Self Directed Violence Classification System

Self Directed Violence Classification System

The Self-Directed Violence Classification System (SDVCS) What it is and why it matters Bridget B. Matarazzo, Psy.D. VISN 19 Mental Illness Research Education and Clinical Center; University of Colorado, School of Medicine, Department of Psychiatry Developed in collaboration with the Centers for Disease Control and Prevention Presentation Overview Brief Introduction Background Information

Development of the SDVCS Using the SDVCS Vignettes Q&A A Brief Introduction to the Epidemiology of Suicide and Veteran Suicide Studies Epidemiological Trends Suicide in the U.S. (2000-2006) 19.7 19.2 19.4 16.1 18.6 20.1

U.S. average suicide rate = 11/100,000 High Epidemiological Trends Suicide in the U.S. (2000-2006) 6-7 U.S. average suicide rate = 11/100,000 Low Facts about Veteran Suicide ~34,000 US deaths from suicide/ year.

Centers for Disease Control and Prevention ~20% are Veterans. National Violent Death Reporting System ~18 deaths from suicide/day are Veterans. National Violent Death Reporting System ~ 5 deaths from suicide/day among Veterans receiving care in VHA. VA Serious Mental Illness Treatment, Research and Evaluation Center

No evidence for increased rates in OEF/OIF Veterans relative to sex, age, and race matched people in the population as a whole. VA Office of Environmental Epidemiology Facts about Veteran Suicide More than 60% of suicides among utilizers of VHA services are among patients with a known diagnosis of a mental health condition Serious Mental Illness Treatment Research and Education Center Before enhancements, rates in facilities depended upon the quality of mental health services Office of Mental Health Services

Veterans are more likely to use firearms as a means. National Violent Death Reporting System ~1000 attempts/month among Veterans receiving care in VHA as reported by suicide prevention coordinators. ~8 % repeat attempts with an average of 3 months follow-up ~0.45% deaths from suicide in attempters with an average of 3 months follow-up ~30% of recent suicides have a history of previous attempts VA National Suicide Prevention Coordinator Blue Ribbon Panel In 2008, former Secretary of Veterans Affairs, Dr. James B. Peake, recommended a standard nomenclature for suicide

and suicide attempts to improve Veterans Affairs (VA): 1. Suicide prevention programs 2. Suicide prevention research 3. Suicide prevention education Suicide Prevention: Basic Strategy Basic Strategy Suicide prevention requires ready access to high quality mental health (and other health care) services Supplemented by programs designed to: Help individuals & families engage in care Address suicide prevention in high risk patients. Specific Initiatives Established for Suicide Prevention Hubs of expertise

CoE MIRECC National programs for education and awareness Operation S.A.V.E Suicide Risk Management Training for Clinicians TBI and Suicide Women Veterans and Suicide (in development) 24/7 Crisis Line, 1-800-273-TALK (8255), Push #1 Veterans Chat Suicide Prevention Coordinators (SPC) Federal partnerships Self-Directed Violence

Classification System Training Objective: to learn and begin using a new nomenclature for self-directed violence Training Overview Review of the language of suicidology Rationale for a self-directed violence classification system Implementation of a new classification system A Brief History of the Development of a Nomenclature and Classification System Case Example A healthy 24-year-old female Veteran is brought by her boyfriend to the Emergency Department after she ingested all remaining pills in a bottle of regular strength Tylenol. She estimates there were 4 to 6 pills total in the

bottle (1300-1950 mg total dose), and she reports no ill effects. Lab tests done at the time of admission to the ED reported her acetaminophen level within the therapeutic range. During triage, she states that before she took the pills she was upset from arguing with her boyfriend and just wanted to die. She feels better now and requests to go home. What is the Behavior? Gesture? Threat? Acting Out/Manipulation? Attempt? Other? What criteria did you use to decide? - Lethality of method? - Expressed intent?

- Number of pills ingested? - Lab results? - Other? The Language of Self-Directed Violence Identification of the Problem

Suicidal ideation Death wish Suicidal threat Cry for help Self-mutilation Parasuicidal gesture Suicidal gesture Risk-taking behavior Deliberate Self-Harm Non-Suicidal Self Injury Suicidal Gesture

Self-harm Self-injury Suicide attempt Aborted suicide attempt Accidental death Unintentional suicide Successful attempt Completed suicide Life-threatening behavior Suicide-related behavior Suicide

The Language of Self-Directed Violence Why Does It Matter? A rose is a rose is a rose is a rose Sacred Emily, by Gertrude Stein, 1913 Whats in a name? that which we call a rose By any other name would still smell as sweet Juliet in Romeo and Juliet, by Shakespeare, 1600 EXCEPT IN THE FIELD OF SUICIDOLOGY: WHERE a Suicide Attempt (by one persons assessment) IS NOT ALWAYS a Suicide Attempt (by anothers)? The Problem The field of suicidology is challenged by the lack of conceptual clarity about suicidal behaviors and a corresponding lack of welldefined terminology - In both research and clinical descriptions of suicidal acts There is a great variability of terms referring to the same

behaviors (e.g., threat, gesture). Terms are often pejorative and based on incorrect notions about seriousness and lethality of methods (e.g., manipulative, non-serious, etc). Hence It becomes very difficult to: Accurately count the number of suicides and suicide attempts that occur annually Accurately differentiate suicide attempts from non-suicidal selfinjuries Conduct longitudinal studies of suicide attempters Communicate between and among clinicians, researchers, patients, and patients families Establish suicide and suicide attempts as a major public health problem that warrants investment of resources The Language of Self-Directed Violence Implications of the Problem Clinical

Research Public Health (e.g., surveillance) Public Policy Current Terminology Research Implications of the Problem Example 1. (Dhossche, 2000) Current Terminology Research Implications of the Problem Example 2. (Hickey, Hawton, Fagg, & Weitzel, 2001) Consequences of Ill-Defined Terms Makes interpreting the meaning of self-injurious acts more

difficult and hampers precise communication on individual or population basis Some Self-injurious acts that should be classified as suicidal may be mislabeled Other types of Self-injurious acts may be inappropriately classified as suicidal The Need for Consistent Definitions & Data Elements Research on suicide is plagued by many methodological problems Definitions lack uniformity reporting of suicide is inaccurate (Reducing Suicide: A National Imperative, Institute of Medicine, 2002) 15 Definitions of Suicide Synonyms for Suicide

Committed Suicide Completed Suicide Failed Attempt Fatal Repeater Fatal Suicide Fatal Suicide Attempt Hastened Death Intentional Self-Murder

Intentional Suicide Lethal Suicide Attempt Rational Suicide Self-Inflicted Death Self-Murder Self-Slaughter

Sub-intentional Death Suicide Victim Successful Attempt Successful Suicide Unintentional Suicide 9 Definitions of Non-fatal Self-Harm Synonyms for Suicide Attempt

Aborted Suicide Attempt Attempted Suicide Cry for Help Death Rehearsals Deliberate Self-Harm Failed Attempts Failed Completion Failed Suicide Instrumental Suicide-Related Behavior Near Lethal Self-Harm Near Miss Attempt

Non-Fatal Suicide-Related Behavior Non-Fatal Self-Harm Behavior Non-Lethal Self-Injurious Act Non-Suicidal Self-injury Parasuicide

Risk-Taking Behavior Self-Assaultive Behavior Self-Destructive Behavior Self-Harm Behavior Self-Inflicted Behavior Self-Injurious Behavior Suicidal Episode Suicidal Manipulation Suicidal Rehearsal Suicidality What does this term actually mean? What behaviors are included in this term?

State of being Suicidal? Suicidal Proneness? Suicidal Motivation? Suicidal Intentionality? Suicidal Proclivity? Suicidal Ideation? Suicidal Intent? Suicidal Gesture? Suicidal Threat? Suicide-Related Thoughts?

Suicide-Related Behavior? Unacceptable Terms Attempted Suicide Completed Suicide Committed Suicide Failed Attempt Failed Completion Fatal Suicide Attempt Parasuicide

Nonfatal Suicide Attempt Nonfatal Suicide Successful Suicide Suicidality Suicide Threat Suicide Victim Suicide Gesture Manipulative Act

The Language of Self-Directed Violence A Solution to the Problem NOMENCLATURE CLASSIFICATION SYSTEM The Language of Self-Directed Violence A Solution to the Problem Nomenclature (def.) - a set of terms that are: Commonly understood Widely acceptable Comprehensive These terms: Define the basic clinical phenomena (of suicide and suicide-related behaviors) Are based on a logical set of necessary component elements that can be easily applied

(Silverman, 2006) What is the Purpose of a Nomenclature? enhance clarity of communication have applicability across clinical settings be theory neutral be culturally neutral use mutually exclusive terms that encompass the spectrum of thoughts and actions Peter Brueghel the Elder, 1563

What is a Classification System? Essential Features Builds upon a nomenclature (e.g., terminology) Exhaustive categorization and breakdown of subtypes of related behaviors (e.g., covers all possibilities) Further differentiates amongst phenomena that appear to be similar by use of modifiers (Silverman, 2006) Beck, et al., Classification (1974) SLTB, 26, 237-252, 1996 OCarroll, et al. Nomenclature (1996)

Rebuilding the Tower of Babel: A Revised Nomenclature for the Study of Suicide and Suicidal Behaviors Part I: Background, Rationale, and Methodology Part II: Suicide-Related Ideations, Communications and Behaviors Morton M. Silverman, M.D. Alan L. Berman, Ph.D. Nels D. Sanddal, M.S. Patrick OCarroll, M.D., M.P.H. Thomas E. Joiner, Jr., Ph.D. SLTB (2007), 37(3), 248-277 Suicide-Related IDEATIONS Suicide-Related COMMUNICATIONS Suicide-Related BEHAVIORS

Suicide-Related Behaviors INTENT TO DIE? NO UNDETERMINED YES SELF-HARM UNDETERMINED SUICIDE ATTEMPT SUICIDE ATTEMPT

SELF-INFLICTED INJURY? SELF-INFLICTED INJURY? SELF-INFLICTED INJURY? NO SELF-HARM I YES NO YES

NO YES FATAL? UNDETERMINED SUICIDERELAGED BEHAVIOR I FATAL? SUICIDE ATTEMPT I FATAL?

NO YES NO YES NO YES SELF-HARM II SELF-INFLICTED UNINTENTIONAL DEATH

UNDETERMINED SUICIDERELATED DEATH II SELF-INFLICTED DEATH with UNDETERMINED INTENT SUICIDE ATTEMPT II SUICIDE Suicide-Related Behaviors Development of the SDVCS Response to The Blue Ribbon Panel

VISN 19 MIRECCs collaboration with Silverman, et al. Development of a clinically feasible system, based on research, theory, and clinician feedback Collaboration with the CDC Pilot testing at VA and non-VA sites Testing of Feasibility via QUERI Phase I Rapid Response Project Why Self-Directed Violence ? Blue Ribbon Task Force recommendation was to work with CDC and other federal agencies on the development of a nomenclature and classification system CDC was already developing a Self-Directed Violence Surveillance System that included Uniform Definitions and Recommended Data Elements The opportunity presented itself for the VHA, DoD, and CDC to adopt the same nomenclature and classification system Violence

is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation. (Source: World Health Organization) Violent episode Interpersonal Homicide Self-directed Assault Suicide

Nonfatal suicidal behavior Nonsuicidal behavior CDC Flowchart for surveillance definitions for self-directed violence Self-directed violence (SDV) Suicidal self-directed violence Fatal (suicide)

Undetermined self-directed violence Non-fatal Fatal Suicidal SDV with or without injury e.g., Interrupted (by self or by another) Other suicidal behavior e.g., Preparatory

Non-suicidal self-directed violence Non-fatal Fatal Undetermined SDV with or without injury e.g., Interrupted (by self or by another) Other undetermined SDV e.g., Preparatory

Non-fatal Non-suicidal SDV with or without injury e.g., Interrupted (by self or by another) Other non-suicidal SDV e.g., Preparatory The Self-Directed Violence Classification System Research Team Members Lisa A. Brenner, Ph.D.

Ryan E. Breshears, Ph.D. Lisa M. Betthauser, M.B.A. Katherine K. Bellon, Ph.D. Elizabeth Holman, Ph.D. Jeri E.F. Harwood, Ph.D. Morton M. Silverman, M.D. Joe Huggins, M.S.W./M.S.C.I.S. Herbert T. Nagamoto, M.D. VISN 19 Mental Illness Research Education and Clinical Center Denver VA Medical Center University of Colorado, Denver, School of Medicine WellStar Health System, Georgia University of Georgia, Athens Department of Biostatistics and Informatics, Colorado School of Public Health Key Concept Suicidal Intent Suicidal Intent:

There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior. The individual COMPONENT 1 wishes to die COMPONENT 2 means to kill him/herself COMPONENT 3 understands the probable consequences (i.e. death) Type Sub-Type Non-Suicidal

SelfDirected Violence Ideation Thoughts Definition Preparatory N/A Behaviors Undetermin ed SelfDirected Violence

Suicidal SelfDirected Non-Suicidal Self-Directed Violence Ideation For example, persons engage in Non-Suicidal Self-Directed Violence Ideation in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention). For example, intrusive thoughts of suicide without the wish to die would be classified as Suicidal Ideation, Without Intent. Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for ones death by suicide (e.g., writing a suicide note, giving things away). For example, hoarding medication for the purpose of overdosing would be classified as Suicidal Self-Directed Violence, Preparatory.

Non-Suicidal SelfDirected Violence Terms Self-reported thoughts regarding a persons desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent. Thoughts of engaging in suicide-related behavior. Suicidal Ideation Modifiers Behavior that is self-directed and deliberately results in injury or

the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent. For example, persons engage in Non-Suicidal Self-Directed Violence in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention). Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based upon the available evidence. For example, the person is unable to admit positively to the intent to die (e.g., unconsciousness, incapacitation, intoxication, acute psychosis, disorientation, or death); OR the person is reluctant to admit positively to the intent to die for other or

unknown reasons. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent. Suicidal Intent -Without Undetermined -With Suicidal Intent -Without Undetermined -With Injury -Without

-With -Fatal Interrupted by Self or Other Injury -Without -With -Fatal Interrupted by Self or Other Injury -Without -With -Fatal

Suicidal Ideation, Without Suicidal Intent Suicidal Ideation, With Undetermined Suicidal Intent Suicidal Ideation, With Suicidal Intent Non-Suicidal Self-Directed Violence, Preparatory Undetermined Self-Directed Violence, Preparatory Suicidal Self-Directed Violence, Preparatory Non-Suicidal Self-Directed Violence, Injury Non-Suicidal Self-Directed Violence, Injury, Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Injury Non-Suicidal Self-Directed Violence, Injury,

Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Without Without With With Fatal Undetermined Self-Directed Violence, Without Injury Undetermined Self-Directed Violence, Without Injury, Interrupted by Self or Other Undetermined Self-Directed Violence, With Injury

Undetermined Self-Directed Violence, With Injury, Interrupted by Self or Other Undetermined Self-Directed Violence, Fatal Suicide Attempt, Without Injury Suicide Attempt, Without Injury, Interrupted by Self or Other Suicide Attempt, With Injury Type Sub-Type Non-Suicidal SelfDirected Violence Ideation Thoughts

Definition Preparatory N/A Behaviors Undetermin ed SelfDirected Violence Suicidal SelfDirected Non-Suicidal Self-Directed Violence Ideation

For example, persons engage in Non-Suicidal Self-Directed Violence Ideation in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention). When both Thoughts and Behaviors are present Behaviors trump Thoughts for purposes of classification For example, intrusive thoughts of suicide without the wish to die would be classified as Suicidal Ideation, Without Intent. Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for ones death by suicide (e.g., writing a

suicide note, giving things away). For example, hoarding medication for the purpose of overdosing would be classified as Suicidal Self-Directed Violence, Preparatory. Non-Suicidal SelfDirected Violence Terms Self-reported thoughts regarding a persons desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent. Self-reported thoughts of engaging in suicide-related behavior. Suicidal Ideation

Modifiers Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent. For example, persons engage in Non-Suicidal Self-Directed Violence in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention). Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based upon the available evidence. For example, the person is unable to admit positively to the intent to die

(e.g., unconsciousness, incapacitation, intoxication, acute psychosis, disorientation, or death); OR the person is reluctant to admit positively to the intent to die for other or unknown reasons. Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent. Suicidal Intent -Without Undetermined -With Suicidal Intent -Without Undetermined

-With Injury -Without -With -Fatal Interrupted by Self or Other Injury -Without -With -Fatal Interrupted by Self or Other

Injury -Without -With -Fatal Suicidal Ideation, Without Suicidal Intent Suicidal Ideation, With Undetermined Suicidal Intent Suicidal Ideation, With Suicidal Intent Non-Suicidal Self-Directed Violence, Preparatory Undetermined Self-Directed Violence, Preparatory Suicidal Self-Directed Violence, Preparatory Non-Suicidal Self-Directed Violence, Injury Non-Suicidal Self-Directed Violence, Injury, Interrupted by Self or Other

Non-Suicidal Self-Directed Violence, Injury Non-Suicidal Self-Directed Violence, Injury, Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Without Without With With Fatal Undetermined Self-Directed Violence, Without Injury Undetermined Self-Directed Violence,

Without Injury, Interrupted by Self or Other Undetermined Self-Directed Violence, With Injury Undetermined Self-Directed Violence, With Injury, Interrupted by Self or Other Undetermined Self-Directed Violence, Fatal Suicide Attempt, Without Injury Suicide Attempt, Without Injury, Interrupted by Self or Other Suicide Attempt, With Injury Type Sub-Type Non-Suicidal SelfDirected

Violence Ideation Thoughts Definition Modifiers Self-reported thoughts regarding a persons desire to engage in self-inflicted potentially injurious behavior. There is no evidence of suicidal intent. N/A Preparatory For example, intrusive thoughts of suicide without the wish to die would be classified as Suicidal Ideation, Without Intent.

Behaviors Undetermin ed SelfDirected Violence Suicidal SelfDirected Suicidal Intent -Without Undetermined -With Suicidal Ideation, Without Suicidal Intent Suicidal Ideation, With Undetermined Suicidal Intent

Suicidal Ideation, With Suicidal Intent When both are present, Self-Directed Violent Behaviors trump Preparatory for purposes of classification Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for ones death by suicide (e.g., writing a suicide note, giving things away). For example, hoarding medication for the purpose of overdosing would be classified as Suicidal Self-Directed Violence, Preparatory. Non-Suicidal SelfDirected

Violence Non-Suicidal Self-Directed Violence Ideation For example, persons engage in Non-Suicidal Self-Directed Violence Ideation in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention). Self-reported thoughts of engaging in suicide-related behavior. Suicidal Ideation Terms Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, whether implicit or explicit, of suicidal intent.

For example, persons engage in Non-Suicidal Self-Directed Violence in order to attain some other end (e.g., to seek help, regulate negative mood, punish others, to receive attention). Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. Suicidal intent is unclear based upon the available evidence. For example, the person is unable to admit positively to the intent to die (e.g., unconsciousness, incapacitation, intoxication, acute psychosis, disorientation, or death); OR the person is reluctant to admit positively to the intent to die for other or unknown reasons.

Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is evidence, whether implicit or explicit, of suicidal intent. Suicidal Intent -Without Undetermined -With Injury -Without -With -Fatal Interrupted by Self or Other

Injury -Without -With -Fatal Interrupted by Self or Other Injury -Without -With -Fatal Non-Suicidal Self-Directed Violence, Preparatory Undetermined Self-Directed Violence, Preparatory Suicidal Self-Directed Violence, Preparatory

Non-Suicidal Self-Directed Violence, Injury Non-Suicidal Self-Directed Violence, Injury, Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Injury Non-Suicidal Self-Directed Violence, Injury, Interrupted by Self or Other Non-Suicidal Self-Directed Violence, Without Without With With Fatal

Undetermined Self-Directed Violence, Without Injury Undetermined Self-Directed Violence, Without Injury, Interrupted by Self or Other Undetermined Self-Directed Violence, With Injury Undetermined Self-Directed Violence, With Injury, Interrupted by Self or Other Undetermined Self-Directed Violence, Fatal Suicide Attempt, Without Injury Suicide Attempt, Without Injury, Interrupted by Self or Other Suicide Attempt, With Injury Using the Clinical Tool

CASE EXAMPLE 1: A Veteran comes in for an initial mental health intake. During the intake, the therapist and the Vet have the following dialogue: Therapist: Have you had thoughts of suicide? Veteran: There have been times when Ive thought about it. Therapist: Times? Like recently? Veteran: Yeah, well sometimes those thoughts enter my mind. Therapist: Can you say more about that? Veteran: Well if you had the pain I have, you might understand. Therapist: Youre telling me that your pain feels unbearable at times? Veteran: Yeah, like yesterday I thought it would be better if I just went to sleep and never woke up. Therapist: So you wanted to die? Veteran: Yeah, you could say that. Therapist: Did you take any actions to make that happen? Veteran: You mean, like, did I try to kill myself? Therapist: Yes. Veteran: Oh no. I mean I thought about it, but I didnt do anything. I just took

my medication like I always do. Therapist: Your medication? Veteran: Yeah, my pain meds. They usually help the pain pretty well. CASE EXAMPLE 2: During a therapy session, a therapist and Veteran engage in the following dialogue: Therapist: Have you had thoughts of hurting yourself recently? Veteran: Ive had thoughts like that for several years. Therapist: Can you tell me about some of the thoughts youve had since your last visit a week ago? Veteran: I would prefer not to. Therapist: I can respect your right to choose what you want to tell me. Veteran: I just dont want you to get the wrong idea. Therapist: You seem concerned that I might. Veteran: Well, the last therapist I mentioned anything to put me in the hospital. I dont want to go through that again. Therapist: Thats understandable. I would certainly like to prevent that if possible. I do, however, want to make sure youre safe.

Veteran: I appreciate that. I think Im ok. Therapist: You think? Veteran: Well, there was a time last week when I was feeling pretty bad, and I was reading online about ways to kill yourself, but I didnt do anything. And I dont plan to do anytime soon. Therapist: I see. When you say you didnt do anything, youre saying that you did not try to hurt yourself? Veteran: Yeah. DECISION TREE B: BEHAVIORS, WITHOUT INJURY CASE EXAMPLE 3: A Veteran is being seen for a psychiatric evaluation. During the diagnostic interview, the clinician inquires about the Veterans history. Therapist: Have you ever hurt yourself on purpose? Veteran: Long time ago. Therapist: Can you tell me about that? Veteran: Well, it was a while ago, but I attempted suicide once.

Therapist: Can you say more about that? Veteran: I tried to throw myself down a flight of steps. Therapist: Tried to? Veteran: Yeah. Therapist: What prevented you from doing it? Veteran: Well, I guess I didnt actually try to. I just thought about doing it. Therapist: So you had the urge or impulse, but didnt actually do it? Veteran: Right. Therapist: I know you said it was a long time ago, but can you tell me about the circumstances that led up to that impulse? Veteran: It was a very long time ago, so it is hard to remember the details. DECISION TREE A: THOUGHTS CASE EXAMPLE 4: Working with a depressed Veteran, you ask if she ever has thoughts of killing herself. She says, Well, sometimes the thought pops into my head, but I would never do it because of my kids.

DECISION TREE A: THOUGHTS CASE EXAMPLE 4: Working with a depressed Veteran, you ask if she ever has thoughts of killing herself. She says, Well, sometimes the thought pops into my head, but I would never do it because of my kids. DECISION TREE A: THOUGHTS Key Terms (Centers for Disease Control and Prevention) Suicidal Intent: There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior. CASE EXAMPLE 5: A wife finds her husband tearful and holding a knife to his wrist. He has already made a few small cuts. On his bed is a note stating, I cant go on like this. Youll be better off without me.

CASE EXAMPLE 5: A wife finds her husband tearful and holding a knife to his wrist. He has already made a few small cuts. On his bed is a note stating, I cant go on like this. Youll be better off without me. 3. Did the behavior involve any injury or did it result in death? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C DECISION TREE C: BEHAVIORS, WITH INJURY CASE EXAMPLE 5: A wife finds her husband tearful and holding a knife to his wrist. He has already made a few small cuts. On his bed is a note stating, I cant go on like this. Youll be better off without me. 3. Did the behavior involve any injury or did it result in death?

If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C DECISION TREE C: BEHAVIORS, WITH INJURY CASE EXAMPLE 5: A wife finds her husband tearful and holding a knife to his wrist. He has already made a few small cuts. On his bed is a note stating, I cant go on like this. Youll be better off without me. 3. Did the behavior involve any injury or did it result in death? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C DECISION TREE C: BEHAVIORS, WITH INJURY CASE EXAMPLE 6: A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years and

contacts his attorney asking to revise his will. His son asks him about these behaviors, and he refuses to answer, changing the subject. CASE EXAMPLE 6: A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years and contacts his attorney asking to revise his will. His son asks him about these behaviors, but he changes the subject. 3. Did the behavior involve any injury or result in death? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C DECISION TREE B: BEHAVIORS, WITHOUT INJURY Key Concept Preparatory Behavior Preparatory:

Acts or preparation towards engaging in Self-Directed Violence, but before potential for injury has begun. This can include anything beyond a verbalization or thought, such as assembling a method (e.g., buying a gun, collecting pills) or preparing for ones death by suicide (e.g., writing a suicide note, giving things away). 4:00 p.m. 5:00 p.m. 6:00 p.m. preparatory behaviors 8:00 p.m. a self-harm or suicidal behavior

occurs CASE EXAMPLE 6: A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years and contacts his attorney to revise his will. His son asks him about these behaviors, but he changes the subject. 3. Did the behavior involve any injury or result in death? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C DECISION TREE B: BEHAVIORS, WITHOUT INJURY Key Terms (Centers for Disease Control and Prevention) Suicidal Intent: There is past or present evidence (implicit or explicit) that an individual wishes to die,

means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior. CASE EXAMPLE 6: A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years and contacts his attorney to revise his will. His son asks him about these behaviors, but he changes the subject. 3. Did the behavior involve any injury or result in death? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C DECISION TREE B: BEHAVIORS, WITHOUT INJURY NOW SUPPOSE: The veteran never purchased the ammunition

Key Terms (Centers for Disease Control and Prevention) Suicidal Intent: There is past or present evidence (implicit or explicit) that an individual wishes to die, means to kill him/herself, and understands the probable consequences of his/her actions or potential actions. Suicidal intent can be determined retrospectively and in the absence of suicidal behavior. CASE EXAMPLE 6: A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years contacts his attorney to revise his will. His son asks him about these behaviors, but he changes the subject. 3. Did the behavior involve any injury or result in death? If NO, proceed to Decision Tree B If YES, proceed to Decision Tree C

DECISION TREE B: BEHAVIORS, WITHOUT INJURY NEW UPDATE: One week later, the veteran is deceased from a selfinflicted gunshot wound. CASE EXAMPLE 6: A 75-year-old veteran loses his wife to cancer. Within hours, he purchases ammunition for a handgun he has had for years and contacts his attorney to revise his will. His son asks him about these behaviors, but he changes the subject. One week later, the veteran is deceased from a self-inflicted gunshot wound. DECISION TREE C: BEHAVIORS, WITH INJURY REVISITING FIRST CASE EXAMPLE: A healthy 24-year-old female Veteran is brought by her boyfriend to the Emergency Department after she ingested all remaining pills in a bottle of regular strength Tylenol. She estimates there were 4 to 6 pills total in the bottle (1300-1950 mg total dose), and she reports no ill effects. Lab tests done at the time of admission to the ED reported her acetaminophen level within the

therapeutic range. During triage, she states that before she took the pills she was upset from arguing with her boyfriend and just wanted to die. She feels better now and requests to go home. REVISITING FIRST CASE EXAMPLE: A healthy 24-year-old female Veteran is brought by her boyfriend to the Emergency Department after she ingested all remaining pills in a bottle of regular strength Tylenol. She estimates there were 4 to 6 pills total in the bottle (1300-1950 mg total dose), and she reports no ill effects. Lab tests done at the time of admission to the ED reported her acetaminophen level within the therapeutic range. During triage, she states that before she took the pills she was upset from arguing with her boyfriend and just wanted to die. She feels better now and requests to go home. VIGNETTE A A Vet is drinking near a lake with a group of friends on Labor Day. On a dare, he and his old Army buddy decide to play Russian

Roulette with a loaded gun. The Vet puts the gun to his head, pulls the trigger, and dies instantly from a gunshot wound to the head. VIGNETTE A A Vet is drinking near a lake with a group of friends on Labor Day. On a dare, he and his old Army buddy decide to play Russian Roulette with a loaded gun. The Vet puts the gun to his head, pulls the trigger, and dies instantly from a gunshot wound to the head. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related

thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined VIGNETTE B A Vet with no history of suicidal behavior points the tip of a hunting knife against his bare chest but, as he begins to apply pressure, decides not to go any further, and calls the VA Crisis Line. When asked why he did this, he repeatedly answers, Gee, I dont know why. VIGNETTE B

A Vet with no history of suicidal behavior points the tip of a hunting knife against his bare chest but, as he begins to apply pressure, decides not to go any further, and calls the VA Crisis Line. When asked why he did this, he repeatedly answers, Gee, I dont know why. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y,

Undetermined VIGNETTE C During a crisis call, a Vet reports she has been feeling depressed and hopeless. The VA Crisis Line responder asks if she ever has thoughts of killing herself. She answers, Well, sometimes I think it would be better if I werent here, but I never really talk to anybody about it, until now. I dont think that I would ever act on those ideas, I just think about it sometimes and it frightens me. VIGNETTE C During a crisis call, a Vet reports she has been feeling depressed and hopeless. The VA Crisis

Line worker asks if she ever has thoughts of killing herself. She answers, Well, sometimes I think it would be better if I werent here, but I never really talk to anybody about it, until now. I dont think that I would ever act on those ideas, I just think about it sometimes and it frightens me. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined

VIGNETTE D Despondent, depressed and angry, a Vet calls the Crisis Line to say that he fashioned a noose out of a piece of rope, climbed up on top of a footstool, and tied the noose around a beam in his garage. As he jumped, the rope broke, and he fell to the ground without sustaining any injuries. He now calls to say that he is frustrated that no matter what he does, he cant do it right. VIGNETTE D Despondent, depressed and angry, a Vet calls the Crisis Line to say that he fashioned a noose out of a piece of rope, climbed up on top of a footstool, and tied the noose around a beam in

his garage. As he jumped, the rope broke, and he fell to the ground without sustaining any injuries. He now calls to say that he is frustrated that no matter what he does, he cant do it right. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined VIGNETTE E Despondent and depressed over a recent job

loss, a female Vet blames herself for getting fired. She begins ruminating about her poor attitude and attendance record. Trying to take her mind off of these bothersome thoughts, she holds a lit cigarette to her arm, and calls the Crisis Line. The responder gets her to take the cigarette off her skin and throw it away, but not before blistering has occurred. VIGNETTE E Despondent and depressed over a recent job loss, a female Vet blames herself for getting fired. She begins ruminating about her poor attitude and attendance record. Trying to take her mind off of these bothersome thoughts, she holds a lit cigarette to her arm, and calls the Crisis Line. The responder gets her to take the cigarette off her skin and throw it away, but not

before blistering has occurred. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined VIGNETTE F A Vet who lives alone often drinks to the point of blacking out. After a recent episode, he wakes up next to his gun and realizes a shot had been

fired. He has no injuries and no recollection of any events from the night before. He does, however, realize that he used his cell phone to text, I hope it doesnt hurt, to several friends. VIGNETTE F A Vet who lives alone often drinks to the point of blacking out. After a recent episode, he wakes up next to his gun and realizes a shot had been fired. He has no injuries and no recollection of any events from the night before. He does, however, realize that he used his cell phone to text, I hope it doesnt hurt, to several friends. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y

Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined VIGNETTE G A very intoxicated Veteran calls the Crisis Line and says, I am so tired of everything. Sometimes I wish I were dead, and then he hangs up. VIGNETTE G A very intoxicated Veteran calls the Crisis Line

and says, I am so tired of everything. Sometimes I wish I were dead, and then he hangs up. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined VIGNETTE H A Veteran with a history of Major Depressive

Disorder and chronic pain reports that he downloaded information on the internet detailing how to overdose on prescription medication. VIGNETTE H A Veteran with a history of Major Depressive Disorder and chronic pain reports that he downloaded information on the internet detailing how to overdose on prescription medication. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y

Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined VIGNETTE I A Veteran is despondent over his pending divorce and failing health. He writes a suicide note, smokes marijuana, and gets into his car with the plan to drive into a concrete wall. On the way, he is stopped by police for speeding and reckless driving, and is arrested due to an outstanding warrant. VIGNETTE I

A Veteran is despondent over his pending divorce and failing health. He writes a suicide note, smokes marijuana, and gets into his car with the plan to drive into a concrete wall. On the way, he is stopped by police for speeding and reckless driving, and is arrested due to an outstanding warrant. Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined

VIGNETTE J Feeling bullied by her partner about losing weight, a female Vet calls the VA Crisis Line to get some support and feedback. She tells the responder that she recently imagined how sorry her partner would feel if she stopped eating altogether and ended up in the hospital. VIGNETTE J Feeling bullied by her partner about losing weight, a female Vet calls the VA Crisis Line to get some support and feedback. She tells the responder that she recently imagined how sorry her partner would feel if she stopped eating altogether and ended up in the hospital.

Key Elements in Decision-Making Is there any indication that the person engaged in SDV behavior, either preparatory or potentially harmful? N/Y Is there any indication that the person had SDV related thoughts? N/Y Was the behavior preparatory only? N/Y, N/A Did the behavior involve any injury or death? N/Y, N/A Was the behavior interrupted? N/Y, N/A Is there evidence (implicit/explicit) of suicidal intent? N/Y, Undetermined References Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. [Online]. (2008). Available: http://www.cdc.gov/ncipc/wisqars/nonfatal/definitions.htm#nonfatal injury reports. De Leo, D. Burgis, S., Bertolote, J.M., Kerkhof, A.J.F.M., & Bille-Brahe, U. (2006). Definitions of suicidal behavior: Lessons learned from the WHO/EURO Multicentre Study. Crisis, 27(1), 4-15.

Dhossche, D.M. (2000). Suicidal behavior in psychiatric emergency room patients. Southern Medical Journal, 93, 310314. Hickey, L., Hawton, L., Fagg, K., & Weitzel, H. (2001). Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: A neglected population at-risk for suicide. Journal of Psychosomatic Research, 50, 87-93. Kang, H.K. (2008). Risk of suicide among US Veterans after returning from the Iraq or Afghanistan war zones. JAMA, 300, 632-633. References cont Kaplan, M.S., Huguet, N., McFarland, B.H., & Newson, J.T. (2007). Suicide among male veterans: A prospective population-based study. Journal of Epidemiology and Community Health, 61, 619-624. McCarthy, J.F., Valenstein, M., Kim, H.M., Ilgen, M., Zivin, K., & Blow, F.C. (2009). Suicide mortality among patients receiving care in the Veterans Health Administration system. American Journal of Epidemiology, 1-6. OCarroll, P.W., Berman, A.L., Maris, R.W., Moscicki, E.K., Tanney, B.L., & Silverman, M.M. (1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26, 237-252. Silverman, M.M. (2006). The language of suicidology. Suicide and Life-Threatening Behavior, 36, 519-532. Silverman, M.M., Berman, A.L., Sanddal, N.D., OCarroll, P.M., & Joiner, T.E. (2007). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors. Part III. Suicide-Related Ideations, Communications and Behaviors. Suicide and Life-Threatening Behavior, 37(3): 264-277, 2007.

Thank you! [email protected] Please visit our website for more information and where you can download the slides from todays presentation http://www.mirecc.va.gov/visn19/

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