15 Lessons on Suicide Prevention From Veterans Affairs
By David Shulkin, M.D.
The US Department of Veteran Affairs has many strengths, but none greater than its' capabilities in behavioral health. Besides employing more than 10,000 mental health professionals, VA has many innovative and effective programs in suicide prevention not seen commonly in the private sector. This is not to say that there is not much to be done in VA, but my hope here is to share some of the Department's incredible work so that leaders in the private sector may learn from the VA's vast experience. Below I will provide 15 of these strategies utilized by VA to address the agencies top clinical priority, suicide prevention.
Lesson 1: Suicide Prevention Coordinators
Every VA has at least one suicide prevention coordinator (1). Currently there are over 300 suicide prevention coordinators throughout VA. Their job is to be a resource for clinicians dealing with veterans with suicidal ideation, identifying veterans at high risk for suicide, promoting awareness at the facility about suicide prevention, on-going education for all staff, and community outreach. In my opinion, every hospital in the country should consider employing suicide prevention coordinators to address these issues in their communities.
Lesson 2: Predictive Analytics
VA's research organization created an analytic tool called "Reach Vet", which uses predictive analytics to identify veterans at the greatest risk of suicide (2). This system uses VA clinical databases to identify veterans who are in the top 0.1 percent tier of suicide risk. VA moved this system from the research labs into the clinical arena in 2016. Each VA is given a list of the veterans in their catchment area that are at highest risk and then proactive outreach to these veterans can be done. Initial results of using these predictive analytics are promising. In 2018, VA reported that veterans identified by the system and contacted, more than doubled their use of VA services (3). While, there is no data yet that I am aware of on the impact of Reach Vet on suicide rates, my personal interactions with VA clinicians assure me that this system is saving lives.
Lesson 3: Behavioral Health Care/Primary Care Integration
More than a decade ago, VA began to co-locate mental health professionals with primary care. This initiative was intended to destigmatize mental health care and provide greater access to behavioral health interventions (4). Since then, VA has expanded this model to most of its' primary care sites throughout the system. Data suggests that this has resulted in an increase in the number of veterans who have accessed a mental health provider (5). In addition, VA has innovated with newer models of team based care, particularly in a program called Whole Health (6). This program, which goes beyond the co-location of primary care and mental health providers, teaches veterans self care skills and provides additional integrative services. Early results from this system of care (some of them unpublished data that I have reviewed), show dramatic improvements in the outcomes of care (7).
Lesson 4: Same Day Appointments
Access to behavioral healthcare remains a critical issue in much of the healthcare system. In 2016, VA implemented same day appointments for urgent behavioral health care in every VA medical center (8). Same day appointments ensure that veterans with urgent medical and psychological problems get the care they need without a delay. Reducing barriers to access are critical in addressing the suicide crisis. Using the same-day access strategy VA has been able to reduce wait times and has average lower wait times than are seen in the private sector (9). VA also publicly publishes these wait times. For the private sectors, same day access to behavioral healthcare services can be an important strategy to reducing the use of emergency rooms for inappropriate psychiatric care.
Lesson 5: Giving Advanced Practice Nurses Full Practice Authority
In 2016 when I was Undersecretary of Health at VA, I made one of my most controversial decisions by granting full practice authority to advanced practice nurses (10). I made this decision based upon a review of the literature on quality of care as well as my personal experience as a physician, having worked for over 25 years alongside advanced practice nurses. The primary reason I enabled the expansion of advanced practice nurses was the principal that expanding access to care was the most important thing I could do as a leader of a health care organization. In many parts of the country we have insufficient numbers of behavioral healthcare professionals and expansion of practice authority can be an important tool in addressing this problem.
Lesson 6: Tele-Behavioral Healthcare
Well before the COVID pandemic, VA was using widescale tele-behavioral health to serve the veteran community. In fact, VA began using tele-behavioral health over 20 years ago. Since 2001, VA has provided close to 3 million tele-behavioral healthcare visits (11). This program has allowed VA to match its mental health workforce to provide care to areas of the country that has limited access to these professionals. More recently, VA has established mental health tele-hubs where these center of excellence can provide expertise to other VA medical centers that may not have this level of specialty care. Veteran satisfaction with tele-behavioral health services in VA is above 90 percent.
Lesson 7. Mental Health Prescriptions without Medications
VA offers many services for veterans suffering from behavioral healthcare issues that do not involved prescribing medications. One of these programs that particularly impressed me, is VA's adaptive sports program (12). By engaging veterans in active competitions, people often experience an increase in well being and an overall reduction in the severity their mental health conditions. I've participated in adaptive skiing programs, surfing programs, and other sports venues such as the Invictus Games, where veterans have shared their stories with me. I became convinced that these programs often had as much, or more, of an impact on a veteran's overall mental health status than many of the traditional medical therapies that they had been prescribed. Last year, these programs served more than 13,000 veterans. My hope is that other health systems can get involved in these programs in their communities and expand access to more patients.
Lesson 8: Emotional Support Dogs
I've had the opportunity to see first hand the impact of emotional support dogs with veterans. Many veterans have told me that their dogs have literally changed their lives and have saved them from suicide. VA's mobility emotional support dog initiative provides support for veterans who can benefit from this service (13) VA is currently doing a research study to determine the effectiveness of emotional support dogs for PTSD, but this is one of those times that I don't need research data to convince me that this is an effective intervention. I am on the Board of a great non profit program, Veterans Moving Forward, that provides veterans with emotional support dogs. We need these organizations since currently private insurance and government programs too often do not provide reimbursement for emotional support animals.
Lesson 9: Social Determinants
While addressing social determinants in healthcare has suddenly become popular, the Department of Veteran Affairs has been doing this for decades. When it comes to suicide prevention, one of VA's most important initiatives is to end veteran homelessness. Veterans who have experienced homelessness are up to 11 times more likely to take their life through suicide (14). VA has made tremendous progress in reducing homelessness (15), but despite these efforts the problem continues to be significant, with more than 40,000 veterans remaining without safe housing. Additional social determinants, such as food security, transportation, medication support, vocational support, economic stability, legal reforms, and others are also important to address in suicide prevention efforts.
Lessons 10: Identifying and Addressing Transitions in Care
Gaps in care are particular areas of risk for those that have taken their own life. In the VA, the single highest period of risk, is the first year after leaving active military service. This is a time when those who have served often no longer have the support of their peers after leaving. Because of this, as Secretary I created a special support program for mental health services for this one year transition period (16). Other times of transition also have increased risk such as the time after discharge from a hospital or loss of a spouse or employment. Designing support programs around these transition times can be critical in the efforts to reduce suicide.
Lessons 11: Connections to Community Organizations
Of the 20 veterans that take their own life each day, only 6 are getting care within the VA system. That means that the majority of veterans are outside of VA and it is essential to coordinate resources with community organizations. VA's program to do this (#BeThere), nationally promoted by Tom Hanks, works with local and state governments, churches and other religious organizations, veteran service organizations, employers, and other community non-profits (17). As Secretary, I asked these organizations to formalize their "pledge" to work together in a collaborative manner to provide outreach, education and services to veterans at risk (18).
Lesson 12: Peer Counselors
VA has had a long commitment to peer counselors. VA Vet Centers offer psychological support for veterans in centers located outside of VA hospitals to ensure a comfortable and informal environment (19). These 300 Vet Centers utilize fellow veterans (72% of staff are veterans) to provide peer support. Peer counseling can be an important tool in getting people to feel comfortable in discussing their issues and in finding ways to comply with medical and psychological therapies (20). Peer counseling can also be important in reducing disparities in care and in addressing issues of cultural competence in the healthcare system.
Lesson 13: Caregivers and Caregiver Support
VA is somewhat unique in providing comprehensive support for caregivers (21). There are currently more than 5.5 million caregivers for veterans (22). Without these caregivers there would be even greater social isolation and more reliance upon institutional long term care and psychiatric services. Caregivers are essential for providing direct care, support for activities of daily living, and psychological support and comfort. VA has recently expanded its caregiver support program for veterans of all age groups (23) But few organizations or companies provide the resources for caregivers other than VA and non profit organizations like the Elizabeth Dole Foundation (24). Caregivers however are essential to the psychologic needs of people who are homebound. Caregivers themselves need support and services. VA and other organizations provide support and education for caregivers. Healthcare organizations in the community should consider outreach and support of local caregivers.
Lesson 14: Addressing Underlying Mental Health Issues
Preventing suicide means addressing the underlying issues that lead to this outcome. Depression, psychoses, PTSD, substance abuse, chronic pain and other mental health conditions are the reasons why we are seeing the increasing number of people taking their own lives. We must make sure that we have programs that identify, diagnose, and provide effective treatments for these conditions. VA has much research in these areas, as do a large number of other organizations. In addition new and novel therapies are being introduced that require effective assessments and when appropriate broader dissemination. The field of genomics, and in particularly pharmacogenomics is changing the approach to behavioral healthcare treatments. Even cellular and regenerative therapies are likely to change the approach towards treatment of these conditions. Digital tools too are having a positive impact on helping more people. VA has a number of mental health apps (25) and companies such as Happify (www.Happify.com) are providing tools that provide digital therapeutics and programs that are making a big difference in the lives of people around the world.
Lesson 15: Emergency Access and Crisis Intervention
Providing immediate access to trained help is critical in the fight against suicide. Since 2007, VA has maintained a 24/7 Suicide Prevention Crisis Line (26). This crisis line has received more than 4 million calls, 500,000 on line chats and 125,000 texts (27). The crisis line has resulted in over 180,000 dispatches of emergency services to intervene in a life saving situation for veterans. VA has learned a great deal about how to provide effective crisis line services and accounts for about 1/3 of all calls received by the national suicide hotline. Health systems can help by making the phone number of the National Suicide Hotlines (800-273-8255) readily accessible to providers and patients. I personally ask people to enter this number in their phone contact list so it is readily available should they ever need to locate it quickly. Thanks to important new legislation, 988 service will become available nationally in 2022 for anyone to call these three numbers from their phone and immediately get directed to trained help in the event of a crisis (28). Health systems can help sharing by this information when the 988 system is operational.