Archive for February, 2016

Military Still Falls Short Treating War-Related Stress

Despite some improvements, service members remain at elevated risk of dying by suicide

A new study released February 18 shows that the U.S. military is struggling to provide adequate care for active-duty troops suffering from post-traumatic stress disorder and clinical depression.

Conducted by RAND Corp., this study surveyed 40,000 cases, making it the largest ever of its kind. The results are chilling: Only a third of soldiers with PTSD and less than one in four soldiers with clinical depression receive even the minimum number of therapy sessions after their diagnosis.

Military man visiting psychologist

According to military officials, the culprit is a lack of personnel. Commenting on the study, Brad Carson, the acting principal deputy undersecretary of defense for personnel and readiness, said, “We just don’t have enough mental health professionals to meet the demand.”

In addition, many service members are unaware of the mental health services available to them – or unwilling to seek help because of the persistent stigma associated with mental health. While the Department of Defense is working to reduce this stigma, a separate study also conducted by RAND Corp. found that some of their efforts may not be as effective as they could be. In particular, some of those stigma-reducing programs do not target service members who are already seeking mental health treatment.

Military treatment in vulnerable periods above national average

The study did find that the military is taking positive steps to treat at-risk service members during one of their most vulnerable times: immediately after discharging from inpatient facilities. During the first year after being released from hospital care, soldiers die by suicide at a rate of 264 per 100,000, more than 20 times above the national average.

According to the study, 86 percent of those with PTSD or depression were seen by a mental health specialist within seven days after discharging from a hospital, and that figure increased to 95 percent within the first 30 days. In this particular area, the military medical system is well ahead of the civilian system.

In part, the military’s success in this field is owed to a 2014 internal Army medical command memorandum, cited by the RAND Corp. study, that stated soldiers need to be seen within 72 hours of discharging from a hospital. Commanders were instructed to require soldiers to attend a make-up session if one is missed. Moreover, the memorandum established a policy of not discharging soldiers during weekends and holidays to avoid issues with losing track of follow-up care.

Even with more mental health professionals, the standard of care remains low

Another seemingly positive element is that the military has increased its staff of mental health professionals by 42 percent over the last seven years – 9,295 today compared to 6,546 in 2009.

However, increasing the number of staff has not necessarily improved the level of care. Many of the new mental health professionals lack experience; meanwhile, many experienced professionals have been forced into early retirement.

Suicide prevention attorney Skip Simpson, a 20-year military veteran, knows that many mental health professionals lack the necessary training to help people at risk of dying by suicide. This influx of inexperienced professionals means that the military medical system is even less likely to be able to recognize the warning signs of suicide and effectively intervene, leaving military personnel at elevated risk.

The study results show that, while the military is taking fairly effective steps to help soldiers when they are most imminently vulnerable to suicide, it is still struggling to provide the sort of early intervention and care that can prevent deaths from suicide in the long run.

Veterans and Inpatient Suicide Risks

As the San Diego Tribune recently reported, suicide rates are high among veterans who have served in combat since the attacks on 9/11/01. Unfortunately, research into veteran suicides reveals that both the VA and civilian health institutions are not doing enough to help when veterans appear to be giving up on treatment or experiencing despair. In some cases, veterans in inpatient care are not even being provided with the minimum level of assistance they need. a-morning-at-the-hospital-1-1440095

When someone is in a VA hospital or other treatment facility and there is a risk of death by suicide, steps need to be taken to ensure the person is properly monitored and an effective treatment plan is in place. When this does not happen and inpatient suicide occurs, the family members of the victim need to hold the institution and mental health professionals working at the institution accountable for their failures. This is especially true in situations where professionals who work with veterans regularly should be aware of signs of suicidal ideation and should ensure the proper healthcare is provided for patients who are receiving inpatient psychiatric care.

Veterans at Risk of Inpatient Suicide

According to the San Diego Tribune, one case which has spurred the VA to try to make some changes involved a 37-year-old Air Force Veteran who died by suicide at a local hospital within days of being released from a lockdown psychiatric hold. He had been released from lockdown even though he clearly was not yet ready for release, as he was still experiencing suicidal ideation. He was admitted to a drug rehabilitation program at the same hospital with the belief he would get further help in the rehab program. Unfortunately, he hanged himself in his room.

Following this veteran’s death, the hospital decided to formalize the process of handoffs among inpatient units so staff members in different units would document that they had reviewed the patient’s case together and were aware of the risks. This is certainly a positive change: If veterans are to be released from one inpatient program to a different one when still at risk of suicide, extra precautions will need to be taken by new care providers to be watchful for continuing signs of suicidal ideation.

Unfortunately, changing the process of handoffs may not be enough to stop the epidemic of veteran suicides. Paul Rieckhoff, the executive director of Iraq and Afghanistan Veterans of America believes the government is downplaying the severity of the suicide crisis, which is a major public health issue more resources are needed to address. He compared the failures to provide appropriate care to suicidal veterans to the lack of response in the early days of the AIDS crisis.

The government has a responsibility to veterans, and the VA in particular has an obligation to make sure veterans are getting the care they need. Most importantly, facilities treating veterans must take seriously their duties to monitor and protect those who served, especially as suicide rates remain high.

Protecting Your Patients and Yourself

Zero Suicide represents a commitment to identify, protect, and treat people who are at risk of suicide. Central to this commitment is the ability to record and properly share accurate information about a patient’s history and treatment. Without this information, each clinician that treats a patient must start from scratch — an inefficiency that will frustrate health care providers and patients, as well as affect the quality of care. Careful documentation also allows us to understand how health care systems can be improved and patient care made more effective.

The documentation essential to Zero Suicide has another benefit. It can protect clinicians and institutions from malpractice suits. Suicide is the most common cause of legal action against mental health care professionals. The central issues in most suicide malpractice cases are whether the clinician should have anticipated the risk of suicide and whether he or she provided care appropriate to this risk. Showing that a clinician met the standard of care appropriate for suicide risk can stop a malpractice suit in its tracks. Patient care should be documented in real time. Juries may suspect that medical records created after the fact rather than during treatment are inaccurate or self-serving.

Assessments of suicide risk should be carefully documented. It is a fundamental principle of good practice that risk assessment is more than simply using a screening instrument—clinical observation and judgment are also essential. These observations should be documented in the patient’s medical record. Patient responses to questions about suicide and self-harm should be recorded in their own words, and quotation marks used to clearly distinguish which statements represent clinical judgments and which are verbatim reports of what a patient said.

Embarrassment and anxiety can make patients reluctant to admit they are thinking about suicide. They may want to protect family secrets about substance abuse, mental health disorders, sexual abuse, or family violence. They may be in denial or afraid of being institutionalized or feel that no one can help. Involving family members can be crucial to accurately assessing a patient’s risk and making care decisions. Family members can provide information that the patient can’t—or won’t—and this information should be carefully recorded. It should also be noted if family members cannot be reached or are uncooperative. If a suicide results in a malpractice suit, it is the family that will sue. Accurate information about the family’s involvement—or lack of involvement—in patient care can be critical to the outcome.

The clinician should also document the decisions made while developing a patient care plan, how this care plan was implemented, and the criteria used to decide the steps needed to preserve the patient’s safety (such as whether the patient admitted to actively planning his or her suicide and whether the patient has access to firearms).

It is also important for the clinician to document his or her review of medical records and consultations with other service providers. If medical records or prior providers are not available, all attempts to obtain records and reach providers should be documented.

Focusing on the possibility of malpractice lawsuits turns the clinician’s attention away from the patient to him- or herself. Thoroughly and accurately documenting the assessment and care of patients who may be at risk of suicide will help deter malpractice lawsuits as well as contribute to quality care, patient safety, and the ability of clinicians and the health care system to work toward the goal of zero suicides.

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