Linda Ganzini, Lauren Denneson,
Nancy Press, Matt Bair,
Drew Helmer, Jennifer Poat
Steve Dobscha
VA Health Services Research & Development Center to Improve Veteran Involvement in Care
(CIVIC), Portland VA Medical Center
Oregon Health & Science University
Richard Roudebush VA Medical Center, Indianapolis
War-related illness and Injury Study Center, VA New Jersey Healthcare System
Presenter Disclosures
Steven K. Dobscha MD
(1)
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
No Relationships to Disclose
VA suicide risk assessment initiative
 Suicide risk assessment for patients with depression
and PTSD became national performance goal in 2007.
 Routine screening for depression and PTSD takes
place using PHQ-2 or PHQ-9 and PC-PTSD
 Electronic Medical Record (CPRS) triggers a reminder
 Administered in primary care by MAs or nurses;
mental health clinicians often do their own
 Positive depression or PTSD screen activates brief
suicidal ideation risk assessment template.
 Templated risk assessment tools to be used in
conjunction with clinical judgment to assess risk
Picture of screen—CPRS
screenshot of pocketcard?
Suicide risk assessment and screening
 Limited empiric support for screening
O’Connor et al, Annals Int Med 2013
 Veterans who die by suicide may deny suicidal
ideation at last clinic appointments
Denneson et al, Psychiatric Services, 2011
 Studies of Afghanistan and Iraq Veterans support
that only a minority who screen positive for
depression or PTSD engage in mental health care
Hoge et al, NEJM 2004, Lu Psych Services 2011
 Little is known about factors that promote or
discourage honest disclosure of suicidal ideation.
VA HSR&D Study: Outcomes and Correlates of
Suicidal Ideation in OEF/OIF Veterans
 Mixed methods study
 Main research questions:
 What are the correlates of positive brief suicide
risk assessments among OEF/OIF Veterans?
 To what extent are processes of care affected by
positive assessments?
 What are Veterans’ experiences of the risk
assessment process and their perceptions of
clinicians’ responses to assessment results?
Qualitative study methods
 Participants
 OEF/OIF Veterans in Oregon, Indiana, and Texas VAs
 Positive screen for PTSD/depression and positive SI risk
assessment in non-mental health ambulatory setting
 Individual interviews 2 to 6 months after assessment
 Patients with psychiatric instability or cognitive
impairment excluded by primary care provider
 Recruitment was purposive with attempts to
enrich with women and ethnically diverse Veterans
 Veterans completed phone interviews, which were
audiotaped, transcribed and de-identified
 Modified grounded theory used to analyze
Strauss and Corbin, Basics of Qualitative Research, 1998
Interview guide
 Recollections of suicide assessment process
 Comfort/discomfort with assessment process
 How the care setting influenced their responses
 Regarding suicidal ideation—
 Hesitance to discuss
 Reactions from providers and staff
 Positive and negative views and consequences of
disclosure
 Experiences in the military with mental health
and suicide screening/assessment
Results—Demographic Characteristics
 34 Veterans
 Mean age 35 years
 91% men
 73% non Hispanic white
 42% had served in the army
 Assessment process
 Primary care or post-deployment clinics
 Multiple disciplines involved in assessments:
Physicians (15) nurses (12) psychologists (1), social
worker (1) physician assistant (1), multiple providers (4)
Results: Positive views of SI assessment
 Straightforward, clear, expected, devoid of ambiguous
language
“they seemed to be pretty straight and cut and dry questions…. You
got the initial standardized questions then, if the solider answered
a yes to certain questions, it’s going to pop up with a different
standardized question. Then eventually they figure out what going
on with Veterans.” (Participant N)
“They are standard. They were what I was here for. I kind of
expected them….She didn’t sugar coat it. I mean there’s not a
delicate way to say, ‘Hey you’re thinking about killing yourself.’ You
just have to ask it. …she didn’t pussyfoot around it either. She was
as delicate as you can be asking the questions, but direct about it.”
(Participant J)
Criticisms of assessment process
 Painful and shameful
“I’ve gotten used to it and know you guys are going to ask me every time…it
is like sticking a needle through your eye sometimes.” (Participant R)
 Repetitive, sense of communication gaps, leading to sense
of futility about getting mental health needs assessed.
“It’s repetitive. Annoying. It feels like I have already answered the
questions for you. And you’re in the same damn office, why should I go to
somebody else and answer them all over again. It is a massive waste of time
to have to spend seven hours at that place answering the same questions
over and over again. But apparently these three people cannot talk to each
other.” (Participant O)
“But I mean that was about the gist of it. So I just, I felt like I gained
nothing. I felt like it wasn’t, there was no attempt to figure out what’s going
on. It was just, “Uh…yep checking the box, it’s still there, see you later.”
(Participant AE)
Criticism—inability to provide context
 Questions too simple, no opportunity to clarify
their thoughts or give complex answers.
“I mean if I were in her shoes I think I would have asked a
little bit more questions. I would have made sure the
individual understood the questions… I mean it almost
seemed like waste of time… it was too short, too simple. I
had thoughts that I wanted to share and I did not get the
opportunity to share them.” (Participant AF)
Barriers to disclosure of SI
 Veterans accustomed to minimizing and suppressing
thoughts of suicide. Believed they should cope on
their own.
“That’s the heartache…I just try to cover it up and faking it to
make it. I know I am hurting, physically and mentally, but
the thought of trying to get help is a sign of weakness.”
(Participant F)
 Veterans were sensitive toward feeling lack of
respect, particularly on initial interactions
“Those that are nice to me and treat me with respect right
away, then they will get the respect—they will get all the
information that they need from me.” (Participant W)
Barriers to disclosure of SI—
experiences in the military
 Stigma and concerns admission of SI might delay
return home
“I finally started accepting that [having suicidal thoughts] was an issue for
me, but prior to that there had been several times I filled out those
questionnaire…and it was just something you had to go through to get
home. You knew pretty much to say no to everything.” (Participant U)
“They ask you, “Do you need to talk to mental health?” you say, “no.” It
does not matter if you do or not. You say no because if your commander
finds out you said yes they give you shit. What, you’re a soldier. You don’t
need any fluffy bunny mental health crap.” (Participant J)
“The doctor I am seeing is supposed to know everything. Not ‘Oh I am
only a doctor for you today’…They are doing their job, I’m just a number,
expendable, I‘m a soldier, I don’t complain and stuff, I feel like a weak
person being in there talking about it.” (Participant F)
Barriers to disclosure—trust and privacy
“If that is the first thing someone were to say to me, I would just say no,
because I wouldn’t want to tell them because I don’t know them. I don’t
trust them. I don’t know who they are.” (Participant AG)
“I wouldn’t feel comfortable. If it was a new doctor or a new nurse, I don’t
feel—it wouldn’t feel comfortable—I’d be too afraid of them. I wouldn’t
know how to explain it. I’d be too uncomfortable with the strangers.”
(Participant H)
“I don’t want to mess up my life even more by being honest with somebody.
And they are strangers so I don’t really want to talk to strangers about
things that are in my head ‘cause they’re my thoughts.” (Participant E)
“I mean people don’t really want to be asked, ‘Hey are you trying to kill
yourself?” You know that like ‘Hey that none of your business,’ you know,
that’s mine—that’s what I’m thinking in my head.” (Participant W)
Barriers to disclosure—consequences
 Worry about hospitalization and medication.
“It’s difficult for me, one of the reasons I was worried about
talking about it is she going to try and lock me up in a straight
jacket, I have no ideas what the response if going to be if I talk
to someone honestly.” (Participant O)
“And to tell someone that you want to admit them, it don’t
make them feel at ease. Now I’m scared to tell you something.
‘Cause you’re telling me, I’m telling you my feeling and you
want to admit me to the hospital, that sometimes makes a
person, especially a soldier clam up. Now we open a can of
worms. Who’s going to take care of my kids? My kids is coming
home from school at 5:00. I mean when you talk about
admitting me you scare the shit out of me.” (Participant AC)
Facilitators of Disclosure
 Trust, provider attitudes of genuine concern,
questions of SI in context of Veteran-centered goals
“Whereas when speaking with (the therapist), it’s ‘Well, you have kids, you
gotta make sure that they’re okay, though to make sure they’re okay, you
have to be okay.’ So it’s a more looking down the road to ‘help me,’ not
checking the blocks, but to help me.” (Participant AB)
“Cause I’ve seen people do that on their screen ‘Have you ever attempted
suicide,’ click on the screen. He didn’t do that. He actually sat down. He
talked to me. He looked at me. He didn’t take his eyes off me. He talked to
me and that’s what made me feel a lot better.” (Participant AG)
“Of course it was difficult. Not so much being asked, he was fairly gentle
and not aggressive. But he was pretty comfortable to talk to. More than
anything else I got the impression right off the bat that he was there to be
supportive.” (Participant C)
Recommendations
 SI risk assessment should be performed by provider
who knows the patient best, not by triage personnel
 Repetitive assessment should be avoided
 Misperceptions about the consequences of
disclosure should be explored
 Risk assessment should be part of a conversation
 The patient should be warned that her/she is likely
to be asked about SI in future and rationale for this
 Providers should be aware of potential for shame
and avoidance around suicidal thoughts.