Suicide is a serious public health problem. In 2013, suicide was the 10th leading cause of death in the United States and the second leading cause of death for adults ages 15-24 and ages 25-34. A person dies by suicide about every 13 minutes in the United States[1].
Defense Suicide Prevention Office (DSPO),provides advocacy, program oversight, and policy for Department of Defense suicide prevention, intervention and postvention efforts to reduce suicidal behaviors in Service members, civilians and their families.
Historically, suicide rates in the military were below that of the civilian population. However, since 2005, suicide rates in the military (specifically for the Army) have continued to increase[2], prompting an urgent need to address suicide in the military. The relationship between the psychosocial factors of the military (i.e., combat exposure, unit cohesion, etc.) and suicide is complex[3]. Research indicates that relationship problems, financial difficulties, and legal issues are all factors related to suicide ideation or completion[4].
Suicide mortality data are provided by the Armed Forces Medical Examiner System (AFMES) with inputs from the individual service suicide prevention programs. Population data are collected from the Defense Manpower Data Center (DMDC). Suicides, defined as self-inflicted death with evidence (either explicit or implicit) of intent to die, are broken down by component, (active component or reserve component), and service. Quarterly Suicide Reports can be found on the DSPO website.
Evidence-based Suicide Risk Assessment and Management
Suicide prevention remains a high priority for both military and Department of Veterans Affairs (VA). In June 2013, the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicidewas released with the goal of providing evidence-based management of patients presenting with suicidal self-directed violent behavior or suicidal ideation.
The clinical practice guideline (CPG) contains three algorithms across four components of care, divided into modules:
Algorithms:
Algorithm A: Assessment and Management of Risk in Primary Care
Algorithm B: Evaluation and management of Risk for Suicide by Behavioral Health Providers
Algorithm C: Management of Patient at High Acute Risk for Suicide
Modules:
Module A: Assessment and Determination for Risk of Suicide
Module B: Initial Management of Patient at Risk for Suicide
Module C: Treatment of Patient at Risk for Suicide
Module D: Follow-up and Monitoring of Patient at Risk for Suicide
The guideline recommends a framework for a structured assessment of person suspected to be at risk of suicide, and the immediate and long-term management and treatment that should follow once risk has been determined.
Topics addressed by the CPG include:
- Definitions, classification of etiology, risk factors, and severity
- Assessment and determination of risk
- Management of urgent/emergent risk – indications for referral to specialty care
- Treatment interventions (modalities) based on risk level
- Safety planning for patient at risk
- Monitoring and re-assessment of patients at risk
The guideline does not address risk in children, universal screening for suicide ideation, population health interventions to reduce the risk of suicide.
Target Population
This guideline applies to adult patients (18 years or older) with Suicidal Self-Directed Violent (SDV) behavior or related suicidal ideation (identified as being at risk for suicide) who are managed in the VA and DoD healthcare clinical settings. The population at risk includes patients who have suicidal ideation with or without an established diagnosis of a Mental or Substance Use Disorder; and patients with any level of risk for suicide ranging from thoughts about death or suicide to SDV behavior or suicide attempt.
Audience
The guideline is relevant to all health care professionals providing or directing treatment services to patients at risk for suicide in any VA/DoD health care setting, including both primary and specialty care, and both general and mental health care settings. This guideline may also be relevant to any provider or health care system providing care and services to military members or Veterans. Many of the recommendations are also relevant to all clinicians caring for patients at risk for suicide.
Goals of the Guideline
- To promote evidence-based management of patients presenting with Suicidal Self-Directed Violent behavior
- To promote efficient and effective assessment of patients’ risks
- To identify efficacious intervention to prevent death in individuals presenting with Suicidal Self-Directed Violent behavior
- To identify the critical decision points in management of patients at risk for Suicidal Self-Directed Violence
- To promote evidence-based management of individuals with (post-deployment) health concerns and behaviors related to Suicidal Self-Directed Violence
References
[1] Centers for Disease Control and Prevention. (2013). Fatal injury and nonfatal injury 2013, Web-based Injury Statistics Query and Reporting System (WISQARS). Retrieved from http://webappa.cdc.gov/sasweb/ncipc/mortrate10_us.html.
[2] Armed Forces Health Surveillance Center. (2012). Death by suicide while on active duty, active and reserve components, U.S. Armed Forces, 1998-2011. Medical Surveillance Monthly Report, 19(6), 7-10.
LeardMann, C.A., Powell, T.M., Smith, T.C., Bell, M.R., Smith, B., Boyko, E.J., …Hoge, C.W. (2013). Risk factors associated with suicide in current and former U.S. military personnel. Journal of the American Medical Association, 31(5), 496-506.
[3] Armed Forces Health Surveillance Center. (2012). Death by suicide while on active duty, active and reserve components, U.S. Armed Forces, 1998-2011. Medical Surveillance Monthly Report, 19(6), 7-10.
[4] Reger, M.A., Smolenski, D.J., Skopp, N.A., Metzger-Abamukang, M.J., Kang, H.K., Bullman, T.A., …Gahm, G.A. (2015). Risk of suicide among U.S. military service members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the U.S. military. Journal of the American Medical Association Psychiatry, 72(6), 561-569.