Strategies for Preventing Suicide in TBI Patients

1. Strategies for Preventing Suicide in TBI Patients Janet E. Kemp, RN, PhD Lisa A. Brenner, PhD, ABPP Beeta Y. Homaifar, PhD VA Eastern Colorado Health Care System VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC) Department of Veterans Affairs Transforming Mental Health Care: Promoting Recovery and Integrated Care

2. Acknowledgments • VISN 19 MIRECC • Colorado Traumatic Brain Injury Trust Fund Program – Education Grant

3. As of March 31, 2006, DOD reported that 1,179 individuals have sustained a traumatic brain injury (TBI) during OIF/OEF. Relevance http://www.fas.org/sgp/crs/natsec/RS22452.pdf

4. TBI - Definition A bolt or jolt to the head or a penetrating head injury that disrupts the function of the brain. Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from “mild” (i.e. a brief change in mental status or consciousness) to “severe” (i.e. an extended period of unconsciousness or amnesia after the injury). A TBI can result in short or long-term problems with independent function. CDC, 2005

5. Leading Causes of Brain Injury • Falls (28%) • Transportation related events (20%) • Assaults (11%) •  Blasts

6. TBI-Related Sequelae • Sensory deficits • Motor disturbances • Psychiatric symptoms: anxiety, depression, psychosis, personality changes • Cognitive dysfunction: attention, concentration, processing speed, memory, language and communication, problem solving, concept formation, judgment, initiation

7. Background: TBI and Suicide • Studies have shown that significant numbers of TBI patients endorse a post-injury history of suicidal ideation (Simpson and Tate, 2002). • In comparison to the general population, people with a history of traumatic brain injury (TBI) have both a higher lifetime prevalence rate of suicide attempts (Silver et al., 2001; Simpson and Tate, 2005) and a significant increased risk of death by suicide (Teasdale and Engberg, 2001).

8. Objectives • Because suicide is a significant issue for individuals with a history of traumatic brain injury (TBI), and since “TBI aware” suicide resources are limited… • A qualitative, interview-based study was conducted in a veteran population to clarify the needs of TBI survivors and their families.

9. Strategies for Preventing Suicide in TBI Patients: Background • Replication study • The Acquired Brain Injury Outreach Service (ABIOS) in Australia. (Kupier and Lancaster, 2000). • Findings: • Knowledge regarding interface between TBI/Suicide • Increased coordination of services • Individual education • Discrepancy between needs of clients/family

10. Strategies for Preventing Suicide in TBI Patients: Recruitment • Patients were recruited into the study if they met the following criteria: • Having received care from members of the ECHCS TBI Interdisciplinary Team • Diagnosis of TBI and a history of suicidal behavior (ideation, self-harm, nonfatal attempts) • Ability to provide informed consent and adequately respond to questions regarding the informed consent procedure • Age 18-74 • 17 participants • (13 TBI survivors and 4 family members)

11. Strategies for Preventing Suicide in TBI Patients: Methods • Interviews were phenomenological in nature, and subsequent questions were based on the responses to open ended questions.

12. Strategies for Preventing Suicide in TBI Patients: Survivor Questions • Have you ever felt really down or even thought about taking your life? • What stopped you or what might have stopped you? • Who did you turn to for help or what did you do and how helpful was this? • If you got really down in the future where would you get help or who would you turn to? • What do you think would be the best way to help a person with TBI who might be depressed or suicidal? • How do you think your military experience has affected your feelings about taking your life or how you feel?

13. Strategies for Preventing Suicide in TBI Patients: Family Questions • In general, what do you think would be the most effective way of preventing suicide among people with TBI? • Who do you think a person with TBI might turn to for help if they were considering suicide? • What do you think would be the most effective way of getting a message across to a person with TBI, who might be at risk of suicide? • What is your relationship to the patient we are interviewing?

14. Strategies for Preventing Suicide in TBI Patients: Analysis • Interviews tape recorded, transcribed and analyzed • General and specific themes • Comments outside specific questions • All 13 patients had attempted suicide or had serious thoughts/plans • Attempts and ideation ranged from 1-30 years post-TBI

15. Strategies for Preventing Suicide in TBI Patients: Findings • Precipitating Themes: • Lack of connection • Others/themselves • Isolated, loneliness, being alone on the holidays, limited support from others, and social anxiety • Loss of self » lack of purpose in their lives. • Frustration, anger regarding sequelae • Hopelessness

16. Strategies for Preventing Suicide in TBI Patients: Findings • Precipitating 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

17. Strategies for Preventing Suicide in TBI Patients: Findings • Preventative Factors • Family and other significant relationships • Children, spouses, parents, friends and pets. • Sense of responsibility • Professional help • Medication, psychotherapy, support groups • Active listening, clarifying questions, patience, talking slowly, repeating instructions several times • Spiritual orientation • Distraction

18. Strategies for Preventing Suicide in TBI Patients: Findings • Family members: • Caregiver burnout • Professionals need to know about TBI and enduring sequelae • Conversations about the possibility of their family member becoming suicidal • Involving them in treatment planning • Assistance with resources and ongoing support • Medication • Case managers • “Somone to go to for help”

19. Strategies for Preventing Suicide in TBI Patients: Findings • 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

20. Strategies for Preventing Suicide in TBI Patients: Findings • Common themes expressed by both patients and family members: • Continued support in the face of no functional improvement “Provide hope while telling us the truth”

21. Be aware of what can precipitate suicidal thoughts in people with TBI: Loneliness Lack of connection Holiday times Lack of support Job/employment issues Lack of resources Frustration over tasks Bad news about prognosis “I had my heart set on it, and for three days I just sat in my room and contemplated how to do this. And finally it got to the point where I tried….” - A TBI Survivor Strategies for Preventing Suicide in TBI Patients: Warning Signs

22. Strategies for Preventing Suicide in TBI Patients: Limitations • Cognitive deficits • Small population size • Saturation reached • Limited to Denver area

23. Strategies for Preventing Suicide in TBI Patients: The Next Steps… • Receive feedback from participants • Receive feedback from providers • Continued study replication in other geographic areas

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

25. VISN 19 MIRECC 1055 Clermont St. Denver, CO 80220 Traumatic Brain Injury and Suicide An information manual for clinicians 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. 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

26. VISN 19 MIRECC 1055 Clermont St. Denver, CO 80220

27. References: • Ahmed, I., Fujii D. (1998). Posttraumatic psychosis. Seminar in Clinical Neuropsychiatry, 3, 23-33. • Alderfer, B., Arcinegas, D.B., Silver, J.M. (2005). Treatment of Depression Following Traumatic Brain Injury. Journal Of Head Trauma Rehabilitation, 20, 6, 544-562. • American Association of Suicidology (2005). Resource Sheet #4 – Basic Terms. Clinical Core Competencies Draft Curriculum. • Centers for Disease Control and Prevention. (2005). WISQARS website and Fatal injury reports. Retrieved from http://www.cdc.gov/ncipc/wisqars/ February 7, 2006. • Cocoran, C., McAllister, T.W., and Malaspina, D. Psychotic Disorders. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 213-229. • 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 Maintenance Organization Population. Archives of General Psychiatry, 61, 53-61. • Hibbard, M.R., Ashman, T.A., Spielman, L.A., Chun, D. Charatz, H.J., Melvin, S. (2004) Relationship Between Depression and Psychosocial Functioning After Traumatic Brain Injury. Archives of Physical Medicine and Rehabilitation, 85, 2, S43-S53. • Hornstein, A. Social Issues. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 571-581. • Jorge, R.E., Robinson, R.G., Arndt, S.V. (1993). Depression Following Traumatic Brain Injury. Journal of Affective Disorders, 27, 233-243.

28. References (cont.): • Kraus, J.F. and Chu, L.D. Epidemiology. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 3-26. • Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2006. • Maris, R.W., Berman, A.L., Silverman, M.M. (2000). Comprehensive Textbook of Suicidology. The Guilford Press: New York. • McCullagh S, Feinstein A. Cognitive changes. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. p 321-35. • McIntosh, J. (2006). USA suicide: 2003 Official final data. Fact sheet developed by the American Association of Suicidology from National Center Health Statistics. www.suicidology.org. • National Center for Health Statistics (1998). Vital Statistics of the United States, 1996: Vol. II. Mortality, Part A. Washington, D.C.: US Government Printing Office. • Robinson, R.G. and Jorge, R.E. Mood Disorders. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbook of Traumatic Brain Injury. Arlington, VA: American Psychiatric Publishing; 2005. 201-212. • Silver, J.M., Kramer, R., Greenwald, S., Weissman, M. The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiological Catchment Area Study. Brain Injury, 15, 11, 935-945.