
function in field environment fully deployable
Leadership &
Education
No COSC course No leaders
creating climate of ethical &
moral behavior and resilience
No stress prevention or
resilience courses
25% COSC leadership course
completion
No leadership training program
50% COSC leadership course
completion
Leadership training program in
development
100% COSC leadership course
completion
Leadership training program 50%
implemented
100% COSC course delivered
Leaders create climate of ethical & moral
behavior and resilience
Leadership training courses fully
implemented
Personnel No COSC
Multidisciplinary & support
personnel in unit
COSC Multi-D workforce staffing is able
to support the theater population-25%
COSC Multi-D workforce staffing is able
to support the theater population-50%
COSC Multi-D workforce staffing is able
to support the theater population-75%
COSC Multidisciplinary personnel in unit
staffing is able to support the theater
population-100% (Deployable)
Facilities No clinical mental health services
avail. in theater & Garrison
Companies vs detachment Co-Locate
with CSH?
Aligned by region at 25%
COSC facilities aligned by region.
Able to provide services 50%
COSC facilities aligned by region, able to
provide services 75%.
Clinical mental health services avail. in
theater & Garrison- aligned by region-
100%
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Combat Operational Stress Control
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Sample Psychological First Aid: Prevention
and Early Intervention Courses.v2
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Psychological First Aid
Suicide Prevention
Technology in Care Mobile Apps
Stigma of MH in Military
Evidence Continuum of Practice
Post-Traumatic Growth
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Behavioral Health Content
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Content for three BH SMEE building blocks were developed by:
• Leveraging existing PHCoE, Services, National Center for PTSD, and CDP materials
• Identifying various courses/modules taught online or in person; include webinars, apps, other available resources for host nations
• Developing standardized SMEE curriculum, and create new courses to bridge existing gaps where they are identified
A: Psychological First Aid – Prevention and
Early Intervention
B: Military Mental Health Framework
C: CoSC
BH SMEE Building Blocks
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Behavioral Health Resources Available
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Capability Definition: A fully capable military Behavioral Health system ensures that individuals exposed to trauma receive appropriate care to minimize post traumatic disorders; it includes a basic framework for understanding and delivering mental health prevention and response services including leadership support for psych health; and it aims toward effective Combat and Operational Stress Control.
Potential partner organizations:-Psychological Health Center of Excellencehttp://www.pdhealth.mil-DIMO http://www.dimo.af.mil/-USU/CDP http://deploymentpsych.org/about-National Center for PTSD https://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp-Peace Corps http://files.peacecorps.gov/multimedia/pdf/library/T0087_culturematters.pdfhttp://files.eric.ed.gov/fulltext/ED059937.pdf-Directors of Psychological Health: Army, Navy, AF, and Marine Corps- US State Department
IMET Courses:•Mental (Behavioral) Health Specialist Course: 302-68X10•Aeromedical Psychology Training (Officers) Course: 6H-F27•Psychiatric / Mental Health Nursing Course: 6F-66C•Management of Combat Stress Casualties Course: 6H-300/A0620 References:AFM4-02 Army Health SystemATP 4-02.55 Army Health System Support Planning ATP 4-02.3 Army Health System Support to Maneuver Forces Dr. Smith, David, FEB15, Global Health Engagement: Smart Power in Defense
Online courses, webinars, mobile apps, websites: www.realwarriors.net; www.t2health.dcoe.mil;
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Behavioral Health Content Organization
A: Psychological First Aid – Prevention and
Early Intervention
B: Military Mental Health Framework
C: CoSC
BH SMEE Building Blocks
Each section contains Chapters with multiple topics, for example:
Section I: Psychological First Aid
Chapter 1Introduction and Overview (Evidence-informed curriculum for non-providers)
Chapter 2 Preparing to Deliver Psychological First Aid
Chapter 3 Core Actions
- Topic 1 Contact and Engagement
- Topic 2 Safety and Comfort
- Topic 3 Stabilization
- Topic 4 Information Gathering: Current Needs and Concerns
- Topic 5 Practical Assistance
- Topic 6 Connection with Social Supports
- Topic 7 Information on Coping
- Topic 8 Linkage with Collaborative Services
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A: Psychological First Aid – Prevention and
Early Intervention
B: Military Mental Health Framework
C: CoSC
BH SMEE Building Blocks
Each building block contains sections, for example:
Military Mental Health Framework: Sections 1-4
(Two tracks for each section: clinical/non-clinical)
I. Intro to Basic Psychological Health/Substance Misuse Concepts
II. Behavioral Health Operational Readiness
III. Intro to Military Mental Health Policies and Procedures
IV. Behavioral Health Clinical Practice Guidelines
Behavioral Health Content Organization
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Behavioral Health
Subject Matter Expert Exchange
Suicide Prevention
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Disclaimer
The views expressed in this presentation are those of the presenter and do not reflect the official policy of the Department of Defense (DoD) or the U.S. Government.
The presenter has no relevant financial relationships to disclose.
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Agenda
Perspectives on Suicide in the United States (US)
Suicide in the US Department of Defense (DoD) Historical Importance Suicide Prevention Approach Service Specific Programs
Clinical Practice Guideline (CPG) CPG Development Processes and Evidence Considerations Identification of Individuals at Risk for Suicidal Behaviors
Risk and Protective Factors Warning Signs and Groups at High Risk Levels of Risk and Recommended Interventions
Recommended Treatments for Suicidal Behaviors
Resources and Tools for Suicide Prevention
Suicide Prevention Scenario
Feedback and Questions
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Suicide in the US Military
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US Common Beliefs about Suicide
Suicide ideation is perceived as cognitive error
Suicide is a preventable tragedy
Suicide deaths are unwelcome and can and should be prevented
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What are the prevalent beliefs about suicide in your culture?
How do these beliefs affect individuals’ or organizational behaviors?
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Suicide in the US DoD: History
Prior to 2005, US military service appeared to confer a “healthy warrior effect” on its Service members, who had lower rates of suicide than the US general population
Between 2005 and 2009, DoD’s suicide rates doubled
In 2008, suicide rates in DoD surpassed rates for age- and sex-matched cohorts from the US general population
Suicide rates in DoD peaked in 2009
DoD’s rates stabilized in 2012 and have not decreased since
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Suicide in the US DoD: Approach
Strategic: DoD Strategy for Suicide Prevention – serves as the “foundation and strategic point of reference for suicide prevention programs in the Department”
Research-Oriented: DoD Military Suicide Research Consortium – for research funding and oversight
Coordinated: Defense Suicide Prevention Office – for advocacy, policy, and oversight of suicide prevention programs
Monitored: DoD Suicide Event Report – for real-time, standardized surveillance data
Collaborative: Partnerships with Department of Veterans Affairs (VA) as well as many Non-Governmental Organizations
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Suicide in the US DoD: Programs
Air Force: Air Force Suicide Prevention Program Wingman culture
Interpersonal connection
Army: Ask, Care, Escort (ACE) & ENGAGE Resiliency
Strategic communications
Navy: Sailor Assistance, Intercept for Life (SAIL) Suicide screening tool
Regular follow-up
Marine Corps: Marine Intercept Program (MIP) Follow-up contact
Health care coordination
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What suicide prevention strategies
or programs are in place in your
community?
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VA/DoD Clinical Practice Guideline:
Assessment and Management of
Patients at Risk for Suicide
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VA/DoD CPG
VA/DoD CPG
Summary
Clinical Practice Guideline (CPG)
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CPG Development Process (1/2)
Systematic Review of Literature by senior subject matter experts in VA and DoD
Literature reviewed every five years and CPGs updated
Explicit, reproducible methods to develop recommendations
CPG Work Group Evidence Chaperone - ensures conformity to standards
Grade Quality of Studies - GRADE
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Strict approach to conflicts of interest
Multidisciplinary development teams
Identification of key questions
Evidence review for key questions
Groups review evidence, apply evidence grading
Development of recommendations and treatment algorithms
Review from trained external & internal subject matter experts
Final CPG reviewed and approved by VA/DoD Evidence-Based Practice Work Group
CPG is disseminated to the field
CPG Development Process (2/2)
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CPG Evidence Hierarchy
Recommendations are explicitly linked to the supporting evidenceand graded according to the strength of that evidence
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Example of Evidence Hierarchy - Therapy
Source: Council of Medical Specialty Societies (2011). Principles for the Development of Trustworthy Specialty Society Guidelines.
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Quality of the Evidence
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GRADE: Rating the Quality of Evidence
Source: GRADE Working Group, 2012. See, e.g.: Balshsem H, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol2011(64), 401-6.
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CPG: Summary
In 2013, the VA and DoD collaborated on the development of the CPG for Assessment and Management of Patients at Risk for Suicide
The CPG summarized the latest evidence-based findings on: Risk and protective factors
Warning signs
Psychotherapeutic treatments
Pharmacologic treatments
Discharge planning
The CPG is currently undergoing a revision, with suicide experts compiling and reviewing all available research results in order to update the CPG’s recommendations
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CPG: Identification of Individuals at Risk
for Suicidal Behaviors (1/5)
Chronic Risk Factors Acute Risk FactorsMental disorders Loss of employment
Medical conditions Loss of a relationship
History of a past suicide attempt Loss of housing
Financial difficulties Onset of psychiatric symptoms
Relationship difficulties Loss of status or rank
Legal problems Interpersonal assault
Adverse childhood experiences Suicide death of a relative or peer
Risk FactorsSome common risk factors for suicide-related thoughts and behaviors:
Protective FactorsSome common protective factors against suicide-related thoughts and behaviors:
Protective FactorsEmploymentResponsibilities to othersStrong interpersonal bondsResilienceSense of belonging and identityAccess to health careOptimistic outlook
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CPG: Identification of Individuals at Risk
for Suicidal Behaviors (2/5)
Warning SignsCommon warning signs of suicidal behavior (i.e., signals of intention to engage in suicidal behaviors):
Warning SignsTalking about wanting to die
Threatening to hurt or kill oneself
Planning or preparing for a suicide attempt (e.g., buying a gun)
Making financial and other arrangements for dependents
Social withdrawal
Substance abuse
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CPG: Identification of Individuals at Risk
for Suicidal Behaviors (3/5)
Groups at higher than average risk for suicide include those with histories of the following:
Previous suicide attempt(s)
Non-suicidal self-injury
Psychiatric diagnoses
Traumatic brain injuries
Military service (i.e., veterans)
In addition to the above groups, clinicians should consider the level of suicide risk for Service members who are or have:
Lesbian, gay, bisexual, and/or transgender (LGBT)1
Exposure to suicide2,3,4,5,6
Traumatic experiences during childhood7,8,9
Recently discharged from a hospital10,11
Other than honorable discharge from the military12
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CPG: Identification of Individuals at Risk
for Suicidal Behaviors (4/5)
The VA/DoD CPG defines the levels of risk as follows:
Level of Risk for Suicide General CharacterizationHigh Acute Risk Serious thoughts of suicide
Suicidal intent and/or plan
Warning signs
A recent suicide attempt
Symptoms of agitation, impulsivity, and/or psychosis
Acute precipitating events
Low levels of protective factors
Intermediate Acute Risk Suicidal thoughts and/or a plan
No suicidal intent or preparatory behavior
Generally able to control suicidal urges
Limited protective factors
Low Acute Risk Suicidal thoughts
No specific suicide plan or intent
No history of suicidal behavior
Some protective factors
Limited risk factors
Not at Elevated Risk No current suicidal thoughts, intent, or plan
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CPG: Identification of Individuals at Risk
for Suicidal Behaviors (5/5)
Recommended interventions in VA/DoD Suicide CPG are as follows:
Level of Risk for Suicide Recommended InterventionsHigh Acute Risk Immediate referral for a specialty evaluation
Direct observation by healthcare professional
Limit access to lethal means
Health care professional should remain with the individual until
he/she is safely escorted to an urgent/emergent care setting for
hospitalization
Intermediate Acute Risk Referral to a behavioral health professional for a comprehensive
evaluation
If necessary, consult a behavioral health professional to determine the
urgency of the evaluation
Limit access to lethal means
Low Acute Risk Consider for referral to a behavioral health professional
If necessary, consult a behavioral health professional to determine
appropriateness of referral
Address safety issues
Follow up with suicide risk reassessments
Not at Elevated Risk Routine care
Periodic suicide risk assessments
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Suicide-focused psychotherapies
Cognitive therapy for suicide prevention
Problem-solving therapy
Medications
Lithium for bipolar disorder
Antidepressants for mood disorder
During discharge planning - safety planning
*All interventions recommended in the 2013 VA/DoD CPG for Suicide
CPG: Recommended Interventions* for
Suicidal Behaviors
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Resources and Tools
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Family brochure
Warning signs for suicide
Treatment settings
Websites and phone numbers
Suicide Prevention Guide for Families
Resources and Tools for Suicide
Prevention – for Family Members
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Overcoming Suicidal Thoughts and Feelings
Patient brochure
Warning signs
Protective factors and coping strategies
Treatments and crisis numbers
Resources and Tools for Suicide
Prevention – for Patients
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Safety Plan Worksheet
Patient handout
Collaboratively completed by patient and provider
Used by patients when in crisis
Contains coping strategies to maintain safety
Resources and Tools for Suicide
Prevention – for Patients
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Resources and Tools for Suicide
Prevention – for Clinicians
Safety Plan Treatment Manual
Written by clinicians
Step-by-step instructions
Evidence based
Webinars available online
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VA/DoD Suicide CPG: Pocket Guide for Providers
12-page provider guide
Comprehensive summary of CPG
Assessment, risk levels, treatment
Flowcharts guiding assessment and management decisions
Resources and Tools for Suicide
Prevention – for Clinicians
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Pocket Guide for Clinicians
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Military Crisis Line For suicide prevention for all US Military Service Members
Option to link callers to US Veteran
Veterans Crisis Line For suicide prevention for all US Military Veterans
Option to link callers with US Veteran
DSTRESS Line For suicide prevention and other stressors for US Marines and their
family members
Links callers with Marine Veterans, family members, and specialists trained in Marine Corps culture
Be There Peer Support Line For non-urgent stressors and problems for all US Military Service
Members and Veterans
Links callers with peer specialists in areas of financial counseling, parenting support, transition assistance, substance abuse, etc.
Resources and Tools for Suicide
Prevention – 24/7 Crisis Lines
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Suicide Prevention Scenario
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[Please populate the next 7 slides with a culturally sensitive scenario. The current example is adapted from the US Suicide Prevention Training Scenarios PowerPoint.]
A 23 year old, active duty Specialist has been deployed to combat for eight months. He is going home on Rest & Relaxation and wants to surprise his family and girlfriend. In fact, he hopes to propose marriage to his girlfriend of four years. Upon arrival, he learns that his girlfriend is no longer interested in him. He is devastated.
You are a friend of this Service Member (SM).
You do not know:1. This SM is very depressed.2. This SM is abusing alcohol.3. He feels as though there is nothing else to live for.4. He has purchased a weapon.
During the conversation, this SM states, “While deployed to combat, thinking about her helped me to cope. I can’t see myself living without her.”
Suicide Prevention Training Scenario (1/4)
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STRATEGIC QUESTIONS:1. As a Commander establishing a suicide prevention program, to what degree do you
consider generational differences, such as “baby-boomers” versus “generation X”?
2. What more can we, as an organization, do to help support unmarried Service members?
3. The military recruits mostly from a pool of young, unskilled individuals who also tend to be socially unskilled. Are there ways we can accelerate the social maturity of such individuals, or do we have to wait for development to take its time? Does the military currently have any mechanism to increase the social skills and maturity of new Service members? If so, what are these mechanisms? What additional measures can the military take to increase the resilience and social maturity of these individuals?
4. How does a Commander promote help-seeking behaviors within his/her organization?
5. How does a Commander monitor his/her unit for possible suicidal intent?
Suicide Prevention Training Scenario (2/4)
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Suicide Prevention Training Scenario (3/4)
TACTICAL QUESTIONS:
1. Peers of Service members are the first line of defense in the military’s suicide prevention program. How do you prepare yourself for this role? What behaviors must you master in order to fulfill this role?
2. How much training in suicide prevention is enough? How much can realistically fit into your training schedule? How frequently should such training be given? How should new arrivals to your unit be included in this process? When can one stop training in suicide prevention?
3. Is suicide a medical or Command problem, or both? How can behavioral health specialists and unit Commanders best work together to reduce the frequency of suicidal behaviors?
4. As a unit commander, do you think someone who has been hospitalized for suicidal behaviors can ever be successfully reintegrated into the unit?
5. What kind(s) of training do you think is necessary to “harden up” Service members, make them more resilient, and make them less vulnerable to suicidal impulses?
UNCLASSIFIED Slide 51
OPERATIONAL QUESTIONS:
1. What risk factors are present to suggest that this individual may act impulsively to harm himself?
2. Since you do not know about these risk factors, how are you going to make a determination regarding this Service member’s needs?
3. Once your friend conveys possible suicidal ideation to you, do you have a moral, ethical, or legal obligation to him?
4. How does one know when the acute danger of suicide has passed?
Suicide Prevention Training Scenario (4/4)
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Feedback & Questions
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Web Links
Suicide-related handouts and toolshttps://www.pdhealth.mil/clinical-guidance/clinical-practice-guidelines-and-clinical-support-tools/suicide
VA/DoD CPG on Suicidehttps://www.healthquality.va.gov/guidelines/mh/srb/
Safety Planning Manual and Presentationhttps://www.mentalhealth.va.gov/docs/va_safety_planning_manual.pdf
http://www.dcoe.mil/files/2012SPC-Stanley-Brown-Holloway-Brenner-Safety_Planning.pdf
UNCLASSIFIED Slide 54
References (1/3)
1 Matarazzo, B. B., Barnes, S. M., Pease, J. L., Russell, L. M., Hanson, J. E., Soberay, K. A., & Gutierrez, P. M. (2014). Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: What does the literature tell us?. Suicide and Life-Threatening Behavior, 44(2), 200-217.
2 Hom, M. A., Stanley, I. H., Gutierrez, P. M., & Joiner, T. E. (2017). Exploring the association between exposure to suicide and suicide risk among military service members and veterans. Journal of Affective Disorders, 207, 327-335.
3 Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12-19.
4 Hom, M. A., Stanley, I. H., Gutierrez, P. M., & Joiner, T. E. (2017). Exploring the association between exposure to suicide and suicide risk among military service members and veterans. Journal of Affective Disorders, 207, 327-335.
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References (2/3)
5 Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12-19.
6 U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. 2012 National strategy for suicide prevention: Goals and objectives for action. Washington, DC: HHS, September 2012.
7 Blosnich, J. R., Dichter, M. E., Cerulli, C., Batten, S. V., & Bossarte, R. M. (2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry, 71(9), 1041-1048.
8 Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001) Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA, 286(24), 3089-3096.
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References (3/3)
9 Bryan, C. J., Griffith, J. E., Pace, B. T., Hinkson, K., Bryan, A. O., Clemans, T. A., & Imel, Z. E. (2015). Combat exposure and risk for suicidal thoughts and behaviors among military personnel and veterans: A systematic review and meta‐analysis. Suicide and Life-Threatening Behavior, 45(5), 633-649.
10 Kessler, R. C., Warner, C. H., Ivany, C., Petukhova, M. V., Rose, S., Bromet, E. J., ... & Fullerton, C. S. (2015). Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army Study to Assess Risk and Resilience in Service members (Army STARRS). JAMA Psychiatry, 72(1), 49-57.
11 Valenstein, M., Kim, H. M., Ganoczy, D., McCarthy, J. F., Zivin, K., Austin, K. L., ... & Olfson, M. (2009). Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts. Journal of Affective Disorders, 112(1), 50-58.
12 Reger, M. A., Smolenski, D. J., Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K., Bullman, T. A., ... & Gahm, G. A. (2015). Risk of suicide among US military service members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US military. JAMA Psychiatry, 72(6), 561-569.