PTSD and Suicide
in Military, Veterans and Law
Enforcement
COL (Ret) Elspeth Cameron Ritchie, MD, MPH
Chief Clinical Officer
Department of Mental Health
Washington DC
Elspeth.Ritchie@us.army.mil
Elspeth.Ritchie@dc.gov
Slide 1
Outline
• A brief history
• Definition of PTSD
• PTSD in Soldiers and veterans
• PTSD in law enforcement
• Suicide
• Suicide in Soldiers and veterans
• Suicides by police (“suicide by cop”)
• Suicides in police officers
• Therapies
• Veterans in Wash DC
Slide 2
A Brief History of Psychological
Reactions to War
• World War I--“shell shock”, over evacuation led to chronic
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psychiatric conditions
World War II--ineffective pre-screening, “battle fatigue”,
lessons relearned, 3 hots and a cot
The Korean War---initial high rates of psychiatric casualties,
then dramatic decrease
Principles of “PIES” (proximity, immediacy, expectancy,
simplicity)
Vietnam
– Drug and alcohol use, misconduct
– Post Traumatic Stress Disorder identified later
Desert Storm/Shield
– “Persian Gulf illnesses”, medically unexplained physical
symptoms
Operations Other than War (OOTW)
– Combat and Operational Stress Control, routine front line
mental health treatment
Slide 3
9/11 in Washington DC
• Beautiful clear fall day
• New York attack
• Pentagon burning
• Reports of bombs elsewhere
• Are We at War?
Combat Stress Control Principles Applied
• Proximity, Immediacy, Expectancy. Simplicity
• DiLorenzo Clinic at the Pentagon
– Army, Air Force, Navy personnel operations for medical and
mental health services
• -Groups
– People more open to talk in workplace or at ‘coffee rounds”
Development of A Sustained
Response
• Family Assistance Center
• Operation Solace
The Pentagon Family Assistance
Center
• Tended to families of all victims
• The Sheraton in Crystal City
– Extended family, children
– Most lived there for up to a month
• Services
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–
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Informational briefings
Red Cross
Department of Justice, FBI
Counseling
Childcare
• recreation
– Medical care
– DNA collection
The Pentagon Memorial at the Dedication
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Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New
Dawn
• Numerous stressors
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•
•
•
– Multiple and extended deployments
– Battlefield stressors
• IEDs, ambushes, severe sleep deprivation,
– Medical
• Severely wounded Soldiers, injured children,
detainees
Changing sense of mission
Strong support of American people for Soldiers
Major Focus of senior Army Staff
Numerous new programs developed to support Soldiers and
Families
Slide 9
The Army since 9/11
• Volunteer Army
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•
•
– Know they are going to war
– Seasoned, fatigued
– Large Reserve Component
– Reserve, National Guard
Elevated suicide rate
Wounded Soldiers
Effects on Families
– Continuous deployments
– Families of deceased
– Families of wounded
• Difficult Economy
Slide 10
Range of Deployment-Related Stress Reactions
• Mild to moderate
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Combat Stress and Operational Stress Reactions (Acute)
Post-traumatic stress (PTS) or disorder (PTSD)
Symptoms such as irritability, bad dreams, sleeplessness
Family / Relationship / Behavioral difficulties
Alcohol abuse
“Compassion fatigue” or provider fatigue
Suicidal behaviors
• Moderate to severe
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Increased risk taking behavior leading to accidents
Depression
Alcohol dependence
Completed suicides
Slide 11
PTSD DSM IV Diagnostic Concept
• Traumatic experience leads to:
• Threat of death/serious injury
• Intense fear, helplessness or horror
• Symptoms (3 main types)
• Reexperiencing the trauma (flashbacks, intrusive thoughts)
• Numbing & avoidance (social isolation)
• Physiologic arousal (“fight or flight”)
• Which may cause impairment in
• Social or occupational functioning
• Persistence of symptoms
mTBI may be associated with PTSD, especially in the context of
Blast or other weapons injury
Slide 12
DSM 5 Definition of PTSD
• Removes Criterion A-2
• Additional criteria
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Somatic reactions
Sleep
Depressive symptoms
Anger and irritability
Slide 13
PTSD in Service Members
• Often accompanied by
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–
–
–
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Irritability
Anger
Pain
Substance abuse (usually alcohol)
Traumatic brain injury
• Impulsivity
– Other physical disabilities
Slide 14
UNCLASSIFIED//FOUO
POST TRAUMATIC STRESS DISORDER
NUMBER OF ARMY SOLDIERS WITH
IDENTIFIED PTSD
Number of Newly Identified Cases, Army Deployed (OIF/OEF Soldiers) and Non Deployed
We expect the number of new cases to be related to the number of exposed troops, the number of
deployments and the overall exposure to combat.
Last updated: 20 January 2010
UNCLASSIFIED//FOUO
Slide 15
PTSD in Police Officers
• Frequent trauma/critical incidents
• Very similar symptoms to service members
• Similar reluctance to admit/share issues
– Worry about career
Slide 16
Assistance
• Psychotherapy
• Medication
• Employee Assistance Program (EAP)
• Non-traditional support (complementary and alternative
medicine)
– Acupuncture
– Therapy dogs
• Resiliency
– Unit morale
Slide 17
Evidence Based Approaches for PTSD
• Psychotherapy
– Cognitive behavioral therapy
• Cognitive processing therapy
– Prolonged exposure
• Pharmacotherapy
– SSRIs
Slide 18
New and
Innovative Approaches
• Pharmacotherapy
– Second generation anti-psychotics
– Sleep medications
• Integrative therapies
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Acupuncture
Stellate ganglion block
Yoga
Canine therapy
other
Slide 19
Selected Dog Programs
Supplement Traditional Rehabilitation/Therapy Programs
• Animal Assisted Activities
• Animal Assisted Therapy
• Specialized Facility Canines
• Military Therapy Dogs
– Combat Stress Units
• Walter Reed
• Warrior Transition Battalion Work
and Education Programs
– Service dog training
• Warrior Canine Connection
– Dog behavior/obedience and care training
• Washington Humane Society
Canine Assisted Therapy and Army Medicine
AMEDD Journal April to June 2012
How training service dogs addresses PTSD
symptoms
PTSD Symptom Clusters
• Re-experiencing (B)
• Avoidance and Numbing (C)
• Increased Arousal (D)
Major Depression
Depression is the most common serious mental
condition
Major Depression: This includes having one or more
episodes that last at least 2 weeks where there is a
very sad mood or the loss of interest in regular
activities or interests
23
Major Depression: SYMPTOMS
Sad mood, “feeling dark, down all the
time”
Change in appetite
Feeling tired, having low or no energy
Feeling helpless, hopeless, or worthless
Suicidal thoughts or actions
Concentration problems
24
Suicidal Thoughts or Intentions
25
Suicide Rates from 1990-2009
among Army Soldiers
Army rate projected to
Exceed U.S.
population rate**
**Comparable civilian rates were only available from 1990-2006
2
DoD Suicide Deaths/Rates Branch CY 2001-2010
350
Confirmed and Suspected Active Duty Military Suicides by Component, Branch, and
Year
January 1, 2001 - December 31, 2010 (as of 2/7/2011)
300
350
300
26
26
Total Deaths
250
200
32
150
27
26
15
145
24
146
158
250
233
200
196
41
25
34
187
171
284
148
150
268
100
100
1st Qtr
50
50
0
0
2001
2002
Regular
2003
2004
Reserve
2005
Navy
2006
2007
Marine Corps
2008
Air Force
2009
Army
2010
Risk Factors Related to
Suicidal Thoughts or Intentions; Civilian
• Making or changing a will
• Giving away prized possessions
• Putting personal or financial matters in order
• Conveying a sense of hopelessness about the
future
• Threat or loss of primary therapist
• Rejection by family or significant other
28
Risk Factors for Suicide in Army Personnel
• Usually young, white, male
• Major Psychiatric Illness Not a Significant Contributor
– Adjustment disorders, substance abuse common
• Relationships
• Legal/Occupational Problems
• Substance Abuse
• Pain/Disability
• Weapons
– 70% with firearm
• Recent Trends
– Older, higher rank, more females
Slide 29
Suicide-by-police
• Also known as “death by cop”, “blue suicide”
• Most common scenario is pointing a firearm at a police
officer or innocent person
– Other weapons or provocative gestures
• Some will fire and/or kill others
• Aftermath often traumatic for police officers
• Research:
– Of 843 police shootings, 50% were victim precipitated
homicide (Parent, 2004)
– Other data hard to obtain
Slide 30
Risk Factors for Suicide among Police
Officers
• White, mid-30s, male
• Divorce or other relationship problem
– Sometimes domestic violence
• Problem on the job
• Medical/disability
• Frequent trauma
• Data
– 300 documented suicides in 1994, which is still often quoted
– Disputes about actual rate; often cited as double the normal
population; others say that the rate is somewhat lower than
equivalent white mid-30’s male
Slide 31
Past Suicide Mitigation Approaches
• Analysis of Incident Suicides
– DOD Suicide Event Report (DODSER)
– Epidemiologic Consultations (EPICONS)
• Clinical interventions to identify and treat high risk individuals
• Training Soldiers, Leaders and Family Members to recognize and
respond
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ASSIST
ACE
Battlemind
Beyond the Front
Stand-Down Training
Slide 32
32
Suicide Risk Assessment
Behavioral health care providers and key unit members play an
active role in the management and treatment of suicidal
Soldiers.
• Improve suicide assessment and evaluation (primary care,
behavioral health clinic, VA).
– Establish best clinical practices and standards of care
– Train behavioral health and medical care providers at all levels
– Conduct routine reviews and audits to ensure compliance
• Improve engagement and retention in behavioral health care
employing motivational interviewing techniques.
• Involve close family members and friends where ever possible.
• Inform and educate unit leaders as appropriate.
• Enhanced focus on postvention efforts (maintain vigilance post
crisis), including cases of completed suicides.
Slide 33
Evidence-Based Treatments
Adapt evidence-based treatments for suicidality among Soldiers.
• Two generally accepted psychotherapeutic approaches for treating
suicidal patients:
– Cognitive behavioral therapy (based on social learning theory
that focuses on changing distorted beliefs and cognitions about
self and the world).
– Dialectical behavioral therapy (a cognitive behavioral approach
that includes social skills and problem solving).
•
Treat the underlying behavioral health disorder.
Slide 34
Causal Factors for Violence Among Soldiers
•Multiple individual, unit, and community factors appear to have converged to shift
the population risk to the right
Percentage of Population
Facts
Individual
• Criminality/Misconduct
• Alcohol / Drugs
• BH Issues (untreated/undertreated)
Individual, Unit, and
Environment Factors
Very Low
Risk
Lower
Risk
Average Risk
Higher
Risk
Number / Severity of Risk Factors
Very High
Risk
Unit
• Turnover
• Leadership (Stigma)
• Training / Skills
Environment
• Turbulence
• Family Stress / Deployment
• Community
• Stigma
Slide 35
Strategies to Decrease Violence
• While it is important to identify and help individual Soldiers, the biggest impact will
come from programs that shift the overall population risk back to the left
• Effective medical treatment can prevent individuals from increasing in risk or
decrease their risk, but it cannot shift overall population risk very much
Percentage of Population
Army Campaign Plan:
• Health Promotion, Risk Reduction, and
Suicide Prevention
• Increase Resiliency
• Decrease Alcohol/Drug Abuse
• Decrease Untreated/Undertreated BH
• Decrease Stigma to Seeking Care
• Decrease Relationship/Family Problems
• Decrease Legal/Financial Issues
Population Interventions
Very Low
Risk
Lower
Risk
Average Risk
Higher
Risk
Number / Severity of Risk Factors
Very High
Risk
Installation:
• Reintegration (Plus)

Mobile Behavioral Health
Teams
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Mental Toughness Training
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Resiliency Training

Military Family Life
Consultants
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Decompression Reintegration

Warrior Adventure Quest
• Consistent Stigma Reduction themes
Slide 36
The Public Mental Health System and
Veterans
Slide 37
“State Example” Washington DC
Slide 38
WASHINGTON, DC
unique characteristics
•
A Tale of Two Cities
•
“City-State” - Collapsed Political Structure
•
Federal and Local Governments Co-Exist
•
Under the Thumb of Congress
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Geographically Condensed
– Home to Very High Income and Very Low Income
– Very Transient residents and multi-generational families
– State and local functions; Mayor is Governor, City Council is State
Legislature
– Relatively stable economy
– Small tax base (federal buildings, universities, hospitals, nonprofit
organizations)
– No vote in Congress, no 10th amendment protection
– No legislative or budget autonomy
– DC National Guard only activated by the President
– All urban, height restrictions on buildings
– 19 hospitals, 19 nursing homes, but no state prison
Slide 39
Washington, DC
a magnet
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Both home-grown and transient
consumers
Consumers come to DC for a variety of
reasons:
Some believe there are lots of jobs
Some believe there are better services
It’s easy to establish residency
“Right to shelter” - access to housing for
the homeless
“Someone put me on the bus to come
here”
Anger at government
Perceived access to the government
Monuments and free museums
In love with the First Lady
Slide 40
Slide 41
Homeless Veterans
Veterans are 12% of the adult homeless in
Wash DC
2/3rds are chronically homeless
30% have histories of substance abuse
28% mental health conditions
Slide 42
Exercise/Case Study; Vet
with a Rifle
You receive a call from a man who is concerned about his
son. The son returned six months ago from Afghanistan and
was discharged from the Army. Since then he has not been
able to find a job. According to his father, he is now holed up
in the basement of the family’s home with a rifle. He has a
history of PTSD, mild traumatic brain injury and has been
drinking heavily. What do you do?
Questions/Discussion
Elspeth.Ritchie@us.army.mil
Elspeth.Ritchie@dc.gov
Combat and Operational
Behavioral Health
www.bordeninstitute.army.
mil
Slide 44