Treatment of veterans with mental health symptoms in VA primary care prior to suicide

What Now?: Experiences of VHA patients following disclosure of suicidal ideation in primary care and mental health settings

OBJECTIVE

While screening and treatment options for patients who disclose suicidal ideation in clinical settings have grown in recent decades, little is known about patient experiences following disclosure. We characterize patient perspectives of responses following disclosure of suicidal ideation in Veteran Health Administration (VHA) primary care and mental health settings.

METHOD

Qualitative thematic analysis using a conventional/directed hybrid approach.

RESULTS

A national sample comprised of sixty participants who recently screened for suicidal ideation in primary care (n = 28) and mental health (n = 32) settings completed interviews. Many patients described therapeutic experiences following disclosure, including caring staff, timely follow-up care, and offers of multiple treatment options. Other patients, however, reported deficits in staff empathy, long waits for follow-up care, or inadequate treatment options.

CONCLUSIONS

While many VA clinical settings provided empathic and helpful responses, these experiences were not universal. Our findings reinforce the importance of a patient-centered approach to screening and response to disclosure, including collaboration with patients in treatment planning. Improved follow-up care coordination processes are needed. Following disclosure, contact with the staff who received the disclosure also helps patients feel cared about, and provides opportunity to troubleshoot barriers a patient may experience in accessing care.

Veteran Perspectives on Population-Based Suicide Risk Screening in VHA Primary Care: Mixed-Methods Study

BACKGROUND

In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings.

OBJECTIVE

The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program.

DESIGN

Mixed methods; survey and qualitative interviews.

PARTICIPANTS

Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews.

MAIN MEASURES

The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID.

KEY RESULTS

Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered.

CONCLUSIONS

Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts.

Complexity of the Relationships of Pain, Posttraumatic Stress, and Depression in Combat-Injured Populations: An Integrative Review to Inform Evidence-Based Practice

BACKGROUND

Understanding the complex interrelationships between combat injuries, physical health, and mental health symptoms is critical to addressing the healthcare needs of wounded military personnel and veterans. The relationship between injury characteristics, pain, posttraumatic stress disorder (PTSD), and depression among combat-injured military personnel is unique to modern conflicts and understudied in the nursing literature.

AIM

This integrative review synthesizes clinical presentations and relationships of combat injury, PTSD, depression, and pain in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) United States military service members and veterans.

METHODS

A literature search was conducted using relative key terms across databases to identify peer-reviewed publications between 2001 and 2016 that examined health outcomes of combat-injured persons in OEF and OIF. The quality of evidence was evaluated and results synthesized to examine the association of combat injury as a risk factor for PTSD, the relationship of PTSD and depression pre- and postinjury, and pain management throughout care.

RESULTS

Twenty-two articles were included in this review. Greater injury and pain severity poses risks for developing PTSD following combat injury, while early symptom management lessens risks for PTSD. Depression appears to be both a contributing risk factor to postinjury PTSD, as well as a comorbidity.

LINKING EVIDENCE TO ACTION

Findings demonstrate a compelling need for improvements in standardized assessment of pain and mental health symptoms across transitions in care. This integrative review informs nurse researchers and providers of the clinical characteristics of pain, PTSD, and depression following combat injury and offers implications for future research promoting optimal surveillance of symptoms.