TY - JOUR
AU - Repke, Diana M
AB - Abstract Objectives Despite significant efforts in suicide prevention over the past several years, suicide rates in the U.S. Army remain largely unchanged. This paper describes a collaborative effort between line-unit leaders, medical personnel, and installation services to synchronize suicide risk identification and communication between these disparate entities. Methods Under the direction of the Installation Director of Psychological Health at Joint Base Lewis-McChord, a Behavioral Health Process Action Team was chartered to identify best practice and formulate policy for identifying and managing service members at risk for suicide. Results Compliance with the new policy reached 100% within 6 months of implementation, as measured by peer review of records. This installation policy was subsequently identified as a best practice and adopted Army-wide as the standard of practice. Discussion Knowledge transfer of research findings into policy and practice is crucial for suicide prevention. The current policy shows good integration of current research with practice in military settings. Conclusions Combined efforts in crafting policy for risk identification and communication resulted in a policy that was acceptable and feasible from the perspective of commanders and clinicians. Synchronization efforts between commanders, clinicians, and support services are crucial to ensure effective intervention to prevent suicide behavior. suicide, military, prevention, policy, implementation INTRODUCTION Suicide deaths remain a pervasive public health problem in the U.S. Army, with annual rates ranging from 18.5 to 29.7 suicides per 100,000 person years between 2004 and 2016.1,2 Despite significant efforts in suicide prevention, the rate of suicide by U.S. Army service members over the past several years remains largely unchanged, with the most recent (calendar year 2016) data showing a rate of 26.7 suicides per 100,000 person years.1 Although the rate of suicide in the U.S. Army historically was significantly lower than in a comparable civilian population, the suicide rate for soldiers nearly doubled between 2003 and 2008.3 In calendar years 2013–2015, the age- and sex-adjusted suicide rate in the U.S. Army did not significantly differ from the rate for the total U.S. population; in calendar years 2012 and 2016, the adjusted suicide rate in the U.S. Army was significantly higher than the U.S. population rate.1 Furthermore, elevated risk of suicide may continue after military service, with significant rates of suicide also identified in the U.S. veteran population.4 Efforts to reduce suicides among service members may occur at the installation, regional, and national level.5 The primary aim of the current work is to describe the process of implementing a suicide risk assessment and management policy at one installation in the Pacific Northwest. This policy was subsequently adopted as the standard of care for the U.S. Army.6 Background The Behavioral Health Process Action Team on Joint Base Lewis McChord (JBLM) was originally convened in Fall 2013. Based on direction from the I-Corps Commander, and under the direction of the Installation Director of Psychological Health, the Behavioral Health Process Action Team brought together key installation personnel from U.S. Army Forces Command (FORSCOM), U.S. Army Installation Management Command (IMCOM), and U.S. Army Medical Command (MEDCOM). These personnel included leaders from the Department of Behavioral Health at Madigan Army Medical Center, representatives from the surgeon cells at 7th Infantry Division and I-Corps, behavioral health officers from two Stryker Brigade Combat Teams on the installation, representatives from the Army Substance Abuse Program, and selected company commanders from JBLM. This group met weekly to address broad behavioral health concerns faced by the installation, particularly risk management and the management of suicide behavior by service members. Suicide behavior included the management of all categories of suicidal self-directed violence and ideation, including suicidal ideation, suicide attempts, suicide deaths, and preparatory actions.7 The guiding principle behind the team was to bring together disparate entities responsible for the care of service members on JBLM. In the past, command had expressed concern that there was no forum for cross-communication among these entities. For example, MEDCOM may be providing psychiatric treatment for a soldier, IMCOM may be providing support services, and FORSCOM ultimately has command authority and responsibility for the soldier. However, there was previously no unified team that brought representatives from each group together to discuss policies and standard operating procedures that would ultimately impact all groups. The Behavioral Health Process Action Team addressed these concerns by fostering active collaboration between MEDCOM, FORSCOM, and IMCOM assets so that each perspective was addressed. The team furthermore allowed stakeholders to ask questions, give recommendations, and collaborate across organizational silos. The first task taken on by the team was to rewrite the standard operating procedure for suicide risk management on the installation. Previous risk policies had been focused solely on clinical procedures without taking the readiness needs of the front-line commander into account, and without notifying commanders about risk levels in a consistent manner.8 Thus, the goal of this updated policy was unifying processes of communication, categorization, and mitigation of suicide risk between the hospital, line unit commanders, and support organizations. METHODS In rewriting the installation policy on suicide risk assessment and management, the Behavioral Health Process Action Team primarily drew from the clinical practice guidelines on the assessment and management of suicide risk established by the Department of Veterans Affairs and the Department of Defense.9 These guidelines established four core tasks: Assessment, Management, Treatment, and Follow-up. In each of these areas, the team identified specified and implied tasks needed in the process of suicide risk identification and mitigation. Risk Assessment Clinical practice guidelines established three categories of risk (high, intermediate, low) based on the recency and persistence of suicidal thoughts, as well as whether or not the patient intended to act on these thoughts.9 The Behavioral Health Process Action Team added a fourth category specifying “no elevated risk” of self-harm for patients with no recent suicide thoughts or behavior. This addition allowed all service members assessed in behavioral health clinics to be stratified based on these risk categories. Note that despite its use in the clinical practice guidelines, risk stratification has not been shown in the literature to accurately predict whether or not a particular individual will die by suicide.10 Rather, the intent of risk stratification in this context was to ensure consistency in risk communication between staff, as well as direct interventions at certain thresholds for command notification and hospitalization. In categorizing risk levels within this framework, clinicians should take several factors into consideration.11 First, identification of risk included assessing the frequency (recent, current, persistent), regularity (monthly, weekly, daily), intensity (fleeting, focused, intense), and duration (seconds, minutes, hours) of suicidal thoughts. Second, the clinician should identify any suicide plans or preparatory behavior. Third, intent to die should be identified through both subjective and objective report, as well as identification of rehearsal behavior. Fourth, the clinician should identify any history of impulsivity by the patient through subjective report and objective signs. In addition to recent thoughts or behavior related to suicide, clinical practice guidelines stress the identification of contributing factors that may increase risk.9 The installation policy specified four broad categories of contributing factors: warning signs (e.g., hopelessness, isolation, perceived loss of control), general risk factors (e.g., relationship problems, substance abuse, financial problems), military-specific risk factors (e.g., unwanted administrative separation, reduction in rank), and static risk factors (e.g., family history of suicide, demographic characteristics).1,12,13 Taken together, these contributing factors provided context for clinicians in assessing current suicide risk category. Another crucial aspect of risk assessment is the endorsement of psychopathology and related symptoms. Prevalence of behavioral health disorders among soldiers who died by suicide remains consistent and unchanged, as 50.7% had a history of at least one behavioral health disorder.1 Mood (26.4%) and adjustment (26.4%) disorders were the most frequently reported.1 Substance use (24.3%) and anxiety (22.1%) disorders also were common.1 Thus, clinical assessment of recent suicidal thoughts and actions was augmented through the Behavioral Health Data Platform (BHDP).14 This is a standardized assessment platform that administers clinical measures through a computer kiosk in outpatient clinics prior to each behavioral health appointment throughout the U.S. Army. This system was initially implemented in 2012, and is mandatory at all behavioral health treatment facilities. Assessments administered by the BHDP include standardized measures of anxiety, depression, PTSD symptoms, alcohol use, marital distress, and suicidality. Patients complete these assessments at a waiting room kiosk when they check in for a behavioral health appointment. After completion, BHDP assessment results are immediately accessible to the treatment team through a web-based platform, and track trends over time for individual patients and clinics. One of the measures included in the BHDP assessment is the Columbia-Suicide Severity Rating Scale (C-SSRS).15 The C-SSRS has been adopted by the U.S. Army as the standard instrument for assessing history of suicidal behavior, to include assessments in outpatient clinics, emergency departments, and inpatient wards.16 This scale includes items related to suicidal ideation, preparatory behavior, and interrupted or aborted suicide attempts with uniform behavioral definitions.15 Despite its mandatory use as a screening instrument in U.S. Army settings, review studies suggest that reliance on the C-SSRS potentially results in errors due to wording issues and misleading category titles.17 Nonetheless, it is crucial to integrate the data collected from this measure into the overall risk assessment. Data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) show that 13.9% of soldiers are estimated to have a lifetime history of suicidal ideation, 5.3% are estimated to have a history of suicide plans, and 2.4% are estimated to have a history of suicide attempts, with 47–60% first occurring prior to service entry.18 By working with the BHDP implementation team, the Behavioral Heath Process Action Team ensured that risk stratification language generated from using the C-SSRS aligned with the risk level categories outlined in the installation policy and the clinical practice guidelines. Furthermore, note that the Behavioral Health Process Action Team did not review individual cases for correspondence between the C-SSRS and risk assessed by clinicians. Rather, the Behavioral Health Process Action Team provided broad guidance to the installation on resolving discrepancies and integrating the C-SSRS into clinical assessments and suicide risk management. Risk Management Managing suicide risk refers to immediate clinician or command responses to an assessed risk level.11 In order to manage suicide risk, specific actions were required depending on the assessed risk level. The installation policy specified that all patients, regardless of identified risk, should receive contact information for emergency and routine treatment, including sources of care on the installation and the Veterans Crisis Line. If classified as low risk, the minimum task for suicide risk management was the collaborative formulation of the elements of a safety plan (also called a crisis support plan or crisis response plan) with the patient.19 The safety plan includes identifying potential signs or events that would increase risk, contact information for the patient’s support system and emergency care, steps to restrict access to lethal means, strategies for decreasing related distress, and long-term personal goals to instill hope about the future. Patients were encouraged by clinicians to share their safety plan with the chain of command, but this was not a requirement for patients at low risk. If classified as intermediate or high risk, then command notification of risk was required. Communication with command included documentation of phone contact, notification of the safety plan, initiation of a duty-limiting profile as appropriate, and communication of duty restrictions to command through Department of the Army Form 3822.20 Command consultation and communication of this kind has been readily implemented through the use of embedded behavioral health clinics throughout the U.S. Army.21 Initial evidence indicates that embedded behavioral health clinics and providers can decrease psychiatric hospitalizations, increase access to care, and decrease personnel losses due to psychological health reasons.21,22 Qualitative evaluations suggest that the effective mechanism behind embedded behavioral health is the alignment of providers with specific command groups, enabling providing regular contact between unit leaders and clinicians.23 Thus, recommended duty limitations and the potential need for command-directed intervention can be discussed, taking into consideration both the needs of the unit and treatment needs of the individual patient.24 For patients at intermediate risk only, if the clinician identified that command notification would have deleterious effects on the patient’s risk level and create a barrier to the patient wanting to engage in care, then documentation of peer consultation was required. This peer consultation was intended to balance command notification of suicide risk with concern for the privacy and confidentiality of the patient.25 A key component of command consultation and potential duty limitations was the consideration of limiting access to firearms.26 Indeed, personal firearms continue to be the most common method for suicide used by service members.1 Because weapons readiness is a key component of deployability for active duty military personnel, such restrictions must balance the safety of the individual patient with the needs of command, while simultaneously ensuring that the patient may remain gainfully employed by the unit. Thus, such restrictions should always involve detailed discussion with unit leaders.24 Treatment Similar to risk management, treatment considerations were directly tied to identified risk levels. For patients who were not at elevated risk or at low risk, routine outpatient care was generally appropriate.24 Interventions to decrease suicide risk in this setting typically utilized cognitive-behavioral treatment techniques that have shown efficacy in military samples.27,28 Once risk was stabilized, medication management might also be transferred back to primary care, depending on the needs of the patient. For patients at intermediate or higher risk, clinicians should increase the frequency of care to ensure that emergent stressors do not increase suicide risk. A change in care intensity could also be appropriate at higher levels of risk, such as hospitalization or an intensive outpatient program.29 Indeed, for patients at high risk, documentation of rationale for or against inpatient psychiatric hospitalization was required by the installation policy. Follow-up In addition to enrollment in clinical care, follow-up for patients with identified suicide risk included two additional tasks. The first task was enrollment in clinic risk tracking, with weekly clinic case review meetings in which all patients at intermediate or higher suicide risk were discussed. Based on the embedded behavioral health model, this included communication back to commanders regarding any changes in assessed risk level and the ongoing need for duty limitations.21,23 These patients also had regular contact with an assigned nurse case manager to ensure timely follow-up appointments and an additional touch point for identifying emerging risk concerns. Second, clinicians regularly engaged patients to follow-up and make updates to the safety plan.27 This follow-up might include the addition of newly learned techniques for reducing distress, or modifying the safety plan if certain items appeared to be impractical. RESULTS Once the installation policy had been finalized by the Behavioral Health Process Action Team and signed by the Installation Director of Psychological Health in late 2013, leaders on the installation began a systematic dissemination process to ensure compliance with the new policy. This included an installation-wide training event for all behavioral health clinicians in 2014, with annual suicide prevention training that included attention to the installation standard of care. At the installation-wide training, clinicians received specific examples for how to implement the new policy and engage command in discussion of risk, as well as templates for documenting risk assessments based on the new policy in the electronic medical record. In order to verify fidelity with the new installation policy, monthly peer reviews of clinical documentation were modified to include compliance with the appropriate suicide risk assessment, management, treatment, and follow-up. Results of these peer reviews showed implementation compliance at 100% within 6 months. Integrating this new process for suicide risk assessment and management into the credentialing peer review process ensured that these efforts became part of the overall culture of suicide reduction on the installation. As an aftereffect of new policy implementation, follow-on installation policies were similarly updated to standardize new requirements for regular review of high risk patients, writing duty-limiting profiles, and initiating the medical retention determination point for patients enrolled in behavioral health care. The Behavioral Health Process Action Team also made formal presentations to the installation Community Health Promotion Council and the JBLM Senior Medical Council. These presentations allowed commanders to see the collaborative effort between MEDCOM, FORSCOM, and IMCOM assets on the installation, formed the foundation for ongoing collaboration on these and related issues. Indeed, after initial successes in unifying risk communication, the I-Corps Commander formalized the Behavioral Health Process Action Team as a JBLM entity in collaboration with the Community Health Promotion Council. This formalization allowed for input from line commanders to be directly addressed by the team on an ongoing basis, and established a regular operations order for attendance by a rotating group of company-level command teams. Following successful implementation, the new installation policy was briefed to the Regional Medical Command, and was identified as a best practice by the Army Audit Agency. As a result, the installation policy was adopted Army-wide as the gold standard in risk assessment and intervention in November 2016.6 DISCUSSION Knowledge transfer, or the translation of research knowledge into clinical practice, is a critical process for improving the delivery of health care services.30 Indeed, the current process of implementing new guidelines for suicide risk assessment and management at one installation is one successful example of directly implementing state-of-the-science techniques through policy and clinical practice standards. Through these efforts, Army-wide policy now incorporates evidence-based guidelines for suicide risk assessment, management, intervention, and follow-up.9,15,19,27 At the core of the current effort was a collaborative approach that synchronized the efforts of several entities on the installation. This collaborative approach is particularly important for overcoming stigma. Many service members do not seek care due to concerns about impact on military career, mistrust of behavioral health clinicians, negative treatment beliefs, and stigma.31,32 For example, some studies show a significant number of soldiers have not disclosed their history of suicidal behavior and considerably underreport suicidal ideation during health screenings.18,33 One avenue to address service member concerns is by sharing with commanders the importance of allowing service members time off to receive care without negative consequenes.32 Another is to communicate to service members the potential negative mental health and career consequences of untreated symptoms.32 As part of this message, increased education that highlights evidence-based military-specific psychosocial interventions have been developed would be key.27,34 This could be further facilitated by having clinicians utilize a needs based approach to develop a collaborative treatment plan with the patient, in turn addressing the readiness needs of military commanders.31,32 The current implementation notwithstanding, there remains inherent tension regarding the effectiveness of risk stratification and the need to communicate risk. Indeed, meta-analytic work has shown minimal utility for risk stratification in predicting whether or not a patient ultimately dies by suicide.10 To overcome this, clinicians must ensure that risk assessment and stratification is not an end unto itself. Rather, risk assessment and management should be part of a comprehensive strategy to reduce the impact of modifiable risk factors driving suicide behavior, collaboratively working to meet the needs of the patient and command.11,19,27 Future efforts at suicide risk management may need to expand beyond the efforts of behavioral health clinicians. Over 62% of soldiers who die by suicide made contact with the Military Health System in the 90 days prior to their death.1 Thus, another direction to facilitate this collaborative approach would be the implementation of similar policies in primary care and other medical settings.9,13 A version of the current Army policy could be tailored to include assessment and management techniques that are most amenable to these settings, with guidelines for care coordination and referrals to specialty behavioral health care. CONCLUSIONS Through a combined effort between MEDCOM, FORSCOM, and IMCOM professionals on the installation, the Behavioral Health Process Action Team crafted a suicide risk assessment and management policy that was suitable to the needs of the patient, feasible for clinicians to implement, and acceptable to line unit commanders. As a result of these synchronization efforts, past fragmented systems of risk stratification and intervention can be overcome, ultimately facilitating a collaborative approach to preventing and reducing suicide behavior among military personnel.5 Previous Presentations Presented as a poster at the 2017 Military Health System Research Symposium – Kissimmee, FL – 29 August 2017. (Abstract number 17–1007) Funding This supplement was sponsored by the Office of the Secretary of Defense for Health Affairs. Acknowledgments The authors thank the members of the Behavioral Health Process Action Team at Joint Base Lewis-McChord for their contributions to improving care through this and similar initiatives. References 1 Pruitt LD , Smolenski DJ, Bush NE, et al. : Department of Defense Suicide Event Report (DoDSER): Calendar Year 2016 Annual Report. Publication No. 0-A2345E05. Washington, DC: Defense Health Agency. 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This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of Association of Military Surgeons of the United States 2019.
TI - Development and Implementation of U.S. Army Guidelines for Managing Soldiers at Risk of Suicide
JO - Military Medicine
DO - 10.1093/milmed/usy284
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/development-and-implementation-of-u-s-army-guidelines-for-managing-cYjedFPS8n
SP - 426
EP - 431
VL - 184
IS - Supplement_1
DP - DeepDyve
ER -