By Brenda L. Mooney
ROCHESTER, MN — With sweeping new initiatives from the White House and elsewhere in response to the burgeoning military suicide rate, little guidance has been offered to the clinicians in the trenches who are best positioned to recognize and prevent such drastic actions.
To remedy that, two new articles recently published in prestigious medical journals offer practical advice to front-line physicians and other healthcare workers to identify and help patients at risk for suicide.
One article is by Timothy Lineberry, MD, a Mayo Clinic psychiatrist who has consulted with the Army on the suicide epidemic. Writing in a recent edition of the Mayo Clinic Proceedings, Lineberry and his co-author, Stephen S. O’Connor, PhD, offer specific steps to assess and address military suicide — including greater use of gun locks, improving primary care for depression and better monitoring for sleep disturbances.1
“Despite the anticipated end of large-scale military operations in Afghanistan and Iraq, the effects on the mental health of active-duty servicemembers, reservists and veterans is only just beginning to be felt,” Lineberry points out. “Moreover, the potential effect on servicemembers of their war experiences may manifest indefinitely into the future in the form of emerging psychiatric illnesses.”
In the article, Lineberry and O’Connor use published research on the etiology of suicide to recommend practical responses by clinicians. Here are the four steps they suggest:
- Ask all veterans with psychiatric illness about their access to firearms and encouraging them to lock up guns, give someone else the key, or remove them from the home altogether. With nearly 70% of veterans who commit suicide using a gun to do it, slowing down gun access by a few minutes might be enough to stop the impulse, they suggest.
- Identify and treat sleep disturbances in patients. Those problems in otherwise healthy active-duty servicemembers, reservists or veterans might signal the need for taking a detailed history and screening for depression, substance misuse and post-traumatic stress disorder. Sleep disturbances have been identified as a risk factor for suicide, Lineberry notes.
- Prescribe opioid medications carefully and monitor them diligently. Lineberry emphasizes that unintentional overdose deaths from opioids outnumber traffic fatalities in many states, and patients with psychiatric illness are over-represented both among those receiving prescriptions for opioids and those overdosing. He cites a recent study that found Iraq and Afghanistan veterans with a diagnosis of post-traumatic stress disorder who were prescribed opioids were significantly more likely to have opioid-related accidents and overdoses, alcohol and non-opioid drug-related accidents and overdoses, as well as self-inflicted and violence-related injuries.
- Improve primary-care treatment for depression. Patients who die by suicide are more likely to have visited a primary-care physician than mental-health specialist in the previous month, according to recent research. Lineberry says programs developed to improve primary-care physicians’ recognition and treatment of depression could help lower suicide rates.
Another article, written by three psychiatrists from the Uniformed Services University School of Medicine, Bethesda, MD, calls for implementation of “trauma-informed care” to stem the high suicide rate among military personnel and other young men and to appropriately treat other emotional damage triggered by traumatic events.Front-Line Clinicians Get Practical Advice To Help Combat Military Suicides
In a recent article in the Annals of Internal Medicine, Robert J. Ursano, MD; David M. Benedek, MD; and Charles C. Engel, MD, MPH, from USU’s Department of Psychiatry, define “trauma-informed care” as “recognizing and planning for detecting and treating the disorders that result after traumatic events.”
They point out that post-traumatic stress disorder (PTSD) not only affects military servicemembers who experienced the rigors of war but potentially anyone who survives natural disasters or man-made maladies such as sexual assault, domestic violence, gang shootings and accidents.
Yet, assessment for PTSD and other trauma-related disorders is not a standard of care in emergency departments or other outpatient settings where patients receive initial care.
Changing that policy, according to the article, “will benefit not only military personnel but all patients. Post-traumatic stress disorder and depression are perhaps the most common disorders related to traumatic events. We have good treatments for both and should identify patients in need of these interventions.”
The article points out that PTSD is not a problem only for servicemembers returning from the Iraq and Afghanistan wars. It can occur with other natural and man-made disasters or even from routine events. They cite statistics that 10 million motor-vehicle crashes result in more than 35 000 deaths each year in the United States.
“If we told our hospitals that 34% of everyone in the intensive care unit had a staphylococcal infection, they would immediately institute screening, treatment and observation,” the authors suggest. “Yet, we know that approximately that rate of post-traumatic stress disorder … occurs in patients presenting to hospital trauma units after serious motor vehicle accidents.”
In fact, the article maintains that, “There are abundant data that everyone is at risk for PTSD, given a sufficiently traumatic event,” adding, “Many, if not most, people have nightmares, avoidance, numbing, negative thoughts and arousal after common trauma. Most also recover over a few months.”
PTSD is described in the article as something that can resolve itself or develop into an acute disorder. “PTSD, similar to other diseases in medicine, can be like a common cold that resolves without treatment or can progress to pneumonia with severe morbidity,” the authors write. “Too often, we and the public speak of all psychiatric illnesses as if they were cancer. But psychiatric illness, like most medical illnesses, may be in the form of a bruise or a broken bone — not always cancer.”
The article also discusses the relationship between PTSD and the increased rates of suicide among military personnel, especially in the Army.
Althouh the military rate has recently become higher, suicide remains a leading cause of death among youth and working-age U.S. men, not only servicemembers, with suicide resulting in almost as many deaths as vehicular accidents, according to the article.
Noting that suicidal ideation is predicted by depression, the authors recommend that primary-care physicians assess for depression as well as PTSD.
“Two questions during patient assessment in a variety of settings can help to determine the need to assess for PTSD or suicidality: ‘Have you ever been in a setting where your life was in danger?’ and ‘Have you had any thoughts of wanting to hurt yourself (or someone else)?’ The first question, which asks about life-threat exposure, is equivalent to an exposure to a “toxin.” And an affirmative answer should lead to further assessment. Similarly, thoughts of wishing to hurt one’s self are of serious concern,” according to the article.
The role of primary care providers also was raised in a new Institute of Medicine report, “Substance Use Disorders in the U.S. Armed Forces.” That report noted that about 20% of active duty personnel reported having engaged in heavy drinking in 2008 and binge drinking increased from 35% in 1998 to 47% in 2008. It also noted that, while rates of both illicit and prescription drug abuse are low, the rate of medication misuse is rising.
“The IOM asserts that the highest levels of military leadership must acknowledge these alarming facts and combat them using an arsenal of public health strategies, including proactively attacking substance use problems before they begin by limiting access to certain medications and alcohol,” according to the DoD-sponsored report brief. “Additional structural changes involve prescribers, who should routinely check local prescription drug monitoring programs before dispensing medications with high abuse potential. Health care professionals also should be trained to recognize worrisome patterns of prescription drug use and medication-seeking behaviors and should be given clear guidelines for referral to specialty providers.”
Back to October Articles
- Lineberry TW, O’Connor SS. Suicide in the US Army. Mayo Clin Proc. 2012
Sep;87(9):871-8. PubMed PMID: 22958991.
- Ursano RJ, Benedek DM, Engel CC. Trauma Informed Care for Primary Care: The Lessons of War. Ann Intern Med. 2012 Sep 11. doi: 10.7326/0003-4819-157-11-201212040-00542. [Epub ahead of print] PubMed PMID: 22964876.
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