Caring Letters for Military Suicide Prevention

The caring letters concept is a suicide intervention that involves the routine sending of the brief expressions of care to high-risk patients following hospitalization or emergency department treatment. Caring letters is one of the only interventions that has been shown to reduce suicide mortality rates in a randomized controlled trial. Additional studies using various modalities including email, SMS texting, postcards, and phone contacts have further supported the caring letters concept in preventing suicide behaviors. Given the high level of suicide risk among posthospitalized psychiatric patients and the rise in suicide rates within the US military over the past decade, it is important to implement empirically supported interventions. This chapter describes the caring letters intervention and a test of the intervention at US military and veterans hospitals. The theoretical basis for the intervention, as well as practical procedures and recommendations for implementing caring contact programs, are discussed.

Person-Centered Suicide Prevention in Primary Care Settings

The increase in the availability of mental health services in primary care settings in large health systems is a positive development for suicide prevention, but challenges remain. Unhelpful power asymmetries in the patient–primary care physician (PCP) relationship, supply-side economic factors, and the disease-centered (biomedical) model make it difficult for PCPs to elicit patient priorities. Thus many of the drivers of suicide risk are marginalized if not ignored in the patient–PCP encounter. Drawing from self-determination theory and systems theory, this chapter offers a person-centered vision of suicide prevention in primary care. It calls for policy initiatives to that accommodate PCPs’ needs for self-determination and outfit primary care settings with the technological and human resources needed to improve the way PCPs and patients communicate about difficult issues. These initiatives are expected to mitigate suicide risk and improve other patient outcomes as well as PCP job satisfaction.

Understanding Traumatic Brain Injury and Suicide Through the Lens of Executive Dysfunction

The care and study of patients with traumatic brain injury (TBI) and suicidal ideation/behavior presents unique challenges to both clinicians and researchers. In this chapter, background information regarding TBI (i.e., definition, severity classifications, epidemiology, assessment, and common postinjury sequelae/psychiatric disorders) are presented to provide context for a discussion of the complicated relationships between brain injury and suicidal thoughts and behaviors. The potential contribution of executive dysfunction (e.g., impairment in reasoning and/or decision-making) is reviewed. In addition, the idea that propensity toward or against engaging in risky behavior can be used to increase understanding regarding the relationship between TBI and suicidal ideation and behaviors is discussed. Last, clinical challenges and future research directions are presented.

The Collaborative Assessment and Management of Suicidality with Suicidal Service Members

This chapter provides an overview of an evidence-based, suicide-specific, clinical approach called the Collaborative Assessment and Management of Suicidality (CAMS). CAMS has a robust evidence base from nonrandomized and randomized clinical trial research. CAMS is designed to form a strong therapeutic alliance and to increase patient motivation to be engaged in their own suicide-specific care. The Suicide Status Form is a multipurpose clinical assessment, treatment-planning, tracking, and outcome tool that provides the essential CAMS roadmap for engaging a suicidal patient in successful treatment. This chapter features the case example of “Jon,” a multiply-deployed suicidal US Army sergeant, to illustrate how CAMS can be used as both a philosophy suicide-specific care tool as well as a flexible clinical framework for engaging and effectively treating suicidal service members in military treatment facilities.

Ethical Issues in the Treatment of Suicidal Military Personnel and Veterans

This chapter reviews the key ethical issues involved in treating active duty military personnel and military veterans who present with suicidal ideation. The primary issue is striving to help while minimizing harm. Central ethical issues involve competence in suicide risk assessment and intervention, confidentiality, and multiple role situations. All of these play out differently from civilian situations because of contextual demands associated with military settings and rules governing patients and providers in the military context. Critical strategies for addressing these issues include using appropriate consent processes and understanding how best to respect the needs of the patient within the constraints of the military context.

Suicide Risk Assessment with Combat Veterans—Part II

The evidence for combat experience per se as a risk factor for suicide is reviewed in this chapter. The chapter discusses assessing the risk of suicide with combat veterans with a particular emphasis on suicide risk factors associated with combat-related PTSD. A controversy about whether combat-related PTSD actually is a risk factor for suicide is reviewed. In conducting a risk assessment with veterans, clinicians are encouraged to be sensitive to issues of particular relevance to veterans who have experienced combat. Finally, the chapter offers suggestions for the management of suicide risk, including comments on when and how suicidal patients can be managed on an outpatient basis and when an emergency intervention might be needed.

Combat-Related Killing and the Interpersonal-Psychological Theory of Suicide

Suicide rates among veterans and military service members have reached unprecedented levels. This underscores the critical need to understand risk factors for suicide in these populations. Combat-related killing is reported by a substantial number of military personnel and veterans and is associated with negative psychiatric and functional outcomes. Killing has been identified as a potentially important and understudied risk factor for suicide in military personnel and veterans. This chapter proposes the interpersonal-psychological theory of suicide (IPTS; Joiner, 2005) as a theoretical model for understanding the relationship between combat-related killing and suicide. The IPTS proposes that thwarted belongingness and perceived burdensomeness cause suicidal desire, whereas prior experiences with pain, provocation, and death result in habituation to the fear and pain associated with suicide, thus influencing one’s capability for suicide. The chapter concludes with a discussion of clinical implications and recommendations for future research.

Introduction to Military Suicide

This chapter examines suicide within the United States military as a whole. A cultural and historical perspective is used to understand the context of current policies regarding the assessment and treatment of mental health conditions of those within the military. Suicide base rates as well as service utilization within the armed forces are discussed and recommendations regarding current practices are presentenced. Currently, perceived stigmas, traumatic exposure, multiple deployments as well as other barriers to care are thought to have contributed to the overall increase in suicide behaviors within the US military. Although policies are currently in place which help reduce stigma and bolster mental health service utilization, suicide continues to be an issue within the military as a whole.

Evidence-Based Treatments for PTSD

Because suicide risk appears to be heightened with individuals who have posttraumatic stress disorder (PTSD), it is crucial that PTSD treatment providers assess for suicidal ideation and that, when mental health clinicians are working with a suicidal patient, they assess for PTSD. Evidence-based treatments for PTSD can significantly help those experiencing both PTSD and suicidality. Although co-occurring suicidality does not prohibit proceeding with these treatments, it does involve additional considerations in delivery of care. Good PTSD assessment involves both diagnostic interviewing and ongoing assessment via administration of self-report measures. A written safety plan should also be developed, actively engaging veterans and minimizing barriers to treatment. Once the decision is made to proceed with PTSD care, all treatments are implemented as usual with ongoing monitoring of suicidal ideation. Strong therapeutic rapport is a critical part of all evidence-based treatments for PTSD, as well as for effective response to suicide risk.

Driving Themselves to Death

Suicide by means of a motor vehicle is more common than is generally realized. Vehicular suicide accounts for approximately 1% of all completed suicides in the United States. Vehicle-related suicidal ideation is common among both psychiatric patients and veterans. This chapter examines the phenomenon of vehicular suicide and its relationship to postdeployment adjustment. The chapter proposes that various war zone experiences may increase the risk of postdeployment risky driving. It also provides recommendations regarding both assessment and treatment based on the idea that clinical awareness of combat veterans’ propensity for risky driving and vehicle-related suicidal ideation is an essential element of veteran suicide prevention.