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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.

Hospital Records Can be Invaluable Evidence After Inpatient Suicide

Mental health facilities have obligations to psychiatric patients to keep them safe, particularly when patients are on suicide watch and there is a risk of death by suicide.  One of the duties in most facilities is simply to monitor patients who are at great risk to ensure they do not try to self-harm.  If a hospital has failed in any of its obligations to patients and inpatient suicide occurs as a result of this failure, it is possible to take legal action against the facility. documents-1427202

Hospitals can be held responsible for negligence in policies which lead to patients dying by suicide. If staff members fail to fulfill the obligations imposed upon them by their jobs, mental health facilities can also be held accountable due to these on-duty errors or the negligence of staff members in fulfilling work tasks.

Hospital records and other internal evidence from mental health facilities can prove invaluable in determining if the facility has lived up to its obligations or not.  An experienced inpatient suicide lawyer can assist family members of patients who died by suicide in obtaining necessary records to help prove negligence.

Video Surveillance Footage Helps to Show Staff Failure in Mental Health Facility

Naples News reported on one tragic case which illustrates how information a hospital collects can be used to help prove negligence after inpatient suicide occurs.  The case involved the suicide of a 51-year-old man who was in a psychiatric inpatient hospital. The man had been admitted because of feelings of paranoia, hopelessness, and depression. His admissions paperwork indicated he had been having suicidal thoughts.

During the time he was in the 103-bed facility, the 51-year-old man was quiet and didn’t participate in any activities or therapy sessions. Two days prior to his death, he asked to talk to a social worker and requested forms for a living will. The social worker didn’t ask the reason for this request, and did not report the request to anyone.   The patient’s doctor indicates he would have put the patient on immediate suicide watch if he had been aware a request for a living will was made.

Even though the patient was not on suicide watch, he was still supposed to be checked on every 15-minutes.  Unfortunately, though written paperwork indicated these checks had happened, surveillance footage from the hospital shows there were two checks missed in a row. Neither a 9:15 and a 9:30 check happened. By 9:45, when the 51-year-old patient was finally checked on, the patient had gone into the bathroom and hanged himself with a tied-up hospital gown.

There were numerous situations in this case where the hospital facility dropped the ball, from the social worker not reporting the living will to the 15-minute checks not being made. The surveillance evidence and the patient records including the living will help to show how the hospital facility fell short of its obligations.  A suicide lawyer can help family members to obtain this type of evidence to prove a mental health facility should be held accountable for lapses.

 

Inpatient Suicides Considered Most Preventable and Avoidable

Approximately six percent of deaths by suicide in the United States occur when patients are under care in a psychiatric hospital, a mental health facility, or a mental health unit of a hospital.  According to Psychiatric Times: “Inpatient suicides are viewed as the most avoidable and preventable because they occur in close proximity to staff.”

Wheelchair

Understanding when and how these suicides occur is key to successful prevention of death by suicide. When psychiatric health professionals fail in effective monitoring and prevention, the facility where the patient was receiving treatment may be held accountable.

Understanding Death by Suicide in an Inpatient Setting

Psychiatric nurses in an inpatient facility generally experience a completed suicide every 2.5 years on average, although these suicides are widely considered the most preventable due to staff-member control of the environment and due to the greater control exercised over inpatients versus outpatients.  Why? See the end of this blog.

The greatest danger to patients of death by suicide occurs in unsupervised areas, and patients are most at risk at night or during hand-offs when one staff member leaves a shift and care transfers to another healthcare worker.  However, patients may die by suicide at any time when staff members fail to fulfill obligations to keep them safe.

The majority of deaths by suicide in psychiatric hospitals occur because of hanging, and 75 percent of the deaths occur in closets, bedrooms, or bathrooms of patient rooms—those hidden areas all nurses and hospital techs know about.  While suicide watch protocols are aimed at preventing these fatalities, they are failing. Why? The observation period is too long.  It takes approximately two minutes of hanging to have irreversible brain damage and five to six more minutes to die—either on the unit or on a respirator a few days later in another hospital where the patient has been transferred due to the emergency.   When the suicide watch protocol involves checking on the patient every 15 minutes (the time interval often selected), this allows sufficient time for the patient to successfully complete a suicide. More frequent monitoring of patients at risk for suicide is called for-usually one to one (where a staff member is within arm’s length) or line of sight monitoring.   In one study of patients who died by suicide in an inpatient facility, 51 percent of patients were being monitored on a 15-minute suicide observation protocol.

Inpatient facilities can also eliminate threats to patients by reducing patient access to tools and conditions which could facilitate death by suicide. For example, grab bars in showers and plumbing fixtures can be used by patients in an attempt to die by suicide.  Adding plates to grab bars and putting safeguards around plumbing fixtures, like stainless steel boxes, can help to eliminate environmental risks.

Staff members must also be able to recognize when patients are at the greatest danger of death by suicide.  Studies suggest in 60 percent of suicides among inpatients, the patient’s level of risk was not adequately determined by psychiatric professionals or the appropriate precautions were not taken based on the risk level identified.  Professional psychiatric staff must be accurate in diagnosing the level of suicide risk posed by each patient in an inpatient facility, and appropriate protocols must be followed to protect patients from harm based on their specific risk levels.

Skip Simpson says: “In a nut shell hospitals must stop providing suicidal patients with the means, time and opportunity to kill themselves. Patient safety is not the goal for these hospitals; it is profits. Simple patient safety rules will stop the suicides if greed is put to the side.”

Back to School Season Means Students at Greater Risk of Death By Suicide

A new school year is starting and kids will soon be heading back to college campuses nationwide. For many of these students, the new school year is not something to look forward to this fall. Instead, returning to college mean means a return to the tremendous pressures to be perfect in a competitive college setting. High expectations and intense stress to succeed often contribute to high rates of campus depression and suicidal thoughts among young people. new-college-lane-1495710

New York Times reported the rate of death by suicide among 15 to 24 year olds has steadily increased since 2007. And college students may be among the most vulnerable segment of society. A recent survey of college counseling centers found that more than half of clients seeking counseling have “severe psychological problems.” College students, who may have limited parental supervision and distant support networks while away at school, face an especially significant risk. College counselors may be the only ones who can determine when a student is considering death by suicide and the only ones available to take action to help the student. That’s why counselors and academic institutions may be held accountable when these warning signs are missed.

Warning signs are missed by clinicians because of lack of training on taking a systematic suicide assessment.  With training a clinician has no excuse for deciding not to take the time to properly assess and document the assessment.  If the student is at risk for suicide then appropriate interventions need to be taken to protect the patient.

College Students and Risks of Death by Suicide

In 2007, there were 9.6 deaths by suicide per 100,000 individuals age 15 to 24. In 2013, that figure had risen to 11.1 suicides per 100,000 individuals within the same demographic group. Among college students seeking counseling, chances a student would be diagnosed with a severe mental condition increased 13 percent over a period of just two years. Anxiety and depression are the two most common mental health diagnoses among college students.

Female students may be especially at risk of suffering from anxiety and depression because reports have shown many feel a pressure to be effortlessly and relentlessly perfect. This means not only excelling academically and in social endeavors, but also putting forth a persona of being happy and self-assured all the time.

Women afraid to fail may hide mental issues they are facing until it is too late for friends and family to help them. College counselors need to be trained to identify when a student is masking deep-seated depression or anxiety so they can provide the mental health assistance students need when coping with the very real pressures they face.

The Times notes there has been several high profile suicides among both college and high school students in recent years attributed to the culture of high expectations and overachievement. In just 13-months, six students from University of Pennsylvania died by suicide. Tulane University lost four students to death by suicide in a single academic year, and there were three deaths by suicide at Appalachian State. From 2009 to 2010, there were also six students at Cornell University who died by suicide. Most of these students appeared to have everything going for them, and were active in campus groups. However, many were likely responding to pressures to act self-assured and mask doubts they had about their futures.

As college students head back to campus this year, schools need to be aware of the toll of the pressure to be perfect can have on students. That’s why colleges and universities need to make sure students receive the support they need to deal with mental health issues before it’s too late.

A suicide attorney at the Law Offices of Skip Simpson can help. Call (214) 618-8222 or visit http://www.skipsimpson.com to schedule a free case consultation.

A Closer Look at National Suicide Prevention Week

More than one million people attempted suicide in the United States in 2013, with total of 41,149 fatal outcomes reported. As the 10th ranking cause of death in the United States, statistics reveal that an average of 113 people died by suicide every day – or roughly one person every 12.8 minutes.

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Sponsored by the American Association of Suicidology, the 41st annual National Suicide Prevention Week is underway from September 7-13, 2015 and aims to bring a simple message to schools, colleges, hospitals, mental health centers and treatment facilities nationwide: suicide prevention is everyone’s business.

As any mental health malpractice attorney knows, it is critical not only to ensure that those with suicidal ideations and behaviors receive the help they need, but for healthcare professionals of all types to receive the training necessary to identify at-risk patients at schools, colleges, hospitals and mental health centers across the United States.

What is National Suicide Week?

In conjunction with World Suicide Prevention Day on September 10, National Suicide Prevention Week is designed to raise awareness for some of the most common factors for suicide – such as mental illness, substance abuse, previous suicide attempts and access to lethal means – and how to engage individuals and organizations alike to the cause of suicide awareness and prevention.

As part of the campaign, organizations are encouraged to recognize suicide as a significant public health problem. States are encouraged to develop accessible behavioral health service programs, use multiple suicide prevention efforts appropriate for different populations and communities and encourage educational initiatives in schools and colleges.

In addition, National Suicide Prevention Week also encourages high schools, colleges and universities to create activities to educate students about the prevalence of suicide, engage students in prevention activities and promote public awareness about the importance of suicide prevention.

By drawing attention to the critical topic of suicide prevention, the campaign also aims to reduce the negative social stigma surrounding the topic of suicide and encourage the assistance and support of people who have faced suicidal thoughts or attempted suicide. As of 2011, the American Association of Suicidology estimated more than 4.6 million survivors of attempted suicide in the United States alone.

As a means of raising awareness for the issue of suicide prevention, National Suicide Prevention Week observance has a specific theme each year. Past themes have included “Suicide Prevention Across the Life Span” in 2007, “Families, Community Systems and Suicide” in 2010 and “Changing the Legacy of Suicide” in 2011.

A Dallas, TX suicide attorney at the Law Offices of Skip Simpson can help. Call (214) 618-8222 or visit http://www.skipsimpson.com to schedule a free case consultation.

Psychiatric Hospital Faces Loss of Funding After Death by Suicide

When someone is having thoughts of suicide, a psychiatric hospital should be a place where they are kept safe: it is the reason for they exist. Psychiatric hospitals must ensure their facilities provide no opportunity for patients to cause themselves harm when they are at risk of suicide. How can it be any other way? When a hospital fails in this duty and patients suffer an experienced suicide attorney can help families to pursue legal action to recover compensation for losses the facility’s carelessness causes. A patient has a right to safety; the patient’s family has a right to know their loved one is safe.

hospital-corridor-1057588-mBesides civil action, regulators can, and should, also take action against hospitals that fail their patients. It is their job to protect us. When hospitals and regulators fail to protect us, it is the duty of juries to protect us—to make our communities safe.

Facilities providing mental healthcare are often state funded or receive federal funds through Medicaid and Medicare. States can threaten their funding, and the Centers for Medicare & Medicaid Services can determine a facility should no longer continue to receive payments if it cannot provide safe patient care. Losing funding can have a major impact on whether the facility can continue operating.

Psychiatric Hospital Faces Loss of Funding

One facility at risk of losing its funding is Timberlawn Mental Health System, which is in Dallas. Officials at the facility were warned doorknobs in patient’s room might be used to hang themselves.  Despite the serious danger the door knobs presented, they were not replaced until February 19. This was two days after the first of safety inspections that occurred unannounced.

The door knobs were not the only problem. Inspections conducted by U.S. Centers for Medicare and Medicaid Services (CMS) uncovered “numerous safety problems,” according to the Dallas News.

On February 17 of last year, federal inspectors indicated there were shortcomings at the facility that left patients at Timberlawn in “immediate jeopardy.” This included things like having plastic liners in garbage cans, and telephone and electrical cords that presented a risk to psychiatric patients. Immediate jeopardy is the most serious warning CMS issues.

While the facility submitted a plan in March to remedy the issues, the changes the hospital indicated it would make came too late for one patient.  A 37-year-old who had checked herself into the facility when struggling with a dissociative disorder had died by suicide in December. Her death took place a full five months after the initial warnings about the doorknobs were issued to the facility.

Suicide attorney Skip Simpson from the Law Offices of Skip Simpson is representing the family and called failing to change the doorknobs “completely reckless.”  The Dallas Morning News quoted Simpson: “This hospital needs to go ahead and put a sign up in front of their building that says ‘Not safe for suicidal patients.”

The hospital’s reckless behavior has had a real cost. While it may make changes now, they are being forced to do so due to the threat of lost funding, those changes should have been made early so the facility could have better fulfilled its basic obligation to keep patients safe.

It should not have taken a threat to close the facility for this hospital to provide a safe environment of care: a culture of safety. Plenty of patient safety rules, for many, many years, have required psychiatric facilities to be safe. The Joint Commission requires patient safety. Doesn’t it just make sense? Texans like rules. They teach their children rules. They teach their children when rules are broken there are consequences.

Sadly a family with their daughter in this facility suffered the biggest consequence. Now Timberlawn will pay the consequences. It is just what happens in Texas. We like rules and folks playing by the rules; nothing new all over America.

Another thing we teach our children: “when you break a rule and it hurts someone or property: you make it right.” My mom said “Skip, you broke the window—admit it and pay for it.” It is just what good citizens do; yes, corporate citizens too. It is just the simple truth.

Is a Shoot-Out Coming to a Campus Near You?

Note from the Law Offices of Skip Simpson: This extremely important blog comes from Dr. Paul Quinnett, president and CEO of The QPR Institute, Inc. Dr. Quinnett is a leading authority on suicide prevention in the United States.

When I started writing this blog, the country was still shaking from the shootings at UC Santa Barbara. Before I finished the first draft, the shooting at Seattle Pacific University had just ended. I am in rewrite today, one day after the tragedy in Las Vegas, and while writing this very sentence I learned of the shooting in Troutdale, Oregon.

Full stop!

America, we need to call a timeout, huddle up, and get an action plan going to stop the carnage.

To prevent the next mass murder-suicide we must, simply must, get upstream from these unfolding events and identify potential suicidal shooters before they purchase weapons, load up, and open fire. Yes, suicidal shooters, not homicidal ones.

I’ve covered this a bit in earlier posts, but bear with me. If suicide contagion is real (and it is), then so is murder-suicide contagion. See one, do one. Humans are highly imitative primates – and not just of good manners, but murder, means and mayhem.

For schools and colleges, one intervention recommended by some is to arm school employees, from teachers to school safety officers, and even students themselves. Armed resistance may reduce the number of persons killed and injured, but in my view it is too little too late. When bullets begin to fly, you’re into intervention, not prevention.

Stopping smoking is prevention; heart surgery is intervention. An armed employee or student can respond to an attack – if they are not killed first – but the homicidal-suicidal person who knows an armed target awaits him at his chosen location is likely to be attracted, not dissuaded, from action. His solution, after all, is to die in a hail of gunfire.

Mass murder-suicides (from Virginia Tech to Sandy Hook to UCSB to Las Vegas) are perpetrated by people who are suicidal first, homicidal second. Once the decision to die has been made – either by their own hand or by another’s – the second decision to seek “justice” for perceived wrongs provides only a final motivation.

Ways to Prevent Mass Murder-Suicides

These are not random acts of violence. Escapes are not planned. The shooter’s intention is to die, usually at the scene. Mass murder-suicides are premeditated, planned, and therefore preventable – if three things are done:

1. Train as many people as possible to recognize and respond to suicide warning signs. This is our collective responsibility to assure ourselves of a safe and sane society. On expert retrospective analysis of these events, suicide warning signs are inevitably present before the shooting begins. Suicide warning signs can be taught and acted upon to cause a formal threat assessment to be conducted, perhaps followed by voluntary or involuntary treatment or other risk mitigation interventions, e.g., denying access to firearms.

2. Train mental health professionals. Currently, few mental health professionals are well trained in how to conduct a comprehensive suicide/homicide risk assessment. Moreover, too many do not routinely intervene with families to see to the removal or security of firearms available to potential suicidal or homicidal loved ones. Thus, even though a potential shooter is in treatment, there is no guarantee a competent risk assessment has been conducted or that all evidence-based risk mitigation strategies have been employed, including restricting access to firearms.

The training, by the way, is called Counseling Against Access to Lethal Means (CALM) and it is available free at: http://training.sprc.org/. It was developed by a dear colleague and friend and I cannot recommend it too highly. If you own a gun, you have a new duty: take CALM training.

3. Train law enforcement officers. Police officers are likewise not well trained to recognize and respond thoroughly to suicide warning signs. If they do detain a person for evaluation, they must rely on emergency room or mental health professionals to determine the level of risk and necessary action steps. But research shows that ED staffers know even less about suicide/homicide risk assessment than do mental health professionals. In the UCSB case, after a 10-minute welfare check, the sheriffs left a number and encouraged Elliot Rodger to call for help.

He didn’t.

Wake up, people…. suicidal males rarely ask for help, and homicidal-suicidal males never do. Or if they do, it is when taking the first steps down the trail to a tragedy for all.

Rarely Do Suicidal Males Ask for Help

This step might be taken in a therapist’s office, or in a conversation with a school counselor, or with someone who might, just might, be in a position to recognize that small but ominous cloud rising from a sea of mental anguish and torment “no bigger than a man’s hand.”

I am, admittedly, an impatient man. Waiting for troubled, angry, suicidal young men to ask for help before they start killing us is unacceptable. Enough with the waiting. If we have satellite spy cameras so powerful we can read a license plate from space, surely we are smart enough to figure out how to identify these people before they gain access to guns and start shooting.

(To my fellow Americans in the NSA reading this blog post: How about lending us all a hand here?  As tax payers, you work for us not the other way around, right?)

Back to the cops who, in this case, and in my view, might have tried the slick Lt. Colombo maneuver to get into the shooter’s house without a warrant, as in, “Oh, by the way… I wonder if it would be OK if we looked around just to make sure, etc. etc.” Stiff resistance to this polite request would raise the index of suspicion and perhaps trigger a deeper investigation.

Mental Health/Law Enforcement Teams

If police officers cannot be trained to detect suicide risk, and then conduct suicide/homicide risk assessments in the field, then pair them with trained mental health professionals and create competent, quick-acting crisis response teams who understand that early identification and intervention may go unrewarded by the general public, but is still heroic. Mental health/law enforcement teams must be fully funded to respond to these threats and yet, currently, many communities are without them.

In the UCSB tragedy it is clear that the two groups of professionals who had contact with Mr. Rodger before he started killing people did not, or could not, communicate with each other about the risk that alarmed his parents and a roommate. The parents acted, but the roommate did not, later saying, “Why did I not say anything?”

The parents did say something, but we can only guess that the professionals involved may not have had the kind of training needed to a) recognize suicide/homicide warning signs, b) conduct a comprehensive suicide/threat assessment, and c) employ their collective civil authority to cause a change in the trajectory of the unfolding event, e.g., a voluntary or involuntary hospital hold to determine how much risk to self and others was present.

It’s a cheap shot for me to opine about this UCSB event while unencumbered by the facts, or the reality of actually having been there, but I have reviewed all of the other high-profile mass-murder suicides in recent history and the pattern is the same again and again and again. And as an old spy myself (retired), I have a pretty good idea of what’s missing. It’s called Intel.

From the 1955 Hoover Commission on American spy work, “Intelligence deals with all the things which should be known in advance of initiating a course of action.” Intelligence is used to prevent violence, and we cannot expect our mental health and law enforcement officers to initiate a course of action to avert violence without better intelligence. The dots are there; they are just not being connected.

But what about confidentiality?

What confidentiality? When lives are at stake, confidentiality is moot.

Too often confidentiality is the screen behind which mental health professionals stand to protect themselves from extra work, like talking to parents or family members when conducting a youth suicide risk assessment. Yes, they don’t get paid for intelligence gathering beyond that provided by their patients, but they should, and this can be fixed with a stroke of the regulatory pen.

Any clinician who relies solely on the statements made by a suicidal and possibly homicidal patient to assess and manage potential risk for violence is either untrained or naive. (Sometime I will share my Top 10 Reasons to Lie to Your Therapist if You Are Suicidal).

When I directed a large emergency service for 25 years and had the authority to invoke involuntary detention to determine if treatment was indicated for anyone suicidal or homicidal or both, people sometimes threatened to sue us over their loss of privacy. None did. But if they had, I was fully prepared to make the case for a temporary suspension of a person’s civil rights in the name of safety for all.

Some say these mass murder-suicides are unpredictable and therefore cannot be prevented. I disagree.  The dots are all there. Through training, education, better intelligence gathering, better intelligence sharing, and better communication among observers, we’ve shown we can greatly reduce American battlefield causalities. Now all we have to do is apply what we already know how do in our own back yards.

A suicide attorney at the Law Offices of Skip Simpson can help. Call (214) 618-8222 to schedule a free case consultation.