Department of Veterans Affairs Transforming Mental Health Care: Promoting Recovery and Integrated...

Department of Veterans Affairs TraDepartment of Veterans Affairs Transforming Mental Health Care: Pronsforming Mental Health Care: Promoting Recovery and Imoting Recovery and Integrated Carentegrated Care

Strategies for Strategies for Preventing Suicide in Preventing Suicide in

TBI PatientsTBI Patients

Janet E. Kemp, RN, PhDJanet E. Kemp, RN, PhDLisa A. Brenner, PhD, ABPPLisa A. Brenner, PhD, ABPP

Beeta Y. Homaifar, PhDBeeta Y. Homaifar, PhD

VA Eastern Colorado Health Care SystemVA Eastern Colorado Health Care SystemVISN 19 Mental Illness Research, Education, VISN 19 Mental Illness Research, Education,

and Clinical Center (MIRECC)and Clinical Center (MIRECC)

AcknowledgmentsAcknowledgments

VISN 19 MIRECCVISN 19 MIRECC Colorado Traumatic Brain Injury Trust Colorado Traumatic Brain Injury Trust

Fund Program – Education GrantFund Program – Education Grant

http://www.fas.org/sgp/crs/natsec/Rhttp://www.fas.org/sgp/crs/natsec/RS22452.pdfS22452.pdf

RelevanceRelevance

As of March 31, 2006, DOD As of March 31, 2006, DOD reported that 1,179 reported that 1,179

individuals have sustained a individuals have sustained a traumatic brain injury (TBI) traumatic brain injury (TBI)

during OIF/OEF.during OIF/OEF.

CDC, 2005CDC, 2005

TBI - Definition TBI - Definition

A bolt or jolt to the head or a penetrating head A bolt or jolt to the head or a penetrating head injury that disrupts the function of the brain. injury that disrupts the function of the brain. Not all blows or jolts to the head result in a Not all blows or jolts to the head result in a TBI. The severity of such an injury may range TBI. The severity of such an injury may range from “mild” (i.e. a brief change in mental from “mild” (i.e. a brief change in mental status or consciousness) to “severe” (i.e. an status or consciousness) to “severe” (i.e. an extended period of unconsciousness or extended period of unconsciousness or amnesia after the injury). A TBI can result in amnesia after the injury). A TBI can result in short or long-term problems with independent short or long-term problems with independent function.function.

Leading Causes of Brain Leading Causes of Brain InjuryInjury

Falls (28%)Falls (28%) Transportation related events (20%)Transportation related events (20%) Assaults (11%)Assaults (11%) BlastsBlasts

TBI-Related SequelaeTBI-Related Sequelae

Sensory deficitsSensory deficits Motor disturbancesMotor disturbances Psychiatric symptoms: anxiety, Psychiatric symptoms: anxiety,

depression, psychosis, personality depression, psychosis, personality changeschanges

Cognitive dysfunction: attention, Cognitive dysfunction: attention, concentration, processing speed, memory, concentration, processing speed, memory, language and communication, problem language and communication, problem solving, concept formation, judgment, solving, concept formation, judgment, initiationinitiation

Background: TBI and SuicideBackground: TBI and Suicide

Studies have shown that significant numbers Studies have shown that significant numbers of TBI patients endorse a post-injury history of TBI patients endorse a post-injury history of suicidal ideation (Simpson and Tate, of suicidal ideation (Simpson and Tate, 2002).2002).

In comparison to the general population, In comparison to the general population, people with a history of traumatic brain people with a history of traumatic brain injury (TBI) have both a higher lifetime injury (TBI) have both a higher lifetime prevalence rate of suicide attempts (Silver prevalence rate of suicide attempts (Silver et al., 2001; Simpson and Tate, 2005) and a et al., 2001; Simpson and Tate, 2005) and a significant increased risk of death by suicide significant increased risk of death by suicide (Teasdale and Engberg, 2001).(Teasdale and Engberg, 2001).

ObjectivesObjectives

Because suicide is a significant issue Because suicide is a significant issue for individuals with a history of for individuals with a history of traumatic brain injury (TBI), and traumatic brain injury (TBI), and since “TBI aware” suicide resources since “TBI aware” suicide resources are limited…are limited…– A qualitative, interview-based study was A qualitative, interview-based study was

conducted in a veteran population to conducted in a veteran population to clarify the needs of TBI survivors and clarify the needs of TBI survivors and their families. their families.

Strategies for Preventing Strategies for Preventing Suicide Suicide

in TBI Patients: Backgroundin TBI Patients: Background Replication study Replication study

– The Acquired Brain Injury Outreach The Acquired Brain Injury Outreach ServiceService (ABIOS) in Australia. (Kupier (ABIOS) in Australia. (Kupier and Lancaster, 2000).and Lancaster, 2000). Findings: Findings:

– Knowledge regarding interface between Knowledge regarding interface between TBI/SuicideTBI/Suicide

– Increased coordination of servicesIncreased coordination of services– Individual educationIndividual education– Discrepancy between needs of clients/familyDiscrepancy between needs of clients/family


in TBI Patients: Recruitmentin TBI Patients: Recruitment Patients were recruited into the study if Patients were recruited into the study if

they met the following criteria:they met the following criteria:– Having received care from members of the Having received care from members of the

ECHCS TBI Interdisciplinary TeamECHCS TBI Interdisciplinary Team– Diagnosis of TBI and a history of suicidal Diagnosis of TBI and a history of suicidal

behavior (ideation, self-harm, nonfatal behavior (ideation, self-harm, nonfatal attempts)attempts)

– Ability to provide informed consent and Ability to provide informed consent and adequately respond to questions regarding the adequately respond to questions regarding the informed consent procedureinformed consent procedure

– Age 18-74Age 18-74 17 participants 17 participants

– (13 TBI survivors and 4 family members)(13 TBI survivors and 4 family members)


in TBI Patients: Methodsin TBI Patients: Methods Interviews were phenomenological in Interviews were phenomenological in

nature, and subsequent questions nature, and subsequent questions were based on the responses to open were based on the responses to open ended questions.ended questions.


in TBI Patients: Survivor in TBI Patients: Survivor QuestionsQuestions

Have you ever felt really down or even thought about Have you ever felt really down or even thought about taking your life?taking your life?

What stopped you or what might have stopped you?What stopped you or what might have stopped you? Who did you turn to for help or what did you do and Who did you turn to for help or what did you do and

how helpful was this?how helpful was this? If you got really down in the future where would you If you got really down in the future where would you

get help or who would you turn to?get help or who would you turn to? What do you think would be the best way to help a What do you think would be the best way to help a

person with TBI who might be depressed or suicidal?person with TBI who might be depressed or suicidal? How do you think your military experience has How do you think your military experience has

affected your feelings about taking your life or how affected your feelings about taking your life or how you feel?you feel?


in TBI Patients: Family in TBI Patients: Family QuestionsQuestions

In general, what do you think would be the most In general, what do you think would be the most effective way of preventing suicide among people effective way of preventing suicide among people with TBI?with TBI?

Who do you think a person with TBI might turn to Who do you think a person with TBI might turn to for help if they were considering suicide?for help if they were considering suicide?

What do you think would be the most effective What do you think would be the most effective way of getting a message across to a person with way of getting a message across to a person with TBI, who might be at risk of suicide?TBI, who might be at risk of suicide?

What is your relationship to the patient we are What is your relationship to the patient we are interviewing?interviewing?


in TBI Patients: Analysisin TBI Patients: Analysis Interviews tape recorded, transcribed Interviews tape recorded, transcribed

and analyzedand analyzed– General and specific themesGeneral and specific themes– Comments outside specific questionsComments outside specific questions– All 13 patients had attempted suicide or All 13 patients had attempted suicide or

had serious thoughts/planshad serious thoughts/plans Attempts and ideation ranged from Attempts and ideation ranged from

1-30 years post-TBI1-30 years post-TBI


in TBI Patients: Findingsin TBI Patients: Findings Precipitating Themes:Precipitating Themes:

– Lack of connectionLack of connection Others/themselvesOthers/themselves Isolated, loneliness, being alone on the Isolated, loneliness, being alone on the

holidays, limited support from others, and holidays, limited support from others, and social anxietysocial anxiety

Loss of self Loss of self »» lack of purpose in their lives. lack of purpose in their lives.

– Frustration, anger regarding sequelaeFrustration, anger regarding sequelae– HopelessnessHopelessness


in TBI Patients: Findingsin TBI Patients: Findings Precipitating ThemesPrecipitating Themes

“I think it took awhile before I realized and then when I started thinking about things and

realizing that I was going to be like this for the rest of my life, it gives me a really down feeling

and it makes me think like—why should I be around like this for the rest of my life?”

- TBI Survivor


in TBI Patients: Findingsin TBI Patients: Findings Preventative FactorsPreventative Factors

– Family and other significant relationshipsFamily and other significant relationships Children, spouses, parents, friends and pets.Children, spouses, parents, friends and pets.

– Sense of responsibilitySense of responsibility– Professional helpProfessional help

Medication, psychotherapy, support groupsMedication, psychotherapy, support groups Active listening, clarifying questions, Active listening, clarifying questions,

patience, talking slowly, repeating patience, talking slowly, repeating instructions several timesinstructions several times

– Spiritual orientationSpiritual orientation– DistractionDistraction


in TBI Patients: Findingsin TBI Patients: Findings Family members:Family members:

– Caregiver burnout Caregiver burnout – Professionals need to know about TBI Professionals need to know about TBI

and enduring sequelaeand enduring sequelae Conversations about the possibility of their Conversations about the possibility of their

family member becoming suicidalfamily member becoming suicidal Involving them in treatment planningInvolving them in treatment planning Assistance with resources and ongoing Assistance with resources and ongoing

support support MedicationMedication Case managersCase managers

– ““Somone to go to for help”Somone to go to for help”


in TBI Patients: Findingsin TBI Patients: Findings Family members:Family members:

“The doctors need to know that the caregiver has no idea what to expect. I don’t know if

they just don’t know that much about it or they just don’t get it.”

- A TBI Survivor’s Wife


in TBI Patients: Findingsin TBI Patients: Findings Common themes expressed by both Common themes expressed by both

patients and family members:patients and family members:– Continued support in the face of no Continued support in the face of no

functional improvement functional improvement

““Provide hope while telling us the truth”Provide hope while telling us the truth”


in TBI Patients: Warning Signsin TBI Patients: Warning Signs Be aware of what Be aware of what

can precipitate can precipitate suicidal thoughts suicidal thoughts in people with TBI:in people with TBI:– LonelinessLoneliness– Lack of connectionLack of connection– Holiday timesHoliday times– Lack of supportLack of support– Job/employment issuesJob/employment issues– Lack of resourcesLack of resources– Frustration over tasksFrustration over tasks– Bad news about prognosisBad news about prognosis

““I had my heart set on I had my heart set on it, and for three it, and for three

days I just sat in my days I just sat in my room and room and

contemplated how contemplated how to do this. And to do this. And

finally it got to the finally it got to the point where I point where I

tried….”tried….”

- A TBI Survivor- A TBI Survivor


in TBI Patients: Limitationsin TBI Patients: Limitations Cognitive deficitsCognitive deficits Small population sizeSmall population size

– Saturation reachedSaturation reached Limited to Denver areaLimited to Denver area


in TBI Patients: The Next in TBI Patients: The Next Steps…Steps…

Receive feedback from participants Receive feedback from participants Receive feedback from providersReceive feedback from providers Continued study replication in other Continued study replication in other

geographic areasgeographic areas

Take Home MessageTake Home Message

The fact that individuals continued to The fact that individuals continued to endorse suicidal behaviors up to 30 endorse suicidal behaviors up to 30 years post-TBI suggests that this is a years post-TBI suggests that this is a problem that requires professional problem that requires professional attention over the course of a attention over the course of a lifetime…lifetime…

VISN 19 MIRECC1055 Clermont St.Denver, CO 80220

Traumatic Brain Injury and SuicideAn information manual for clinicians

Inside this manual:

Background Information: 2

Suicide and TBI: 8

Suicide Warning Signs: 11

Provider Tips: 13

Treatment-Literature: 15

Our Study: 16

Findings: 17

Resources: 18

References: 24

Introduction

There is a need for more resources that are specifically targeted toward Traumatic Brain Injury (TBI) survivors who may be considering suicide. Based upon this need, researchers at the VISN 19 MIRECC applied for a Colorado TBI Trust Fund Education Grant in order to:

1. Develop a resource manual and brochure regarding TBI and suicide prevention aimed at meeting the needs of Colorado State veterans.

2. Make this material available to the state-wide community of providers who work with brain injured individuals.

VISN 19 MIRECC1055 Clermont St.Denver, CO 80220

References:References:

Ahmed, I., Fujii D. (1998). Posttraumatic psychosis. Ahmed, I., Fujii D. (1998). Posttraumatic psychosis. Seminar in Clinical Seminar in Clinical NeuropsychiatryNeuropsychiatry, 3, 23-33., 3, 23-33.

Alderfer, B., Arcinegas, D.B., Silver, J.M. (2005). Treatment of Depression Alderfer, B., Arcinegas, D.B., Silver, J.M. (2005). Treatment of Depression Following Traumatic Brain Injury. Following Traumatic Brain Injury. Journal Of Head Trauma Rehabilitation, 20, Journal Of Head Trauma Rehabilitation, 20, 6, 6, 544-562.544-562.

American Association of Suicidology (2005). Resource Sheet #4 – Basic American Association of Suicidology (2005). Resource Sheet #4 – Basic Terms. Clinical Core Competencies Draft Curriculum.Terms. Clinical Core Competencies Draft Curriculum.

Centers for Disease Control and Prevention. (2005). WISQARS website and Centers for Disease Control and Prevention. (2005). WISQARS website and Fatal injury reports. Retrieved from Fatal injury reports. Retrieved from http://www.cdc.gov/ncipc/wisqars/http://www.cdc.gov/ncipc/wisqars/ February 7, 2006.February 7, 2006.

Cocoran, C., McAllister, T.W., and Malaspina, D. Psychotic Disorders. In: Silver Cocoran, C., McAllister, T.W., and Malaspina, D. Psychotic Disorders. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 213-229.Arlington, VA: American Psychiatric Publishing; 2005. 213-229.

Fann, J.R., Burington, B., Leonetti, A., Jaffe, K, Katon, W., Thompson, R.S. Fann, J.R., Burington, B., Leonetti, A., Jaffe, K, Katon, W., Thompson, R.S. (2004). Psychiatric Illness Following Traumatic Brain Injury in an Adult Health (2004). Psychiatric Illness Following Traumatic Brain Injury in an Adult Health Maintenance Organization Population. Maintenance Organization Population. Archives of General PsychiatryArchives of General Psychiatry, 61, , 61, 53-61.53-61.

Hibbard, M.R., Ashman, T.A., Spielman, L.A., Chun, D. Charatz, H.J., Melvin, S. Hibbard, M.R., Ashman, T.A., Spielman, L.A., Chun, D. Charatz, H.J., Melvin, S. (2004) Relationship Between Depression and Psychosocial Functioning After (2004) Relationship Between Depression and Psychosocial Functioning After Traumatic Brain Injury. Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation, 85, Archives of Physical Medicine and Rehabilitation, 85, 2, 2, S43-S53.S43-S53.

Hornstein, A. Social Issues. Textbook of Traumatic Brain Injury. Arlington, VA: Hornstein, A. Social Issues. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 571-581.American Psychiatric Publishing; 2005. 571-581.

Jorge, R.E., Robinson, R.G., Arndt, S.V. (1993). Depression Following Jorge, R.E., Robinson, R.G., Arndt, S.V. (1993). Depression Following Traumatic Brain Injury. Traumatic Brain Injury. Journal of Affective Disorders, 27, Journal of Affective Disorders, 27, 233-243. 233-243.

References (cont.):References (cont.):

Kraus, J.F. and Chu, L.D. Epidemiology. In: Silver JM, McAllister TW, Kraus, J.F. and Chu, L.D. Epidemiology. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 3-26.American Psychiatric Publishing; 2005. 3-26.

Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. United States: Emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006.for Injury Prevention and Control; 2006.

Maris, R.W., Berman, A.L., Silverman, M.M. (2000). Comprehensive Maris, R.W., Berman, A.L., Silverman, M.M. (2000). Comprehensive Textbook of Suicidology. The Guilford Press: New York.Textbook of Suicidology. The Guilford Press: New York.

McCullagh S, Feinstein A. Cognitive changes. In: Silver JM, McAllister TW, McCullagh S, Feinstein A. Cognitive changes. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. p 321-35.American Psychiatric Publishing; 2005. p 321-35.

McIntosh, J. (2006). McIntosh, J. (2006). USA suicide: 2003 Official final data. USA suicide: 2003 Official final data. Fact sheet Fact sheet developed by the American Association of Suicidology from National Center developed by the American Association of Suicidology from National Center Health Statistics. Health Statistics. www.suicidology.orgwww.suicidology.org..

National Center for Health Statistics (1998). National Center for Health Statistics (1998). Vital Statistics of the United Vital Statistics of the United States, 1996: Vol. II. Mortality, Part A.States, 1996: Vol. II. Mortality, Part A. Washington, D.C.: US Government Washington, D.C.: US Government Printing Office.Printing Office.

Robinson, R.G. and Jorge, R.E. Mood Disorders. In: Silver JM, McAllister TW, Robinson, R.G. and Jorge, R.E. Mood Disorders. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 201-212.American Psychiatric Publishing; 2005. 201-212.

Silver, J.M., Kramer, R., Greenwald, S., Weissman, M. The association Silver, J.M., Kramer, R., Greenwald, S., Weissman, M. The association between head injuries and psychiatric disorders: findings from the New between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiological Catchment Area Study. Haven NIMH Epidemiological Catchment Area Study. Brain InjuryBrain Injury, 15, 11, , 15, 11, 935-945.935-945.

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