_____________________________________________________________ Suicide Assessment and Prevention
Being aware of the factors that increase a professional’s risk of burnout is very valuable in contributing to a prevention strategy. Contributing factors may be individual/personal, systemic, or frequently a combination of both. It is important to know what does not work (or what makes a toxic environ- ment) first in order to prevent exposure and the associated fallout from such exposure. Creative Personalities Anecdotes of famous painters, writers, and musicians who were depressed and died by suicide have occurred for centuries, but only recently has science been able to identify the underlying basis of vulnerability to depression and suicide among creative people. Treatment of major depressive or bipolar illness in art- ists presents unique problems, one of which is the concern that creativity and the disorder are so intertwined that treatment might suppress the artist’s unique talent [73; 74; 76]. Holiday Suicide Myth The idea that suicide occurs more frequently during the holiday season is a myth perpetuated in part by the media and has been debunked [2]. The National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) reports that the suicide rate is actually lowest in December, with peak rates in the spring and the fall. This pattern has remained constant for many years [77]. The holiday suicide myth has been considered important to counter because it provides misinformation about suicide that might ultimately hamper prevention efforts [78].
poor social support, feelings of not belonging or of being a burden to others or society, acquired ability to inflict lethal self-injury, and access to lethal means [52; 58; 81; 82; 83]. There is conflicting evidence of the role of PTSD in suicide risk, with some studies finding PTSD diagnosis to be protective while others indicated it increased risk. Other possible risk factors include [79; 123]: • Disciplinary actions • Reduction in rank • Career threatening change in fitness for duty • Perceived sense of injustice or betrayal (unit/command) • Command/leadership stress, isolation from unit • Transferring duty station • Administrative separation from service/unit • Military sexual trauma Case Scenario: Patient B Patient B is 56 years of age, married with one grown daughter. She consults a primary care physician because of a gradual decline in health over the past 12 to 18 months. She has come at the insistence of her daughter, who accompanies her. Her given purpose is vague: a “check-up” and perhaps laboratory work. Her daughter tells the nurse, “My mother’s not well. She’s home alone, doesn’t get enough sleep, and won’t eat right. She complains about her stomach and thinks she has food allergies; she has tried special diets, supplements, and herbal remedies and claims she’s getting better, but she’s not.” The patient is petite, well-groomed, and smiles readily. She tells the physician, “I’ll be okay, but I do want to be sure I’m not anemic or have a thyroid problem.” She gives a history of chronic, recurrent abdominal discom- fort, bloating, periodic constipation, and intolerance to many foods. As a young woman, she was told she has irritable bowel syndrome and was given trials of medication, but she reports being unable to take these medications and being “very sensitive to any prescription medication.” She thinks she has lost maybe 5 pounds in the past year. Her examination is unrevealing, except she is thin and there is a hint of generalized muscle atrophy. Over the course of the interview, she appears tired and to have a slightly blunt affect. The following laboratory tests are ordered: complete blood count, chemistry profile, vitamin D and B12 levels, and thyroid function tests. She is given an appointment to return in five days to discuss the results and plan a course of treatment. IMMINENT SUICIDE While risk factors for suicide represent broader, durable, and ongoing factors, a suicide crisis is a time-limited event that signals an immediate danger of suicide. A suicide crisis can be triggered by a particularly distressing event, such as loss of a loved one or career failure, and involve an intense emotional state in addition to depression, such as desperation (anguish plus urgent need for relief), rage, psychic pain or inner tension, anxiety, guilt, hopelessness, or acute sense of abandonment.
ACTIVE-DUTY MILITARY AND VETERANS Protective Factors
Several general protective factors may be more prevalent among military service members and veterans, including strong interpersonal bonds, responsibilities/duties to others, steady employment, sense of belonging/identity, and access to health care [79]. Historically, the selection bias for healthy recruits, employment, purposefulness, access to health care and a strong sense of belonging were believed to be protective against suicide, but increasing rates have challenged this assumption [79]. In one study, having a service-connected disability was associated with a lower risk of suicide in veterans, likely due to greater access to VA health care and regular compensation payments [52]. It is interesting to note that many of these pro- tective factors do not apply to discharged or retired veterans. Other potentially protective factors include older age, African American/Black race, and admission to a nursing home [79]. Risk Factors Veterans and military members often possess many risk factors for attempting or completing suicide. This includes combat exposure (particularly deployment to a combat theater and/ or adverse deployment experiences), combat wounds, post- traumatic stress disorder (PTSD) and other mental health problems, comorbid major depression, traumatic brain injury,
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