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.
Interapy	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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The biggest problem the Army and service members face is the stigma that is associated with a PTSD diagnosis. If we can beat this we will get those who need help the help they need. In being true to my preaching I have decided to speak with a counselor even if it just for a wellness check and to ensure that there is something I am not seeing. Do the same.....
"A study published in the Archives of General Psychiatry in October found that soldiers were two to four times more willing to report PTSD, depression, and suicidal thoughts if they were allowed to answer a survey anonymously, rather than put their names on a routine post-deployment screening form."

Idea to take the 'D' out of PTSD being studied

By Lindsay Wise

Houston Chronicle

Published: January 16, 2012

 

The president of the American Psychiatric Association says he is "very open" to a request from the Army to come up with an alternative name for post-traumatic stress disorder so that troops returning from combat will feel less stigmatized and more encouraged to seek treatment.
Dr. John Oldham, who serves as senior vice president and chief of staff at the Houston-based Menninger Clinic, said he is looking into the possibility of updating the association's diagnostic manual with a new subcategory for PTSD. The subcategory could be "combat post-traumatic stress injury," or a similar term, he said.
"It would link it clearly to the impact and the injury of the combat situation and the deployment experience, rather than what people somewhat inaccurately but often assume, which is that you got it because you weren't strong enough," Oldham said.
The potential change was prompted by a request from Gen. Peter Chiarelli, the Army's vice chief of staff, who wrote to Oldham last year, suggesting APA drop the world "disorder" from PTSD.
"Calling it a disorder contributes to the stigma and makes it so some folks -- not all, but some folks -- don't get the help they need," Chiarelli said.
The general doesn't like to use the word disorder. "It's not a dirty word, but I think it's misused here," he said. "I don't think that the post-traumatic stress that soldiers experience is a disorder. It's not something that happens just to weak people or people that are somehow inclined to be affected by horrible things that they see or are required to do. I think it causes an actual injury to the brain and how the brain works."
Early discussions
After receiving Chiarelli's letter, Oldham wrote back to say he appreciated his concern, but dropping the word disorder might not be the best way to go. He said he was eager to work with Chiarelli to see what APA could do.
The general invited Oldham to the Pentagon to discuss the situation. They met for about an hour and a half on Dec. 9. Oldham agreed to bring the general's suggestion to the APA work group tasked with reviewing PTSD for the next version of the association's Diagnostic and Statistical Manual of Mental Disorders, the classification book used by psychiatrists in America. APA is finalizing the fifth edition of the manual, due in May 2013.
Oldham cautioned the discussion is very preliminary but speculated that a new subcategory like "combat post-traumatic stress injury" might work.
Although Chiarelli still would prefer to lose "disorder" entirely, he said a new subcategory would be a start. "I'm frustrated with how long this is taking to be honest," he said.
The general pointed out that PTSD has had many names over the years, from shell shock to battle fatigue. "It's been called all kinds of different things and somehow we decided to go with PTSD and I think that's just wrong," he said.
Chiarelli's campaign to change the name of PTSD is part of the Army's effort to reduce alarming suicide rates among soldiers. Statistics released last month identified 260 potential suicides in 2011. Of that total, 154 were active-duty soldiers, 73 were National Guard troops and 33 were reservists.
Silence over stigma
Stigma is a major problem. A study published in the Archives of General Psychiatry in October found that soldiers were two to four times more willing to report PTSD, depression, and suicidal thoughts if they were allowed to answer a survey anonymously, rather than put their names on a routine post-deployment screening form.
Of the soldiers who screened positive for PTSD or depression, 20 percent said they weren't comfortable answering honestly on the routine form. The study concluded that the Army's screening process misses most soldiers with significant mental health problems.
Dr. Harry Croft, a psychiatrist in San Antonio, said the findings jibe with what he hears from veterans he treats for PTSD.
"Even though the rules, as I understand them, say you don't get kicked out if you get diagnosed with PTSD, depression or any other issues, a lot of veterans say, 'I knew damn well if I answered the questions right my chance to get promoted was gone,' " Croft said.
Croft has mixed feelings about changing the name of PTSD. He understands the concern about stigmatizing troops but thinks whether the condition is called PTSD or something else will have little effect on the suicide rate.
"Rather than concentrate on what we call it, we need to concentrate more on how to help warriors coming back from the combat zone, because I don't think the name we give it will have much of an impact on the 18 suicides a day and all the other problems that we see," Croft said. "That's putting a Band-Aid on a much bigger wound."
Chiarelli says his main concern is getting soldiers into treatment, so if calling post-traumatic stress a disorder keeps them from seeking help, then the wording needs to change, the sooner the better.
"You can have the very, very best treatments in the world, but if you can't get people take advantage of them, they don't do any good," he said.

Afghanistan Battle Shows War Rarely Fought to Plan

Another article by our imbedded AP reporter Chris Torchia in Helmand.

CPT Kovalsky and me in Helmand 2010

A Co 1-17th INF from left CPT Michael Kovalsky (CO), 1SG Gene Hicks and LT Brian Zangenberger  (XO)

Afghanistan Battle Shows War Rarely Fought to Plan

NATO, Afghan troops plot their assaults each night but day brings the messy reality of war

By CHRISTOPHER TORCHIA

The Associated Press

BADULA QULP, Afghanistan

The intelligence said a Taliban commander planned to dispatch a suicide bomber against an American patrol base. But where? Would more than one attacker strike? What day and time? On foot, or in a vehicle that would pack more explosives?

The attack didn't happen as predicted last week in a farming area where Army units are supporting a U.S. Marine offensive against insurgents in Marjah in southern Afghanistan.

Could it happen later? Uncertainty is a certainty of war. As generals over the centuries have noted, no matter how much soldiers plan and try to impose order on the battlefield, reality rarely matches.

Over the past week, men belonging to the 5th Stryker Brigade and Afghan forces have swept through villages and compounds once held by Taliban fighters, advancing with painstaking caution to avoid casualties from booby traps and harassing fire.

In the military's innocuous-sounding jargon, the soldiers have cleared "objectives" and had "contact," which really means vicious firefights. They "engaged the enemy" and "possibly destroyed" snipers. The Taliban rarely leave their dead, if they are, in fact, dead.

At night, U.S. and Afghan commanders, with Canadian advisers, pore over maps based on satellite imagery as they plot the next day's assault. The mission has a start time and an estimated end. There are questions, comments. It has the feel of a classroom exercise, removed from the shouting, the diving and hugging of cover, the cacophony of battlefield bullets and machinery.

It's intellectual, with nothing of the fear, fury and exhilaration of men firing and taking fire.

A detachment from Alpha Company of the 1st Battalion, 17th Infantry Regiment got another taste of these contradictory currents when they moved through fields, irrigation ditches and mud-walled homes on Friday.

An Afghan villager told them the Taliban appeared the previous night with picks and shovels, possibly to hide homemade bombs and other booby traps. A soldier with a metal detector checked a wall where dirt had been freshly dug. Unfazed, the platoon bypassed it, following the point man like a trail of ants to avoid untested terrain.

All quiet, except for a barking dog.

"What's up dog? Want to fight?" a soldier said. Another joked about the suicide bomber report — the attacker could be anywhere, he said, maybe on the Pakistani border.

Up ahead, an American Stryker infantry carrier crossed a cord or string, a classic device used by insurgents for bombs known as Improvised Explosive Devices, or IEDs. A vehicle or person yanks the line unsuspectingly, and the hidden bomb detonates. In this case, nothing happened. Soldiers pulled the cord to see where it led. And pulled and pulled. Hundreds of meters of it, leading nowhere.

Sometimes, said 1st Sgt. Gene Hicks of Tacoma, Wash., insurgents put down line as a decoy to lure the Americans into another trap, or just to gauge the soldiers' patterns of behavior.

"Don't get blown up, PLEEAASE!!" Capt. Michael Kovalsky of Fords, N.J. said in a text message to Hicks, who was coordinating the operation from a communications truck in the front line.

"I won't," Hicks wrote. A 20-year military veteran, he's sparing with words.

The next set of compounds looked like trouble. Civilians, including two women in powder-blue, all-enveloping burqas, hurried from the looming shootout. Another intelligence report: Insurgents had concealed an anti-aircraft gun in one of the buildings, and would either use it on the "dismounts" — soldiers on foot — or on the vehicles as they rolled closer.

Troops on the ground tried to get a reconnaissance aircraft to take a look, but they couldn't immediately get through to the controllers. In the end, a false alarm.

Afghan soldiers approached, with half a dozen Strykers providing cover on their flank. Coordination between the two militaries slowed movement.

"There's not a job in the world that could be so exciting at one moment, so boring the next," drawled Hicks' fair-haired gunner, Staff Sgt. Van Forbes of Decatur, Ala. He ate sunflower seeds from a bag. Hicks chewed tobacco, spat into a plastic bottle.

Inevitably, gunfire began. Bullets bounced off at least one Stryker. Forbes fired bursts on his 50-caliber machine gun at a wall where two men in black were spotted. He wore safety glasses and cursed because his gun wasn't working properly. It was difficult to pinpoint the shooters.

"I can't see where it's coming from," Forbes said. The Afghan soldiers fired more freely, but the Americans couldn't identify their target. Then the Afghans, their Canadian mentors not far behind, moved into the Americans' line of fire.

"Want to make sure I'm not lighting up the Canucks," Forbes said.

"Frustrating," Hicks said.

More waiting. But sure enough, gunfire started up as scheduled.

The military vehicles rolled forward in a field, staying off trails in case IEDs were planted there. Hicks saw what looked like moist earth, a favored place for hiding bombs because it's easy to dig up the earth. Insurgents also pour water to break up the soil.

"See those two soft areas directly in front of us? Let's not run into those," Hicks said to his driver, Staff Sgt. Jorge Banuelos of Mission, Texas.

Surveillance from the air and ground, the high-tech and human kinds, yielded more circumstantial evidence of Taliban movements. A motorcycle moving in the area. Two vans heading away. A dark spot on the thermal imaging camera of a Stryker. Was it a person kneeling? Or maybe a flag blowing in the wind? In the bright sun, Hicks saw something: Is that an insurgent or a tree branch?

"Now look across the pasture here at those buildings. ... OK, now we're taking fire. ... Stand by to suppress those buildings," he said, headphones wrapped around his helmet, a microphone millimeters from his lips.

A plan and a schedule was made. At 1309 and 30 seconds, the Strykers would fire intensively to kill or force the insurgents to pull back. At 1310, Afghan troops would advance. The guns thudded, and Kovalsky gave the go-ahead to fire a light anti-tank missile at a building. The soldiers were delighted, as though getting to play with a new toy.

The missile made a loud noise, but didn't score a direct impact. Later, soldiers found a blood trail that suggested an insurgent sniper had been injured or killed. Was he even a sniper? He had a lot of targets, but didn't hit anyone.

"It could be just a guy who didn't have a Kalashnikov. It could have been an Enfield," Forbes said. "It could be a guy with a scoped rifle who doesn't know how to zero it."

Still, objective cleared.

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