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Key findings

It's about trust: VA study yields ideas on how to make suicide assessment more effective

Posted August 30, 2013
(Fall 2013 VA Research Currents; online ahead of print)

When a VA team interviewed 34 Iraq and Afghanistan Veterans about their experiences with suicide risk assessment in the military and at VA medical centers, the researchers got an earful.

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VA researchers conducted in-depth interviews with 34 Veterans to learn about their experiences with—and perceptions of—suicide risk assessments in VA and the military. (Photo: iStock)

VA researchers conducted in-depth interviews with 34 Veterans to learn about their experiences with—and perceptions of—suicide risk assessments in VA and the military. (Photo: iStock)

Some of the Veterans talked about the hassle of being asked the same types of questions repeatedly throughout the day by different clinical staff.

Some said they resented being asked personal questions by staff they didn't know, with whom they had no ongoing relationship. Others disliked how the clinician failed to make eye contact while conducting the assessment, and seemed more interested in checking off a box on the computer screen.

Regarding the process in the military, some respondents told of routinely denying suicidal thoughts—even when they felt suicidal—so as to not risk unwanted hospitalization, or other delays in returning home after their deployment.

These were just some of the themes—positive and negative—that emerged from the in-depth, open-ended interviews. The full results, and an analysis, are available online in the Journal of General Internal Medicine and will be presented in November at the annual meetings of the Academy of Psychosomatic Medicine and the American Public Health Association.

'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.'

The goal was to learn specifically about Veterans' experiences with brief structured assessments for suicidal thinking, which are administered routinely in VA primary care settings to those with indicators of depression or posttraumatic stress disorder. Suicide warning signs that surface during the initial assessment trigger more extensive clinical evaluation, with referrals to mental health care as appropriate.

"We wanted to explore these Veterans' perceptions of this process," says lead author Linda Ganzini, MD, MPH, of the Portland VA Medical Center and Oregon Health and Science University. "We wanted to learn about the factors that lead Veterans to disclose or not disclose suicidal thoughts, and what their perceptions are about the consequences of doing so."

The study was part of a larger VA-funded project headed by Steven Dobscha, MD, titled "Outcomes and Correlates of Suicidal Ideation in OEF/OIF Veterans." The research was based at the Portland, Indianapolis, and Houston VA medical centers.

VA adopted the assessment process to help stem the tide of Veteran suicides—22 per day, on average, according to a 2012 VA report. The report indicated that while the percentage of Veterans who die by suicide has gone down slightly since 1999, the estimated total number of Veteran suicide deaths per year has increased.

By all accounts, VA has taken some effective steps to help counter the trend—setting up a national crisis hotline, for example, hiring more mental health staff, and training all hospital staff to recognize suicide warning signs. VA also instituted the routine assessments of suicide risk for patients with depression or PTSD.

In their own words

Below are samples of the anonymous Veteran comments included in the study by Dr. Linda Ganzini's group on suicide screening and assessment:
  • They actually did all the standardized questions...for depression as well as suicide—they seemed to be pretty straight and cut and dry questions.
  • 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.
  • 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.
  • 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."'
  • It was too short, too simple. I had thoughts that I wanted to share and I did not get the opportunity to share them.
  • 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 about it…
  • It was actually a big weight off my shoulders ‘cause it was something that I don't really share very often, not even to my family, just because I didn't want to be a burden on them, so it was actually extremely helpful for me.
  • 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.

Dobscha and Ganzini's study is important because some research has suggested that routine risk assessments do not always do a good job of preventing suicide. For example:

  • A review of the medical records of 112 Veterans in Oregon who had committed suicide showed that of the 18 who had been assessed for suicidal thinking at their last health care visit, 13 denied such thoughts. (Psychiatric Services, Dec. 2010)
  • A report by Army doctors cited the "low predictive value" of suicide screens used in certain settings, and the "unwillingness of many Service members to truthfully report concerns, because of stigma and other reasons." (Journal of the American Medical Association, Aug. 15, 2012)
  • A VA study on 244 Veterans who had died by suicide found that most of those who had been assessed for suicidal thinking denied having such thoughts, even within a week prior to their death. (Journal of Clinical Psychiatry, March 2013)

The Veterans interviewed for Ganzini's study all had positive risk assessments for suicidal thinking in VA primary care clinics during 2009 or 2010. Some admitted to not having disclosed their suicidal thoughts during earlier assessments.

Based on the interviews, the researchers identified four themes they believe hold the key to improving assessment for suicide risk. Here are some of their recommendations in each area:

  • Relationship—The researchers advise that assessments be conducted, when possible, by the provider who has the "best and most long—term relationship with the patient and knows the patient's story." Repetitive assessments should be avoided.
  • Empathy/genuineness—Providers should acknowledge the difficulty, shame, emotional pain, and avoidance that many patients feel around this topic. Questions should be framed in a personal, not medical, context, and patients should be given time to clarify and express their thoughts.
  • Communication—Veterans prefer language that is direct, understandable, and free of jargon. The tone of the assessment should be conversational, not rote. Providers should maintain eye contact and not fill out forms while asking the questions.
  • Information—Providers should clearly explain the reasons for assessment, and what happens when an assessment is positive.

Ganzini says the study questions the effectiveness of suicide risk assessments that are implemented "in the context of routine medical screening or by triage personnel."

The main take-home message, she says, is that "candid discussion of suicidal thoughts is enhanced when the assessment is done by trusted providers who communicate genuine concern."

To read the full paper, including numerous anonymous comments from Veterans interviewed for the study, visit http://bit.ly/144OqBP.