Suicide Prevention in the Veteran Population - PowerPoint Presentation

Suicide Prevention in the Veteran Population Laura Watlington, LCSW Suicide Prevention Program Manager Central Arkansas Veterans Healthcare System

A little housekeeping before we start: Suicide is an intense topic for some people. If you need to take a break, or step out, please do so, with one condition … Let me know if you are okay, by giving me a “thumbs up.” If you aren’t okay, give me a discreet “thumbs down” so I can follow up with you. Resources National Suicide Prevention Lifeline: 800 273 8255 Veterans Crisis Line: Press 1

Overview Objectives Who are Veterans? About the Department of Veterans Affairs Facts and myths about suicide S.A.V.E intervention Safety Planning VA and Community Resources

Objectives By participating in this training you will : Have a general understanding of the scope of suicide within the United States Know how to identify Veteran-specific risks for suicide Know how to fully assess level of risk for suicide Understand how to engage clients in the safety planning process Be knowledgeable of VA and community resources for Suicide Prevention

Military Service Branches Army Navy Marine Corp Air Force Coast Guard 5

Status Active Duty Reserve National Guard 6

Who are Veterans? Federal definition: Any person who served honorably on active duty in the armed forces of the United States

Department of Veterans Affairs What is the Department of Veterans Affairs? Veterans Health Administration Veterans Benefits Administration National Cemetery Administration How do Veterans know if they are eligible for healthcare through VA? http://www.va.gov/healthbenefits/apply/veterans.asp Other VA benefits http://benefits.va.gov/benefits/ http://www.cem.va.gov/

Suicide in the United States More than 42,000 deaths from suicide per year among the general U.S. population. 1,2 Suicide is the 10th leading cause of death in the U.S. 3 17,250 U.S. deaths from homicide per year Less than 1/2 the number of annual suicides

Suicide in the United States It is estimated that close to one million people make a suicide attempt each year, One attempt every 35 seconds Gender disparities: Women attempt suicide 3 times more often than men. 1 Men die by suicide 4 times more often than women. 1

Cultural Diversity and Suicide Risk Gender disparities Women attempt suicide 3 times more often than men Men die by suicide almost 4 times more often than women

Cultural Diversity and Suicide Risk Gender disparities Women attempt suicide 3 times more often than men Men die by suicide almost 4 times more often than women

Diversity and Suicide Risk Are Some Ethnic Groups or Races at Higher Risk? Number of men and women who died by suicide per 100,000 by ethnic/racial categories Ethnicity/Racial Category Male Female White, non-Hispanic * 25.80 * 7.47 American Indian/Alaskan Native * 16.39 * 5.50 White, Hispanic 10.98 2.67 Black, non-Hispanic 9.64 2.10 Black, Hispanics 4.20 0.91 Asian and Pacific Islander 8.74 3.45 Note: * Indicates highest rates per category

Diversity and Suicide Risk Elder Suicide: Among depressed Veterans, older ( > 65) and younger Veterans (18-44) were more likely to die by suicide than middle aged Veterans (45-64). Veterans who die by suicide were more likely than non-Veterans to: Be older, Caucasian and educated ( > 12) Have more activity limitations at baseline Have used a firearm at the time of death Be single, divorced or widowed Be less likely to be discovered and rescued. Be less likely to recover from an attempt due to physical frailty. Older adults are less likely to report suicidal ideation and have well-constructed suicide plans. At a rate of 36 suicides per 100,000 annually, the greatest risk for suicide in the United States is seen in older ( > 75 years) Caucasian men.

Diversity and Suicide Risk Lesbian, Gay, Bisexual and/or Transgender People Like other minority groups, people who are lesbian, gay, bisexual, and/or transgender (LGBT) may experience prejudice and discrimination. Research indicates that mental health problems, misuse of alcohol and other drugs, and suicidal thoughts and behaviors are more common in this group than in the general population. Risk and Protective Factors Risk factors Depression and other mental health problems; Alcohol or drug use; Stress from prejudice and discrimination (family rejection, harassment, bullying, violence); Feelings of social isolation Protective factors Family acceptance; Connections to friends and others who care about them; Sense of safety

Facts about Veteran suicide 18% of all deaths by suicide among U.S. adults were Veterans. 4 Veterans are more likely than the general population to use firearms as a means for suicide. 4 On average, there are 764 suicide attempts per month among Veterans receiving recent VA health care services. 5 25% of Veterans who died by suicide had a history of previous suicide attempts. 5 22 Veterans a day – based on a study of 3 million Veterans in 20 states released in 2010 20 Veteran a day – based on a study of 55+ million Veterans in 50 states from 1979-2014. 6 of the 20 were enrolled in VHA services

Myths and Realities about Suicide Myth or reality? Asking about suicide may lead to someone to taking his or her life. Reality: Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. Myth Reality Asking about suicide may lead to someone taking his or her life.

Myths and Realities about Suicide Myth Reality Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the Veteran permission to talk about his or her thoughts or feelings.

Myths and Realities about Suicide Myth or reality? Asking about suicide may lead to someone to taking his or her life. Reality: Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. Myth Reality There are talkers and there are doers.

Myths and Realities about Suicide Myth Reality Most people who die by suicide have communicated some intent. Someone who talks about suicide provides others with an opportunity to intervene before suicidal behaviors occur. Almost everyone who dies by suicide or attempts suicide has given some clue or warning. Suicide threats should never be ignored. No matter how casually or jokingly said, statements like, "You'll be sorry when I'm dead," or "I can't see any way out" may indicate serious suicidal feelings.

Myths and Realities about Suicide Myth or reality? Asking about suicide may lead to someone to taking his or her life. Reality: Asking about suicide does not create suicidal thoughts. The act of asking the question simply gives the veteran permission to talk about his or her thoughts or feelings. Myth Reality If somebody really wants to die by suicide, there is nothing you can do about it.

Myths and Realities about Suicide Myth Reality Most suicidal ideas are associated with treatable disorders. Helping someone connect with treatment can save a life. The acute risk for suicide is often time-limited. If you can help the person survive the immediate crisis and overcome the strong intent to die by suicide, you have gone a long way toward promoting a positive outcome.

Myths and Realities about Suicide Myth Reality

Myths and Realities about Suicide Myth Reality The intent to die can override any rational thinking. Someone experiencing suicidal ideation or intent must be taken seriously and referred to a clinical provider who can further evaluate their condition and provide treatment as appropriate.

S.A.V.E. S.A.V.E. will help you act with care and compassion if you encounter a Veteran who is in suicidal crisis. The acronym “S.A.V.E.” helps one remember the important steps involved in suicide prevention: S igns of suicidal thinking should be recognized A sk the most important question of all V alidate the Veteran’s experience E ncourage treatment and E xpedite getting help

Importance of identifying warning signs There are behaviors that may indicate/reveal that a Veteran needs help. Veterans in crisis may show behaviors that indicate a risk of harming or killing themselves.

Scenarios You are meeting with Poppy, a colleague whom you supervise. You have been a bit concerned about Poppy lately. Her usual enthusiastic outlook on life has changed over recent weeks. She is behind with her work and you no longer hear her usual friendly laugh. You tell her she has been looking tired lately and she says she has no energy to get out of bed in the morning. She has lost some weight and does not look as well groomed as she usually is. You become increasingly concerned during the course of the discussion about Poppy’s willingness and ability to keep going. Leila hasn’t been the same since her mom died. It’s been especially tough because she doesn’t get along with her dad. For months, she’s been saying that if it weren’t for her boyfriend, Dillon, she wouldn’t have anyone who cares about her. But Dillon just broke up with her and Leila is devastated. She talks about needing to end her pain and just last night told you where the key to her diary was in case anyone wants to read it “afterward.”

Scenarios 1)What would you say to this person to help him/her? 2) What else would you do or say to help this person?

S igns of suicidal thinking Learn to recognize these warning signs: Hopelessness, feeling like there’s no way out Anxiety, agitation, sleeplessness or mood swings Feeling like there is no reason to live Rage or anger Engaging in risky activities without thinking Increasing alcohol or drug abuse Withdrawing from family and friends

Veteran-specific risks Frequent Deployments to hostile environments (though deployment to combat does not necessarily increase risk). Exposure to extreme stress Physical/sexual assault while in the service (not limited to women) Length of deployments Service-related injury

A sking the question Know how to ask the most important question of all… “Are you thinking about killing yourself?”

A sking the question Are you thinking of suicide? Have you had thoughts about taking your own life? Are you thinking about killing yourself?

A sking the question DO ask the question if you’ve identified warning signs or symptoms DO ask the question in such a way that is natural and flows with the conversation DON’T ask the question as though you are looking for a “no” answer “You aren’t thinking of killing yourself are you?” DON’T wait to ask the question when he/she is halfway out the door

How to ask about suicide Suggested Clinician Style: Friendly (compassionate, warm, concerned, supportive, client-centered), Frank (direct, candid, unafraid to ask or talk about risks plainly), and Firm (asking in a confident tone and insisting that this discussion is essential, imperative, and necessary). These help establish therapeutic trust, clear expectations, and relational honesty. Suicidal Ideation (Normalize): When someone feels as upset as you do , they may have thoughts that life isn’t worth living. What thoughts have you had like this? Suicidal Planning (Means) If you decided to try to end your life, how would you do it? Tell me about the plans you’ve made. Access to Means You mentioned that if you were to hurt yourself, you’d probably do it by (describe method). How easy would it be for you to do this? 7

How to ask about suicide Protective Factors (Normalize): People often have very mixed feelings about harming themselves. What are some reasons that would stop you or prevent you from trying to hurt yourself? What is it that most holds you back from actually doing this? Past Experiences What have been your past experiences of making attempts to hurt yourself? What other people do you know who have tried to or have ended their own life? Future Expectations What are some of this things happening in your life or likely to happen in your life right now that would either make you more or less likely to want to hurt yourself? How do you think people who know you would react if you killed yourself? What would they say, think or feel? 7

Things to consider when talking with a Veteran at risk for suicide Remain calm Listen more than you speak Maintain eye contact Act with confidence Do not argue Use open body language Limit questions-let the Veteran do the talking Use supportive, encouraging comments Be honest-there are no quick solutions but help is available

V alidate the Veteran’s experience Talk openly about suicide. Be willing to listen and allow the Veteran to express his or her feelings. Recognize that the situation is serious Do not pass judgment Reassure that help is available

Encourage treatment and E xpediting getting help What should I do if I think someone is suicidal? Don’t keep the Veteran’s suicidal behavior a secret Do not leave him or her alone Try to get the person to seek immediate help from his or her doctor or the nearest hospital emergency room, or Call 911 Reassure the Veteran that help is available. Call the Veterans Crisis Line at 1-800-273-8255, Press 1

Suicide Risk Assessments Complete a full Suicide Risk Assessment on all Patients: A positive depression and/or post-traumatic stress disorder (PTSD) clinical reminder (PHQ2; PHQ9; CSSRS) A primary complaint of emotional or behavior disturbance Upon initial contact with Mental Health Service At times of significant changes in mental status Prior to discharge from an inpatient mental health admission Report of suicidal ideations/suicidal behaviors

Suicide Risk Assessments A full Suicide Risk Assessment MUST INCLUDE: Ideation Risk Factors Protective Factors Level of Risk Assigning a level of risk protects the clinician.

Suicide Risk Assessments SUICIDE INQUIRY : (Specific questioning about thoughts, plans and intent) IDEATION : Denies ideation or Admits to ideation (if Admits, then complete the PLAN, INTENT, and ACCESS sections. PLAN: Yes (describe)   INTENT: Yes (describe)   ACCESS TO FIREARMS OR OTHER MEANS: Firearms? Y/N Discussed securing and removing firearms from the home by someone other than self. Other Means: Y/N Family involvement in safety/means reduction (describe) Other strategies to reduce access to means (describe)

Suicide Risk Assessments RISK FACTORS : PAST ATTEMPTS: Y/N ---- How many? SOCIAL/DEMOGRAPHIC FACTORS: Age [Young adult or Elderly] Ethnicity [Caucasian] Sex [Male] Marital Status [Single/Divorced] Sexual Orientation [Homosexual or Transgendered] Living Situation [Alone] CURRENT OR PAST PSYCHIATRIC DISORDERS: Bipolar disorder Other Mood Disorder/Depression Alcohol/Substance Abuse PTSD Cluster B Personality Disorder Conduct Disorder Psychotic Disorder TBI Other:

Suicide Risk Assessments KEY SYMPTOMS: Anhedonia Impulsivity Anxiety/panic Agitation Hopelessness Insomnia Command hallucinations Other: FAMILY HISTORY OF SUICIDE OR SUICIDE ATTEMPTS: Y/N (Describe:)

Suicide Risk Assessments STRESSORS AND INTERPERSONAL DIFFICULTIES: Triggering events leading to humiliation Shame or despair Loss of relationship Financial Health status deteriorating/Newly diagnosed problem Chronic medical illness (especially CNS disorders, pain) Intoxication Substance abuse Family turmoil/chaos History of physical or sexual abuse Social isolation Thwarted belongingness Perceived burdensomeness Other:

Suicide Risk Assessments RECENT CHANGES IN TREATMENT: Medication changes (describe) Provider or treatment change (describe) Discharge from psychiatric hospital (describe) Other:

Suicide Risk Assessments PROTECTIVE FACTORS : Has problem solving/coping skills Has religiosity/spirituality Able to tolerate frustration Has responsibility to children or beloved pets Is pregnant Has positive therapeutic relationships Is motivated in treatment Has good social/family supports Has economic security Has a sense of responsibility for family, Other:

Suicide Risk Assessments ASSESSED LEVEL OF SUICIDE RISK : (Determination of risk level is a clinical judgment based on assessment of risk factors, protective factors, suicide inquiry and overall clinical presentation. The definitions below represent a range of risk levels and not actual determinations. MINIMAL RISK: No significant risk factors. LOW RISK: Suicidal ideation of limited frequency, intensity and duration; no identifiable plans, no intent, no behavior, good self-control and strong protective factors. MODERATE RISK: Suicidal ideation with a plan but without intent or behavior; some risk factors present, and identifiable protective factors, good self-control, limited dysphoria/symptoms. HIGH RISK: Recent suicide attempt, significant aborted attempt or attempt that was interrupted; Frequent intense, enduring suicidal ideation with specific plans with intent; Frequent, intense, and enduring suicidal ideation, specific plans, and the presence of multiple risk factors such as substance abuse, poor impulse control, a history of aggressive acts, hopelessness, command hallucinations and few protective factors. IMMINENT RISK: Protective factors not relevant.

Suicide Risk Assessments PLAN : Refer to the treatment plan in the progress note. Referred to treating psychiatrist. Admission to inpatient psychiatry Will place a Suicide Behavior Consult Safety plan developed and copy provided to Veteran Provided Veteran and/or family member/significant other with emergency/crisis numbers Counseled regarding avoiding/minimizing use of alcohol and avoiding illegal substances Other:

Definitions Suicidal Self-Directed Violence - Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself with evidence, whether implicit or explicit, of suicidal intent. Suicide - Death caused by self-inflicted injurious behavior with any intent to die as a result of the behavior. Suicide Attempt - A non-fatal self-inflicted potentially injurious behavior with any intent to die as a result of the behavior. Preparatory Behavior - Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away). Suicidal Intent - There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and inferred in the absence of suicidal behavior. Suicidal Ideation - Thoughts of engaging in suicide-related behavior. (Various degrees of frequency, intensity, and duration.) Interrupted By Self or Other - A person takes steps to injure self but is stopped by self or another person prior to fatal injury. The interruption may occur at any point. Physical Injury - A bodily injury resulting from the physical or toxic effects of a self-directed violent act interacting with the body .

What Care is Provided to Those Identified at High Risk? The VA Suicide Prevention Program provides an enhanced level of care for those Veterans identified as high risk. The Enhanced Care protocol includes: High Risk Flag (90 day period- can be continued) Missed Appointment follow-up Weekly contacts from their Mental Health team for the first 30 days and then at least monthly for the next 60 days Safety Planning

It is a brief clinical intervention , NOT a treatment plan. It is one component of comprehensive care of the suicidal individual. ( Other components include risk assessment, appropriate psychopharmacologic treatment, psychotherapy and hospitalization.) A prioritized list of coping strategies and sources of support for use during or preceding suicidal crises Involves collaboration between the Veteran and clinician to have a discussion to facilitate identification of warning signs and specific activities to alleviate the crisis. It is a written document that is brief , easy to read , and in the Veteran’s own words. 9 What is a Safety Plan ?

Safety Plans utilize four evidenced based suicide risk reduction strategies: Means reduction Increasing social support Provides emergency resource information Promotes problem solving skills 9 Safety Planning and Suicide Risk Reduction

No-suicide contracts ask patients to promise to stay alive without telling them how to stay alive. No-suicide contracts may provide a false sense of assurance to the clinician. No Suicide Contract The Safety Plan is NOT a “No-Suicide Contract”

Step 1: Recognizing Warning Signs Step 2: Using Internal Coping Strategies Step 3: Utilizing Contacts With People as a Means of Distraction from Suicidal Thoughts and Urges Step 4: Contacting Family Members or Friends Who May Help to Resolve the Crisis Step 5: Contacting Mental Health Professionals and Agencies Step 6: Reducing the Potential for Use of Lethal Means 6 Steps of Safety Planning

Step 1: Recognize Warning Signs Purpose: To help the client identify and pay attention to their warning signs. The safety plan is only useful if the Veteran can recognize the warning signs. Ask “How will you know when the safety plan should be used?” Ask “What do you experience when you start to think about suicide or feel extremely distressed?”

Step 1: Recognizing Warning Signs Examples Automatic Thoughts “I am a failure.” “I don’t make a difference.” “I am worthless.” “I can’t cope with my problems.” “Things aren’t going to get better.” Thinking Processes “Having racing thoughts.” “Thinking about a whole bunch of problems.” 56 Images “Flashbacks.” Mood “Feeling irritable.” “Feeling down.” “Worrying a lot.” Behavior “Spending a lot of time by myself.” “Not doing activities I usually do.” “Using drugs.”

The clinician should obtain an accurate account of the events that transpired before, during, and after the most recent suicidal crisis.And then... List the warning signs (thoughts, images, thinking processes, mood, and/or behaviors) using the Veteran’s own words . Step 1: Recognize Warning Signs

Purpose: To take the client’s mind off of problems to prevent escalation of suicidal thoughts . Ask “ If you’re feeling suicidal, what can you do on your own to prevent you from acting on those thoughts?” List activities the client can do without contacting another person. (examples: go for a walk, listen to music, take a shower, play with a pet, exercise) It is useful to have patients try to cope on their own with their suicidal feelings, even if it is just for a brief time. Step 2: Using Internal Coping Strategies

Step 2: Using Internal Coping Strategies Ask “Do you think you would be able to do this step during a time of crisis?” If doubt about using coping strategies is expressed, ask “What would keep you from doing this step?” Use a collaborative, problem solving approach to ensure that potential roadblocks are addressed and/or that alternative coping strategies are identified. 59

Purpose: To engage with people and social settings that will provide distraction from their suicidal thoughts and urges. Ask “Who do you enjoy socializing with?” or “Where can you go where you’ll have the opportunity to be around people in a safe environment? You don’t have to tell them about your suicidal feelings.” Identify family, friends, acquaintances or places to go (e.g. local coffee shop) where you may find support and distraction from the crisis. Ask patients to list several people, in case they cannot reach the first person on the list. Step 3: People and Social Settings that Provide Distraction

Step 3: People and Social Settings that Provide Distraction A suicidal crisis may be averted if Veterans feel more connected with other people. The client is not telling someone they are in distress during this step. Avoid listing any controversial relationships or unhealthy environments. 61

Purpose: To explicitly tell a family member or friend that they are in crisis and need support and help. Ask “Among your family or friends, who do you think you could contact for help during a crisis?” Examples: Spouse/partner, sibling, parent, close friend, clergy Can be the same people as Step 3, but with a different purpose. Step 4: Contacting Family Members or Friends Who May Offer Help

Step 4: Contacting Family Members or Friends Who May Offer Help Ask patients to list several people, in case they cannot reach the first person on the list. Include their phone numbers. Prioritize the list. Patients should be asked about the likelihood that they would contact these individuals and to identify potential obstacles and problem solve ways to overcome them. If possible, identify someone close to the patient with whom the safety plan can be shared. This is not mandatory and should not be a source of burden for the patient. 63

Purpose: The client should contact a professional if the previous steps do not work to resolve the crisis. Include name, phone number and location. Primary mental health provider Other providers 24-hour urgent care facility or emergency department National Suicide Prevention Lifeline: 800-273-TALK (8255) 911 Identify potential obstacles and develop ways to overcome them. Step 5: Contacting Professionals and Agencies

Purpose: Eliminating or limiting access to any potential lethal means in the patient’s environment. Ask patients what means they would consider during a suicidal crisis. Ask “How can we go about developing a plan to limit your access to these means?” Always ask about access to firearms and discuss how to secure the weapon. Discuss medications and how they are stored and managed and restricting access to knives. Consider alcohol and drugs as possible means for suicide. Step 6 : Reducing the Potential for Use of Lethal Means

Ways to increase collaboration Sit side-by-side Use a paper form Allow the client to write Safety Plans should consist of brief instructions using the client’s own words and should be easy to read . Address barriers and use a problem-solving approach Tips for Developing a Safety Plan

Assess how likely it is that the client will use the safety plan. Identify and problem solve potential obstacles and difficulties to using the safety plan. Discuss where the client will keep their safety plan (Multiple copies; wallet-size versions) The most important feature of the safety plan is that it is readily accessible and easy to use. Periodically review, discuss, and possibly revise the safety plan after each time is it used. The plan is not a static document (It should be revised as Veterans’ circumstances and needs change over time.) Implementing the Safety Plan

Be familiar enough with the safety planning steps that you won’t have to go through it robotically. The most useful information we can glean in our interactions does not come from a checklist; it comes from taking the time to find out who the person is and letting him or her know we are interested. Bridget Bulman, Psy.D. and Patricia Alexander, Ph.D., VISN 19 MIRECC The Big Picture: It’s About the Relationship

“It is clear that the capacity to think about the future with a sense of hope is absolutely protective against suicide. It follows that a sense of hopefulness within our future thinking and key beliefs help us weather the rough spots that we invariably encounter in life. Alternatively, the absence of hopefulness-particularly in the absolute sense of hopelessness- is an extremely pernicious risk factor for suicide… there is perhaps no single construct that has been more highly correlated with completed suicide than hopelessness”. (Beck, 1986; Brown, Beck, Steer ,& Grisham, 2000) Bring Hope to the Relationship

Safety Planning Resources Apps MY3 – Support Network (California Mental Health Services Authority) Suicide Safety Plan (Eddie Liu) Safety Plan (Two Penguins Studios LLC) http://www.suicidepreventionlifeline.org/learn/safety.aspx

Resources Mental Health VHA provides specialty inpatient and outpatient mental health services at its medical centers and community-based outpatient clinics. All mental health care provided by VHA supports recovery, striving to enable a person with mental health problems to live a meaningful life in the community and achieve his or her full potential. For more information on VA Mental Health Services visit www.mentalhealth.va.gov Vet Centers Vet Centers are VA community-based centers that provide a range of counseling, outreach, and referral services. For more information about Vet Centers and to find the Vet Center closest to you visit www.vetcenter.va.gov

VA Resources Make the Connection MakeTheConnection.net is a one-stop resource where Veterans and their families and friends can privately explore information about physical and mental health symptoms, challenging life events, and mental health conditions. On this site, Veterans and their families and friends can learn about available resources and support. Visit www.MakeTheConnection.net to learn more. Post-Traumatic Stress Disorder (PTSD) Each VA medical center has PTSD specialists who provide treatment for Veterans with PTSD. For more information about PTSD and to locate the VA PTSD program nearest you visit www.ptsd.va.gov PTSD Coach App: The PTSD Coach application, allows phone users to manage their symptoms, links them with local sources of support, and provides information on PTSD. Visit www.ptsd.va.gov/public/pages/PTSDCoach.asp

Veterans Crisis Line Veterans Crisis Line/Chat/Text 1-800-273-8255, Press 1 http://www.veteranscrisisline.net/ Text to 838255 VA Suicide Prevention Coordinators Each VA Medical Center has a suicide prevention coordinator to make sure Veterans receive needed counseling and services. Resource locator - http://www.veteranscrisisline.net/

Community Resources Community Mental Health Centers Community Advisory Boards in more rural areas of state Veteran Service Offices Local Emergency Rooms (Always inform staff they are a Veteran, so local hospital can contact the VA.)

REFERENCES 1 Suicide facts. (2016). Retrieved August 1, 2016, from SAVE Suicide Awareness Voices of Education, http://www.save.org/index.cfm?fuseaction=home.viewPage&page_id=705D5DF4-055B-F1EC-3F66462866FCB4E6 2 United States Suicide Injury Deaths and Rates per 100,000 in 2014. Retrieved August 2, 2016, from Centers for Disease Control and Prevention WISQARS, http://webappa.cdc.gov/cgi-bin/broker.exe . 3 Suicide Facts at a Glance. (2015). Retrieved August 1, 2016, from Centers for Disease Control and Prevention, http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.PDF 4 CDC. (2016, July 6). Assault or Homicide . Retrieved August 1, 2016, from National Center for Health Statistics, http://www.cdc.gov/nchs/fastats/homicide.htm 5 U.S. Department of Veterans Affairs (2016). Suicide among Veterans and other Americans 2001-2014. Washington, DC: Office of Suicide Prevention. 6 Based on suicide/ suicide attempts reported within the VA Suicide Prevention Application Network (SPAN) during calendar year 2014.

REFERENCES 7 Merril, G. (2013). Berkeley Social Welfare. Assessing client dangerousness to self and others: stratified risk management approaches [PowerPoint slides]. Retrieved from http://socialwelfare.berkeley.edu/sites/default/files/users/gregmerrill/Assess 8 DEPARTMENT OF VETERANS AFFAIRS MEMORANDUM NO. 116-19, CAVHS, May 2016 9 Stanley, B., & Brown, G.K. (with Karlin , B., Kemp, J.E., & VonBergen . H.A.). (2008). Safety Plan Treatment Manual to Reduce Suicide Risk: Veteran Version.

QUESTIONS?