Applying Research to Advance Suicide Prevention in Women Veterans.

Abstract

A national focus on suicide has sparked innovative research and a growing knowledge base. This is critical work that informs policy and clinical care, and this special issue on suicide in women is particularly timely. Rates of suicide among women are on the rise and are markedly higher among some subgroups of women. In 2017, women veterans were 2.2 times more likely to die by suicide than civilian women; the age-adjusted rates were 16.8/100,000 for women veterans compared with 7.6/100,000 for nonveteran women.1 The reasons for these disparities are multifactorial and effective strategies to reduce disparities—and suicide rates more generally—are critically needed. Here we illustrate some of the ways the Office of Mental Health and Suicide Prevention (OMHSP) of the Department of Veterans Affairs (VA) is applying research findings to develop new resources and initiatives to support women veterans’ well-being and mental health, and to mitigate their suicide risk. One notable clinical resource is the VA Reproductive Mental Health Consultation Program, recently launched by the Women’s Mental Health (WMH) Section of OMHSP. Reproductive cycle stages can influence suicide risk in women. Women with premenstrual dysphoric disorder (PMDD) have a greater likelihood of having suicidal thoughts, plans, and attempts,2 and women who attempt suicide have a greater likelihood of experiencing PMDD.3 Suicidal ideation is more frequently endorsed by women who are in the transition to menopause (perimenopause) as compared to premenopausal and postmenopausal women, and as compared to men.4 Pregnancy is a major cause of discontinuing antidepressants,5 which can increase suicide risk in vulnerable women. Accurately diagnosing and effectively treating mental health challenges during these reproductive cycle stages is an essential part of suicide prevention efforts. To this end, VA offers a Reproductive Mental Health Consultation Program available to all VA clinicians. Subject matter experts respond to questions about reproductive mental health concerns with evidence-based replies tailored to individual circumstances, allowing for direct translation of research findings into clinical applicability. New provider training resources have been developed to broadly disseminate clinically relevant research findings. The Suicide Prevention Program in VA’s OMHSP has developed the From Science to Practice series of brief evidence summaries. Each focuses on specific suicide risk and protective factors and includes a concise review of relevant research in the general population and, when available, specific to veterans. Evidence-informed actions and resources providers can use to support their patients are also included. In addition to informing suicide prevention efforts within the VA, these products are available to community providers and include community-based resources. Of particular relevance to suicide prevention in women veterans, the series includes evidence summaries of associations between suicide risks and women’s mental and sexual health, reproductive health and the experience of military sexual trauma. Evidence about suicide prevention and risks in women has also been integrated into the core curriculum of VA’s annual WMH Mini-Residency. The WMH Mini-Residency, led by the WMH Section of OMHSP, provides in-depth training within a specific area of focus (women’s mental health), concentrated within several days of expert-led didactics and highly interactive small-group sessions. For example, suicide risk is increased in the context of several traumas more common in women, such as intimate partner violence6 and sexual trauma7,8 and, among women veterans, military sexual trauma.9–11 It is also associated with a variety of mental health diagnoses,12 as well as sleep disorders,13 physical conditions such as chronic pain14 and multimorbidity.13 To enhance clinicians’ understanding of these links, relevant material about suicide risk is incorporated into every topic taught during this intensive training, which is attended by mental health clinicians from every VA medical center nationally. For instance, training content on bipolar disorder includes factors associated with suicide that differ by sex15 and content on women’s perinatal mental health notes that intimate partner violence during the perinatal period increases risk for suicide.16 Content on nonsuicidal self-injury (NSSI) addresses the distinction between NSSI and self-directed violence with suicidal intent, and the complex links between NSSI, onset of suicidal ideation, and initiation of suicidal behaviors.17,18 The WMH Mini-Residency is essential training for VA’s WMH Champions, who serve as local points of contact for women’s mental health at all VA medical centers. Following their participation in the WMH Mini-Residency, WMH Champions complete a 6-month action plan to advance gender-sensitive women’s mental health services at their local VA facilities. Some action plans directly focus on strengthening suicide prevention efforts for women veterans by, for example, organizing community outreach events and sharing information about women veterans’ suicide risks and prevention strategies, or partnering with VA Suicide Prevention Coordinators to teach clinical staff about gender-tailored safety planning strategies. Others indirectly strengthen suicide prevention efforts, for instance by implementing gender-tailored intake and assessment procedures and developing new clinical resources that address suicide risks in women veterans, such as problems with distress tolerance and emotion regulation. In addition to integrating material about suicide risk across topics covered in the WMH Mini-Residency, the WMH Section of OMHSP developed a case-based interactive workshop to enhance clinicians’ knowledge and skills regarding women-specific suicide prevention. Through stepwise case discussions, multidisciplinary clinicians learn how PMDD, pregnancy, the postpartum period, and perimenopause can affect women’s suicide risk, how to assess mental health and suicide risk across female reproductive cycle stages, and how to adapt mental health treatment during reproductive cycle stages. This foundational workshop provides screening, assessment and tracking tools, and relevant resources. Use of composite case examples and guided discussion model evidence-informed clinical decision making and mirror processes used by VA’s Reproductive Mental Health Consultation Program to apply research findings to inform clinical decision making. A final example of how the growing evidence base continues to inform VA suicide prevention efforts is the development and dissemination of lethal means safety strategies, specifically around gun storage and medication disposal. Self-inflicted firearm injury and poisoning are the leading causes of suicide death in women veterans, accounting for 43.2% and 28.7% of suicide deaths in women veterans, respectively.1 All VA health care facilities provide veteran patients with gun safety locks, free of charge, and VA’s MedSAFE Program offers prepaid envelopes that can be used to return unused medications for safe disposal. A new training resource, in development by VA’s Suicide Prevention Program in OMHSP, is designed to educate VA women’s health providers about ways to tailor lethal means safety counseling to address gender-related risks, motivating factors, and obstacles. For instance, framing safe gun storage and medication disposal as child safety practices may resonate strongly with mothers and encourage uptake of these methods. Another example is the importance of addressing feelings of vulnerability and fear as potential barriers to safe storage of firearms for women who have experienced interpersonal assault and report feeling safer with a loaded weapon close by. These gender-sensitive suicide prevention efforts are the product of close collaborative ties between VA policymakers, clinical leaders, and the very talented research community whose work potentiates important innovations for real world impact. Significant strides have already been made and greater advances are on the horizon.