Suicide, including veteran suicide, handled back to front

This article discusses suicide among returning veterans:

Suicide Prevention Expert Outlines New Steps to Tackle Military Suicide

The up-side is, it brings more attention to this national shame: "..while only 1% of Americans serve in the military, the suicide rate of veterans accounts for [20 %] of the overall total in the US." [Emphasis mine.] They're overrepresented in suicidal despair, even at this time of epic national meltdown, at a rate of 19:1.

There are some good ideas (badly put) under this deceptive title (new? Hardly), with an unfortunate insularity and gee-whizz ignorance in parts:  "the effects on the mental health of active-duty service members, reservists, and veterans is only just beginning to be felt."

Only just beginning to be felt? By whom? Reports started streaming out of this population from the start!

The horrific rate of PTSD, brain injury and subsequent/consequent suicide among modern veterans has been in the news nearly since the Iraq war started. And the effects were "felt" by affected veterans and those who love them from the beginning.

That was an astoundingly insensitive choice of words, and when a social scientist is astoundingly insensitive, it automatically makes me question his insight and judgement. After all, social scientists have to pay attention to social cues and have some social awareness in order to do their jobs well.

The suggestions made by this article are,

• Reduce access to guns and other means of suicide.
• Watch for sleep disturbances. 
• Prescribe opioid medications carefully and monitor.
• Improve primary care treatment for depression.

These instructions are useful and appropriate (though not new at all), but the order puts the primary burden in the wrong place.

The reflex is to consider first how to change the patient's context and control, and second how to change the provider's context and control.

But which person -- doctor or patient -- do the policy makers have more access to?

Which has broader (and more cost-effective) reach per person?

Where does influence and support really come from -- especially when the patients themselves are desperate and don't have the resources to face what they're dealing with?

Hint: Only one of these two people is licensed, monitored -- and paid to show up.

It might be time to focus first on how to change the provider's context and control -- in this case, train primary care physicians in how to evaluate for mental health issues without losing their own minds, and make it easier for them to be more mindful, conscientious and appropriate when prescribing CNS depressants such as opioids.

Policies regarding these things may need to be updated. Despite some alterations and improvements, they still focus on controlling the patient's access to meds and autonomy, rather than on changing the provider’s involvement and awareness of what's going on.

This is exactly back-to-front.

This is the best we can do??

At-risk patients -- those with PTSD, intrusive pain, or some other confounding factor -- need to be seen more often and have mental health screens at each visit. Since many of the well-tested screening tools are short checkbox quizzes, that's a reasonable addition to care. Some can be filled out in the lobby by the patient.

This serves several purposes: the frequent care provides a disproportionate feeling of support to the patients, reducing despair and helplessness; if the visits feel excessive, it motivates the patients to improve their own resources and self-care, reducing passivity, which improves outcomes; and bad findings on the quizzes provide quantifiable, documented need for mental health care, which can then be provided in a more timely manner and with less argument from payors.

Speaking as someone with significant confounding factors (chronic pain, neuro dysregulation, and acute life stress) I'd be delighted to know my doctor and health care system would do that for me, even though I'm not remotely suicidal myself.

When the behavior of those who are easiest for policies to reach AND most influential in patient care is more appropriate and effective, then it makes more sense to go to the trouble and expense to reach further out into the population's private lives and try to manage them there.

A more rational and effective approach might be,

1. Train and retrain all primary care doctors to look for mental health issues. This is something that suicide prevention specialists have been screaming for for years. It's mentioned last in this article, but should be mentioned first: people who commit suicide were likely to have seen their doctors within a month. Talk about a cry for help falling on deaf ears!
   
   But most doctors turn into deer in the headlights in the face of mental distress, because they have no real idea about what to do. There need to be better guidelines, a clearer path to mental health follow-up, and failure to meet basic requirements of care needs to create problems for the provider -- as they inevitably do for the patient.
    
2. Manage access to obvious methods of suicide, like CNS depressants and firearms. There are many profoundly depressed people who will kill themselves if it's easy, but fewer who will really put a lot of energy into it, because energy plummets with major depression -- along with impulse control. A deadly combination.
   
   Reducing access involves having primary doctors get more involved with patients who get CNS depressants like opioids and benzodiazepines; implementing and enforcing access laws to firearms and ammunition; and noticing at-risk people with drug and firearm access and giving them the training they need to reduce their own access on an impulsive basis. (Yes,that's right, engage the patient's own inner and outer resources, rather than simply impose limits outside their control.)
    
3. Increase time span between impulse and action, giving second thoughts a chance to kick in. This is important, because the despair is stubborn, but the suicidal impulse comes and goes. Give it a chance to go, so the person has a future and a chance to recover.
   
   This involves, again, noticing them; engaging them to leverage their own capacity for self-management; and getting logistical support from those around them.
    
4. Look for early signs, like sleep disturbance, mood swings and eating or weight disturbances. Don't know why the latter signs aren't even mentioned here, when they're easier to notice from the outside. Veterans certainly have them.

We've been pushing for effective education for all primary doctors around both mental health and pain control (which are tightly linked) for decades. It's not new, it's just ignored, underfunded, and badly implemented, costing billions in direct and indirect costs.

Mental health and pain control are tightly linked because:

• Pain is depressing.
• Pain is limiting.
• The helplessness of those limitations is depressing.
• CNS depressants are, literally, depressing.
• Depression and helplessness significantly increase pain response in the brain and nerves.
• And back around we go.

It's a vicious cycle, keeping overtaxed minds between frying pan and fire...

Lasting treatment success is tied to increasing someone's sense of self-governance and engagement with life (reducing actual helplessness) not limiting their options and patronizing them into submission (increasing actual helplessness.)

[Limiting options is necessary and useful for inpatient treatment, but is highly problematic in outpatient care -- which is where most mental health issues take place.]

That same engagement and sense of self-governance also reduces the neural system's susceptibility to pain.

It breaks the cycle.

One of these people is not engaged in life. The other is. Which seems better?

Let's do all that now -- at last -- and see how much faster the suicide rates drop than at any prior point in history. For veterans, civilians, everyone.

It'd be cheap, effective, and useful. It'd serve our veterans and increase productivity. It'd brighten up the lives of everyone affected by it. Is there a downside?

Links:

Suicide Prevention Expert Outlines New Steps to Tackle Military Suicide. ScienceDaily (Sep. 10, 2012)
6,500 US Military Veterans Commit Suicide Every Year, International Business Times (April 2012).
Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. NEJM (July 2004)
PubMed search for "PTSD veterans" results.
PubMed search for "TBI veterans" results. TBI stands for Traumatic Brain Injury.
Make the Connection, bringing generations of vets together for mutual support and counseling.
Suicides — United States, 1999–2007 Centers for Disease Control (January 2011).