Wednesday, November 20, 2013

Veterans diagnosed with PTSD are more likely to die from suicide than those without PTSD

Hello everyone I apologize for not being as pro-active in keeping up my blog. Well a lot has happened since my last post. I am now in my final two semesters of graduate school (graduate Aug 2014) I also have run into a few bumps in the road that have helped re-evaluate some actions and think about how poor choices can adversely effect the goals you place for yourself. But more about that later! As for now I want to post a few things I have written concerning suicide and the impact that Post Traumatic Stress Disorders plays in increasing the propensity for completed suicide as well as increased attempts. Although this is a dark subject it is something that needs to be addressed.

Suicide is unquestionably the most challenging mental health issue after Post Traumatic Stress Disorder (PTSD) that is being faced by the military today. Suicide has been the second leading cause of death in the United States military, exceeding the number of combat-related losses in both Iraq and Afghanistan (Rudd, 2012).
Veterans diagnosed with PTSD are more likely to die from suicide than those without PTSD, and this risk is substantially greater among veterans with PTSD and comorbid mental disorders such as substance abuse (Jakupcak, 2011).

Can addressing PTSD decrease the number of suicides by service members diagnosed with PTSD? Yes, and steps are currently being taken to further research and present empirical and best treatment practices that will lessen the symptoms of PTSD and thus reduce the number of suicide attempts and completions. While there are a number of treatment options available to practitioners the three that have been successful are: Cognitive Behavioral Therapy more specific Cognitive Therapy, Cognitive Processing Therapy (CPT) and Prolonged Exposure (PE) Therapy (see figure 1). For the purpose of this paper I will discuss Cognitive Behavioral Therapy in which the treatment focus relies on relearning thoughts and beliefs generated from the traumatic event, which may impede current coping skills.
Studies have linked the relationship between suicidal ideation and self-reported psychiatric symptoms among 407 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) combat veterans in a post deployment study at a specialty Veterans Affairs clinic. Accounting for symptoms of major depressive disorder, alcohol abuse, and illegal drug abuse, veterans who screened positive for PTSD were found to be more than four times more likely to report suicidal ideation relative to non-PTSD veterans (Jakupcak, 2011).

 Cognitive Behavioral Therapy is an individualized type of psychotherapy used to treat PTSD that is based on the principles of learning theory and cognitive psychology. From a cognitive psychological perspective, trauma exposure is thought to evoke erroneous automatic thoughts about the environment (as dangerous and threatening) and about oneself (as hopeless and incompetent). CBT directly confronts such PTSD-related distortion thinking.

 Cognitive therapy addresses the thoughts and beliefs that are often associated and generated by the traumatic event rather than the conditioned emotional responses addressed by exposure therapy. This approach focuses on how individuals with PTSD have interpreted the traumatic event with respect to their appraisals about the world and themselves (Friedman, 2003).

 Cognitive therapy has a number of elements that are distinctive in its treatment plan compared to others types of therapy. Some of the elements that make it appealing to service members and their families include being relatively short-term (for the most part), active, directive, structured, and collaborative, with a core theme being the development of individual understanding, coping, and mastery of skills essential for day-to-day living (Rudd, 2012).
There have been several studies that have shown that the effectiveness of CBT in reducing suicidal behaviors. There are several effective treatments used to reduce suicidal behaviors and they all share several of the same common elements, including theory-driven, structured strategies that are designed to target suicidal risk factors, increase motivation and treatment compliance, and introduce skills training to promote self-reliance, responsibility, and the ability to manage distress and crisis. A 2005 study by Brown, G.K titled Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial found that, compared to participants receiving usual care from community providers, participants in CBT therapy for suicidality reported significantly less depression and hopelessness six months after initiating therapy and were significantly less likely to reattempt suicide in the 18 months following their initial suicide attempt (Jakupcak, 2011).

One proposed approach to treating PTSD with OEF/OIF veterans at high risk for suicide is based on a treatment plan with core features of psychosocial interventions designed for the treatment of suicidal behaviors and the treatment guidelines proposed by the International Society for Traumatic Stress. This successful (validated and reliable) approach consists of three phases: (a) comprehensive assessment, treatment engagement, and initial safety planning; (b) suicide risk reduction and CBT skills specific to suicidality; and (c) CBT for PTSD and comorbid mental disorders. The implementations of the three phases are only the beginning of a whole treatment concept which involves maintaining regular supportive contact, fostering motivation for treatment, and continually assessing changes in risk factors and symptoms must remain a priority through the treatment process.

Phase I: Assessment, Treatment Engagement, and Initial Safety Planning

  This phase allows the clinician and initial assessment opportunity to fully assess warning signs and risk factors involved in suicidal behaviors. This time can be critical in establishing rapport necessary to engage the veteran in care. Not only is this a time to discuss things such as unanticipated assignments outside of the veterans primary Military Occupational Specialty (MOS) but also the possibility of being personally re-deployed or the possibility of friends or family members being redeployed it is also a time to assess other factors of risk behaviors such as recent aggression, smoking status, family history of suicide, childhood or adult sexual or physical victimization, and current access to firearms. This will assist the provider in estimating the level of current risk and will help to guide safety and treatment planning (Jakupcak, 2011).
Phase II: Suicide Risk Reduction and CBT Strategies Targeting Suicidality
 After the initial assessment takes place suicide risk reduction and safety plan refinement is an ongoing process. The clinician is encouraged to take the lead in facilitating a coordinated treatment plan, with each provider identifying their role in a collaborative process to reduce suicide risk. There are many ways other treatment providers can provide critical support in the reduction of suicidal risk. During this phase the veteran is encouraged to identify specific emotional states that frequently cue suicidal thoughts (Jakupcak, 2011). Those veterans that devalue or fear discussing vulnerable emotions may benefit from an emotional examination of personal and cultural schemas regarding traditional norms as part of the emotional skills training. Reviewing both general and idiosyncratic functions of specific emotional states can normalize the experience of vulnerable emotions and help to address skills deficits (Jakupcak, 2011).

Phase III: Treating PTSD and Comorbid Psychiatric Symptoms
After the introduction of the safety plan and basic CBT skills to help reduce suicidal thoughts , impulses, or self-harm behaviors, it is important to address more specific psychiatric disorders. During this phase it is important that the provider remain flexible approach in treating specific disorders and other psychiatric symptoms, carefully monitoring safety, continued ambivalence, and resistance to treatment. It is not uncommon that for the veteran to become resistant to the treatment process. These resistance actions can be seen through active resistance (e.g. cancelling appointments or no-showing multiple appointments, using alcohol, or other substances immediately prior to or following a session) or may be expressed less directly through such behaviors as forgetting to do “homework for sessions, or bringing up topics that distract from trauma-related session (Jakupcak, 2011). See figure 2 for some common barriers to mental health care in general population and among former deployed military personnel.

 The most common resistant that most veteran’s exhibit is substance abuse, substance use can increase impulsivity and suicidality, but OEF/OIF veterans abusing alcohol may not be aware of the problematic nature that their drinking may be playing in their recovery process. Many veterans will reference their behaviors to peer-based norms and may even perceive benefits from alcohol consumption in terms of sleep and anxiety reduction (Jakupcak, 2011).

  In conclusion the necessity to understand local and national resources that are available to practitioners who work with OEF/OIF veterans are important to help with complex psychiatric profiles and physical disorders. IT is also important to acknowledge that treating patients who are at risk for suicide is often both challenging and stressful to providers. A substantial portion of mental health providers report having experiencing a patient suicide (rates that vary 11% to 50% across types of professions and clinical settings) and providers may experience significant emotional distress in response to a patient’s suicide attempt or completed suicide. It is just as important for providers to seek out appropriate supervision, consultation, and peer support.
Figure 1:

Cognitive Behavioral Techniques Used in PTSD Treatment
CBT Technique
Treatment Focus
Prolonged Exposure Therapy (PE)
Disconnecting the overwhelming sense of fear from trauma
Cognitive Therapy
Relearning thoughts and beliefs generated from the traumatic event, which impede current coping skills.
Cognitive Processing Therapy (CPT)
Understanding both emotional and cognitive consequences of trauma exposure
Stress Inoculation Training (SIT)
Anxiety Management to increase coping skills for current situations.
Exposure and cognitive restructuring through a protocol-driven CBT treatment accessed via the internet.
Imagery Rehearsal Therapy
Changing disturbing traumatic nightmares by rehearsing "new dreams"
Biofeedback and Relaxation Training
Anxiety management to help patients master overwhelming anxiety feelings and physiological reactions elicited by a trauma reminder.
Dialectical Behavior Therapy (DBT)
Treating borderline personality disorder, a syndrome of associated with PTSD and complex PTSD.

 Figure 2:

Barriers To Mental Health Care in General Population and Among Former Deployed Military Personnel
In General Population  (Kessler, Berglund, et al., 2001)
Among Formerly Deployed Military Personnel (Schell and Marshall, 2008)
Lack of perceived need
Negative career repercussions
Unsure about where to go for help
Inability to receive a security clearance
Cost (too expensive)
Concerns about confidentiality
Perceived lack of effectiveness
Concerns about side effects of medications
Reliance on self (desire to solve problems on one's own or thoughts that the problem will get better)
Preferred reliance on family and friends
Perceived lack of effectiveness

 Written by Gene Hicks 2013
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