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New Comprehensive VA/DoD Guideline Seeks to Stem Tide of Suicides

by Brenda Mooney

October 9, 2019

Servicemembers, Veterans Take Their Own Lives at Higher Rates

WASHINGTON—In recent decades, suicide rates have soared in the United States, increasing 25% from 1999 to 2016.

The issue has been especially acute among military servicemembers and veterans. During the same time period, the DoD’s active component suicide rate leapt from 10.7 to 21.5 suicide-related deaths per 100,000 servicemembers. Veterans, meanwhile, have a 21% higher suicide rate than age- and sex-matched civilian cohorts, resulting in a shocking average of 20 veterans taking their lives each day.

In an effort to curb the suicide epidemic, the VA and DoD approved this spring an update to the 2013 joint clinical practice guideline for assessing and managing patients who are at risk for suicide.

The new guideline was designed to provide federal healthcare providers a framework by which to screen for, evaluate, treat and manage the individual needs and preferences of VA and DoD patients who might be at risk for suicide, according to a synopsis published in Annals of Internal Medicine.1

The process began in January 2018, when the VA/DoD Evidence-Based Practice Work Group convened to develop a joint VA/DoD guideline. The panel drafted key questions, systematically searched and evaluated the literature through April 2018, created algorithms, and advanced 22 recommendations in accordance with the Grading of Recommendations Assessment, Development and Evaluation system.

Recommendations include three clinical practice algorithms addressing screening and evaluation, risk management and treatment and other management methods. In addition, the guideline panel formulated 22 evidence-based recommendations organized into three categories.

From: Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines
Algorithm A: Identification of risk for suicide. * Continue to Step 7 if screening results are negative but additional evidence (e.g., collateral) suggests the need for continued screening or evaluation. (Ann Intern Med. 2019;171(5):343-353. doi:10.7326/M19-0687 )

Risk Factors

Among the recommendations are assessing risk factors as part of a comprehensive evaluation of suicide risk, as well cognitive behavioral therapy–based interventions focused on suicide prevention for patients to reduce future incidents of self-directed violence in patients with a recent history of those actions.

On the other hand, despite widespread promotion of strategies for community-based intervention, evidence for the benefits of such interventions is lacking, according to the authors.

The advice includes risk management and treatment recommendations for both pharmacologic and nonpharmacologic approaches for patients with suicidal ideation and behavior. Other management methods address lethal means safety, such as restricting access to firearms, poisons and medications and installing barriers to prevent jumping from lethal heights.

The authors recommend screening for and evaluating suicide risk in the clinical setting. They caution, however, that, since an effective method has not been fully verified, a range of efforts, such as self-report measures and clinical interviews, are recommended.

In a systematic review published in the Annals of Internal Medicine, the panel found strong evidence that both cognitive behavioral therapy and dialectical behavior therapy reduce suicide risk compared with usual treatment. It also pointed out that Ketamine and lithium reduced the rate of suicide compared with placebo but decried the limited information on harms.2

Researchers from ECRI Institute reviewed and synthesized evidence from eight reviews and 15 randomized controlled trials of nonpharmacologic and pharmacologic interventions intended to prevent suicide in those at risk.

Nonpharmacologic treatments included psychological interventions, such as cognitive behavioral therapy or talk therapy and dialectical behavioral therapy, which combines elements of CBT, skills training and mindfulness techniques which seek to help borderline personality disorder patients develop skills in emotion regulation, interpersonal effectiveness and distress tolerance.

Moderate-strength evidence was found to support the use of face-to-face or internet-delivered CBT in reducing suicide attempts, suicidal ideation and hopelessness compared with usual care. At the same time, low-strength evidence suggested that DBT could help reduce suicidal ideation.

Pharmacologic treatments included in the study were ketamine and lithium. Moderate-strength evidence was found to support use of short-term intravenous ketamine for reducing suicidal ideation and for the use of lithium, alone or in combination with another psychotropic agent, for reducing suicide. Clozapine may be used for patients with a previous suicide attempt, according to the guidance.

“Given the need for interventions to mitigate risk for suicide, particularly in the veteran and active military populations, the lack of evidence to support current nonpharmacologic and pharmacologic interventions and the lack of information on potential harms is significant,” the authors wrote. “We found modest benefit of CBT and DBT in reducing suicidal ideation compared with [treatment-as-usual] or wait-list control and CBT also reduced suicide attempts compared with TAU. Both ketamine and lithium had modest benefit in reducing the rate of suicide compared with placebo.”

In an accompanying editorial, Michael Hogan PhD, of Case Western Reserve School of Medicine in Cleveland pointed out that the guideline update the VA’s 2013 recommendations, and ”strengthen what was already the strongest clinical guidance regarding suicide, and has the potential to improve the quality of care for at-risk patients. However, these recommendations are unlikely to dramatically reduce the burden of veteran suicide.”3

“Why is this the case? What else must be done to address this intolerable loss of life among those who have served their country? The great majority of veterans are not eligible for VA healthcare or do not use it; therefore, more than two-thirds of the veterans who die by suicide were not receiving care within the VA system. Thus, reducing veteran suicide depends largely on actions to improve suicide care outside the VA,” the researcher said.

Hogan’s commentary emphasized that the suicide rate has decreased among veterans who use VA services “possibly because of the 2013 guideline and the addition of suicide prevention specialists at all VA medical centers.”

The differences in suicide rates between veterans who do and those who do not use VA services are significant. The report pointed out that an 8% increase in suicides was observed among VA health services vs. 35.5% among those who did not.

It also noted that rates among female veterans who do not use VA services have increased by 81.6% but that rates among female veterans who do use VHA services decreased by 2.6%.

 

1.   Sall J, Brenner L, Bell AMM, Colston MJ. Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med. 2019 Aug 27. doi: 10.7326/M19-0687. [Epub ahead of print] PubMed PMID: 31450237.2.    D’Anci KE, Uhl S, Giradi G, Martin C. Treatments for the Prevention andManagement of Suicide: A Systematic Review. Ann Intern Med. 2019 Aug 27. doi:10.7326/M19-0869. [Epub ahead of print] PubMed PMID: 31450239.  3. Caine ED. Seeking to Prevent Suicide at the Edge of the Ledge. Ann Intern Med. 2019 Aug 27. doi: 10.7326/M19-2347. [Epub ahead of print] PubMed PMID: 31450242.



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