PTSD
PTSD and Suicide
Post-Traumatic
Stress Disorder (PTSD) People with PTSD tend to experience:
Definition It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it. This “fight-or-flight” response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened even when they are not in danger. Signs and Symptoms Not every traumatized person develops ongoing (chronic) or even short-term (acute) PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic. A doctor who has experience helping people with mental illnesses, such as a pschiatrist or psychologist, can diagnose PTSD. To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:
Re-experiencing symptoms include:
Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms. Avoidance symptoms include:
Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car. Arousal and reactivity symptoms include:
Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating. Cognition and mood symptoms include:
Cognition and mood symptoms can begin or worsen after the traumatic event, but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members. It is natural to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a month, seriously affect one’s ability to function, and are not due to substance use, medical illness, or anything except the event itself, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders. Do children react differently than adults? Children and teens can have extreme reactions to trauma, but their symptoms may not be the same as adults. In very young children (less than 6 years of age), these symptoms can include:
Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge. For additional information, visit the Learn More section below. The National Institute of Mental Health (NIMH) offers free print materials in English and Spanish. These can be read online, downloaded, or delivered to you in the mail. Risk Factors Anyone can develop PTSD at any age. This includes war veterans, children, and people who have been through a physical or sexual assault, abuse, accident, disaster, or many other serious events. According to the National Center for PTSD , about 7 or 8 out of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men, and genes may make some people more likely to develop PTSD than others. Not everyone with PTSD has been through a dangerous event. Some people develop PTSD after a friend or family member experiences danger or harm. The sudden, unexpected death of a loved one can also lead to PTSD. Why do some people develop PTSD and other people do not? It is important to remember that not everyone who lives through a dangerous event develops PTSD. In fact, most people will not develop the disorder. Many factors play a part in whether a person will develop PTSD. Some examples are listed below. Risk factors make a person more likely to develop PTSD. Other factors, called resilience factors, can help reduce the risk of the disorder. Risk Factors and Resilience Factors for PTSD Some factors that increase risk for PTSD include:
Some resilience factors that may reduce the risk of PTSD include:
Researchers are studying the importance of these and other risk and resilience factors, including genetics and neurobiology. With more research, someday it may be possible to predict who is likely to develop PTSD and to prevent it. Treatments and Therapies The main treatments for people with PTSD are medications, psychotherapy (“talk” therapy), or both. Everyone is different, and PTSD affects people differently so a treatment that works for one person may not work for another. It is important for anyone with PTSD to be treated by a mental health provider who is experienced with PTSD. Some people with PTSD need to try different treatments to find what works for their symptoms. If someone with PTSD is going through an ongoing trauma, such as being in an abusive relationship, both of the problems need to be addressed. Other ongoing problems can include panic disorder, depression, substance abuse, and feeling suicidal. Medications The most studied medications for treating PTSD include antidepressants, which may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Antidepressants and other medications may be prescribed along with psychotherapy. Other medications may be helpful for specific PTSD symptoms. For example, although it is not currently FDA approved, research has shown that Prazosin may be helpful with sleep problems, particularly nightmares, commonly experienced by people with PTSD. Doctors and patients can work together to find the best medication or medication combination, as well as the right dose. Check the U.S. Food and Drug Administration website (http://www.fda.gov/ ) for the latest information on patient medication guides, warnings, or newly approved medications. Psychotherapy Psychotherapy (sometimes called “talk therapy”) involves talking with a mental health professional to treat a mental illness. Psychotherapy can occur one-on-one or in a group. Talk therapy treatment for PTSD usually lasts 6 to 12 weeks, but it can last longer. Research shows that support from family and friends can be an important part of recovery. Many types of psychotherapy can help people with PTSD. Some types target the symptoms of PTSD directly. Other therapies focus on social, family, or job-related problems. The doctor or therapist may combine different therapies depending on each person’s needs. Effective psychotherapies tend to emphasize a few key components, including education about symptoms, teaching skills to help identify the triggers of symptoms, and skills to manage the symptoms. One helpful form of therapy is called cognitive behavioral therapy, or CBT. CBT can include: Exposure therapy. This helps people face and control their fear. It gradually exposes them to the trauma they experienced in a safe way. It uses imagining, writing, or visiting the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings. Cognitive restructuring. This helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about something that is not their fault. The therapist helps people with PTSD look at what happened in a realistic way. There are other types of treatment that can help as well. People with PTSD should talk about all treatment options with a therapist. Treatment should equip individuals with the skills to manage their symptoms and help them participate in activities that they enjoyed before developing PTSD. How Talk Therapies Help People Overcome PTSD Talk therapies teach people helpful ways to react to the frightening events that trigger their PTSD symptoms. Based on this general goal, different types of therapy may:
Beyond Treatment: How can I help myself? It may be very hard to take that first step to help yourself. It is important to realize that although it may take some time, with treatment, you can get better. If you are unsure where to go for help, ask your family doctor. You can also check NIMH's Help for Mental Illnesses page or search online for “mental health providers,” “social services,” “hotlines,” or “physicians” for phone numbers and addresses. An emergency room doctor can also provide temporary help and can tell you where and how to get further help. To help yourself while in treatment:
Caring for yourself and others is especially important when large numbers of people are exposed to traumatic events (such as natural disasters, accidents, and violent acts). For more information, see the Learn More section, below. Next Steps for PTSD Research In the last decade, progress in research on the mental and biological foundations of PTSD has lead scientists to focus on better understanding the underlying causes of why people experience a range of reactions to trauma.
Source: projectsemicolon.com/post-traumatic-stress-disorder/
PTSD Awareness Month This year—during a global pandemic that has created significant challenges for so many people—PTSD Awareness Month comes at a time of increased public attention to how racism affects people of color. PTSD and Racial Minorities Racial minorities are more likely than whites to have PTSD. One explanation for these differences may be that racial minorities have more frequent exposure than whites to some types of traumatic events. For example, racial minorities are more likely to live in areas with higher rates of community violence. But higher risk of being exposed to a traumatic event only partially explains the racial differences in PTSD prevalence. Additional factors are involved, including those that could affect recovery, such as the ongoing stresses of poverty and limited access to mental health care. PTSD and Racial Discrimination Racial discrimination is associated with worse physical and mental health and poorer quality of life. Growing evidence also points to experiences with racial discrimination as a factor that increases the risk of PTSD for racial and ethnic minorities. Extreme experiences, such as racially-motivated physical or sexual assaults, meet the classic definition of a traumatic stressor: exposure to actual or threatened death, serious injury, or sexual violence. Whether experiences of racial discrimination that are less severe, such as verbal threats, can be said to “cause” PTSD is a topic of debate among experts, but it is clear that these other kinds of experiences are related to increased risk of PTSD. Events known as microaggressions—everyday, more subtle experiences that communicate hostility or are derogatory toward a particular group—can also contribute to the overall negative impact of racism on mental health. Future Research Based on these known negative health effects of systemic racism and the racial disparities in PTSD, we are committed to promoting a focus on issues of race, racism, and cross-cultural competence in National Center for PTSD research and education projects. Understanding the relationship of race
and racism to PTSD are critical aspects of PTSD awareness.
If you or someone you know has PTSD, reach out. PTSD is a
treatable disorder, and there are a variety of effective
treatments. The
Relationship Between PTSD and Suicide Often the most difficult part of obtaining treatment is the initial call to a mental health professional. It is usually easier for a suicidal individual to accept professional help if they have assistance with this part of the process. For help making referrals see Get Help in a Crisis. How Common Is Suicide? It is challenging to determine an exact number of suicides. Many times, suicides are not reported and it can be very difficult to determine whether or not a particular individual's death was intentional. For a suicide to be recognized, examiners must be able to say that the deceased meant to die. Other factors that contribute to the difficulty are differences among states as to who is mandated to report a death, as well as changes over time in the coding of mortality data (1). Data from the National Vital Statistics System, a collaboration between the National Center for Health Statistics of the U.S. Department of Health and Human Services and each US state, provides the best estimate of suicides (2). Overall, men have significantly higher rates of suicide than women. This is true whether or not they are Veterans (3). For comparison:
Does Trauma Increase an Individual's Suicide Risk? A body of research indicates that there is a correlation between many types of trauma and suicidal behaviors. For example, there is evidence that traumatic events such as childhood abuse may increase a person's suicide risk (4,5). A history of military sexual trauma (MST) also increases the risk for suicide and intentional self-harm, suggesting a need to screen for suicide risk in this population (6). Importance of combat exposure in Veterans Though considerable research has examined the relation between combat or war trauma and suicide, the relationship is not entirely clear. Some studies have shown a relationship while others have not (1). There is strong evidence, though, that among Veterans who experienced combat trauma, the highest relative suicide risk is observed in those who were wounded multiple times and/or hospitalized for a wound (7). This suggests that the intensity of the combat trauma, and the number of times it occurred, may influence suicide risk in Veterans. This study assessed only combat trauma, not a diagnosis of PTSD, as a factor in the suicidal behavior. Does PTSD Increase an Individual's Suicide Risk? Considerable debate exists about the reason for the heightened risk of suicide in trauma survivors. Whereas some studies suggest that suicide risk is higher among those who experienced trauma due to the symptoms of PTSD (8-10), others claim that suicide risk is higher in these individuals because of related psychiatric conditions (11,12). However, a study analyzing data from the National Comorbidity Survey, a nationally representative sample, showed that PTSD alone out of six anxiety diagnoses was significantly associated with suicidal ideation or attempts (13). While the study also found an association between suicidal behaviors and both mood disorders and antisocial personality disorder, the findings pointed to a robust relationship between PTSD and suicide after controlling for comorbid disorders. A later study using the Canadian Community Health Survey data also found that respondents with PTSD were at higher risk for suicide attempts after controlling for physical illness and other mental disorders (14). Some studies that point to PTSD as a precipitating factor of suicide suggest that high levels of intrusive memories can predict the relative risk of suicide (9). Anger and impulsivity have also been shown to predict suicide risk in those with PTSD (15). Further, some cognitive styles of coping such as using suppression to deal with stress may be additionally predictive of suicide risk in individuals with PTSD (9). PTSD and suicide risk in Veterans Other research looking specifically at combat-related PTSD in Vietnam era Veterans suggests that the most significant predictor of both suicide attempts and preoccupation with suicide is combat-related guilt (16). Many Veterans experience highly intrusive thoughts and extreme guilt about acts committed during times of war. These thoughts can often overpower the emotional coping capacities of Veterans. With respect to OIF/OEF Veterans, PTSD has been found to be a risk factor for suicidal ideation (17). Subthreshold PTSD also carries risk. A recent study found that among OIF/OEF Veterans, those with subthreshold PTSD were 3 times more likely to report hopelessness or suicidal ideation than those without PTSD (18). Can PTSD Treatment Help? Current practice guidelines for treatment of PTSD indicate that trauma-focused therapies are not recommended for individuals with "significant suicidality" (19,20). Because "suicidality" is a vague term and there is no guidance for what significant suicidality means, we interpret this recommendation to pertain to actively suicidal patients, or those in an acute clinical emergency for whom suicidality should be addressed without delay. Providers must therefore use clinical judgment prior to initiating and throughout trauma-focused therapy. Individuals with PTSD who present with intermittent but manageable suicidal thoughts may benefit from trauma-focused therapy. Two effective treatments for PTSD, Cognitive Processing Therapy (CPT) and prolonged exposure (PE) have been shown to reduce suicidal ideation. A recent study that randomized women who experienced rape into CPT or PE treatment found that reductions in PTSD symptoms were associated with decreases in suicidal ideation throughout treatment. The reductions were maintained over a 5-10 year follow-up period. The effect of PTSD treatment on suicidal ideation was greater for women who completed CPT (21). Further research is needed to provide additional evidence in other populations. Suicide as a traumatic event. Researchers have also examined exposure to suicide as a traumatic event. Studies show that trauma from exposure to suicide can contribute to PTSD. In particular, adults and adolescents are more likely to develop PTSD as a result of exposure to suicide if one or more of the following conditions are true: if they witness the suicide, if they are very connected with the person who dies, or if they have a history of psychiatric illness (22-24). Studies also show that traumatic grief is more likely to arise after exposure to traumatic death such as suicide (25,26). Traumatic grief refers to a syndrome in which individuals experience functional impairment, a decline in physical health, and suicidal ideation. These symptoms occur independently of other conditions such as depression and anxiety. VA developed fact sheets to share with family members of Veterans who have made a suicide attempt. Products include guides for talking about a suicide attempt with children and are available in Spanish. Although these resources were created with military families in mind, the material includes resources and information that may be useful for civilians as well. References 1. Knox, K.L. (2008). Epidemiology of the relationship between traumatic experience and suicidal behaviors. PTSD Research Quarterly, 19(4). www.ptsd.va.gov/publications/rq_docs/V19N4.pdf (PDF) 2. Statement of the Honorable James B. Peake, MD, Secretary of Veterans Affairs, Before the Committee on Veterans' Affairs, United States House of Representatives, May 6, 2008. Accessed December 10, 2009: www.va.gov/OCA/testimony/hvac/08050600.asp 3. Kemp, J. & Bossarte, R. (2012). Suicide Data Report, 2012. (Report prepared for the U.S. Department of Veterans Affairs) Available from www.va.gov/opa/docs/Suicide-Data-Report-2012-final.pdf (PDF) 4. Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.J.G., Stein, M.B., & Sareen, J. (2008). Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98, 946-952. doi: 10.2105/AJPH.2007.120253 5. Ystgaard, M., Hestetun, I., Loeb, M., & Mehlum, L. (2004). Is there a specific relationship between childhood sexual and physical abuse and repeated suicidal behavior? Child Abuse and Neglect, 28, 863-875. 6. Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97, 2160-2166. doi: 10.2105/AJPH.2006.092999 7. Bullman, T. A., & Kang, H. K. (1995). A study of suicide among Vietnam Veterans. Federal Practitioner, 12(3), 9-13. 8. Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidal behavior after severe trauma. Part 1: PTSD diagnoses, psychiatric comorbidity and assessment of suicidal behavior. Journal of Traumatic Stress, 11, 103-112. 9. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide risk and coping styles in posttraumatic stress disorder patients. Psychotherapy and Psychosomatics, 68, 76-81. doi: 10.1159/000012316 10. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic stress disorder as risk factors for suicide attempts in a sample of low-income, inner-city women. Journal of Traumatic Stress, 12, 59-72. doi: 10.1023/A:1024742215337 11. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among Vietnam Veterans: A model of etiology in a community sample. American Journal of Psychiatry, 152, 102-109. 12. Robison, B. K. (2002). Suicide risk in Vietnam Veterans with posttraumatic stress disorder. Unpublished Doctoral Dissertation, Pepperdine University. 13. Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G. (2005). Anxiety disorders associated with suicidal ideation and suicide attempts in the National Comorbidity Survey. Journal of Nervous and Mental Disease. 193, 450-454. doi: 10.1097/01.nmd.0000168263.89652.6b 14. Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., & Asmundson, G.J.G. (2007). Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample. Psychosomatic Medicine. 69, 242-248. doi: 10.1097/PSY.0b013e31803146d8 15. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity, social support, and suicide risk in patients with posttraumatic stress disorder. Journal of Nervous & Mental Disease, 189, 162-167. doi: 10.1097/00005053-200103000-00004 16. Hendin, H., & Haas, A. P. (1991). Suicide and guilt as manifestations of PTSD in Vietnam combat veterans. American Journal of Psychiatry, 148, 586-591. 17. Jakupcak, M., Cook, J., Imel, Z., Rosenheck, R., & McFall, M. (2009). PTSD as a Risk Factor for Suicidal Ideation in Iraq and Afghanistan War Veterans. Journal of Traumatic Stress, 22, 303-306. doi: 10.1002/jts.20423 18. Jakupcak, M., Hoerster, K. D., Varra, A., Vannoy, S., Felker, B., & Hunt, S. (2011). Hopelessness and Suicidal Ideation in Iraq and Afghanistan War Veterans Reporting Subthreshold and Threshold PTSD, Journal of Nervous and Mental Disease, 199, 272-275. doi: 10.1097/NMD.0b013e3182124604 19. VA/DoD Clinical Practice Guideline: Management of Post-traumatic Stress, 2010: Guideline Summary. Washington, DC: Department of Veterans Affairs; 2010. Retrieved from: www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp 20. Foa, E. B., Keane, T. M., Friedman, M. J., Cohen, J. A., Effective Treatments for PTSD: Practice Guidelines for the International Society for Traumatic Stress Studies. New York: Guilford; 2009. 21. Gradus, J. L., Sucak, M. K., Wisco, B. E., Marx, B. P., & Resick, P. A. (Article in press.). Treatment of posttraumatic stress disorder reduces suicidal ideation. Depression and Anxiety. doi: 10.1002/da.22117 22. Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who discovers or witnesses suicide? Psychological Reports, 42, 759-764. doi: 10.2466/pr0.1978.42.3.759 23. Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers, J., Allman, C., McQuiston, L., Boylan, M. B., Roth, C., & Balach, L. (1993b). Adolescent witnesses to a peer suicide. Journal of the American Academy of Child and Adolescent Psychiatry, 32, 1184-1188. doi: 10.1097/00004583-199311000-00011 24. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., Richardson, D., Canobbio, R., Schweers, J., & Roth, C. (1995). Posttraumatic stress disorder in peers of adolescent suicide victims: Predisposing factors and phenomenology. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 209-215. doi: 10.1097/00004583-199502000-00016 25. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., & Brent, D. A. (2004). Traumatic grief among adolescents exposed to a peer's suicide. American Journal of Psychiatry, 161, 1411-1416. doi: 10.1176/appi.ajp.161.8.1411 26. Prigerson, H. G., Shear, M. K.,
Jacobs, S. C., Reynolds, C. F. I., Maciejewsk, P. K.,
Davidson, J. R., Rosenheck, R., Pilkonis, P. A., Wortman, C.
B., Williams, J. B., Widiger, T. A., Frank, E., Kupfer, D.
J., & Zisook, S. (1999). Consensus criteria for
traumatic grief: A preliminary empirical test. British
Journal of Psychiatry, 174, 67-73. doi:
10.1192/bjp.174.1.67 Children are not immune to the challenges of post-traumatic stress disorder. The National Child Traumatic Stress Institute (NCTSI) states that more than two-thirds of children have reported at least one traumatic experience by the age of 16.15? Additionally, it is estimated that 19 percent of injured and 12 percent of physically ill youth have PTSD. Potential Childhood Traumatic Experiences
Because children can have a more difficult time processing their experiences and coping with the lasting emotional impact of trauma, it is important for support people (caregivers, relatives, etc) to allow children the opportunity to talk about their experience. A critical part of a child's recovery and healing is their support system. Having a strong support system and access to trauma-informed care is essential to their healthy coping and overall healing. For Loved Ones Finding ways to support a loved one with PTSD can be a struggle. One of the most helpful things you can do is learn about the symptoms and the challenges of living with post-traumatic stress disorder? Becoming familiar with what your loved one might be experiencing can help increase compassion and understanding, making it easier to have conversations about their challenges. Inviting and encouraging your loved one to seek help from a trained professional is paramount. Since unaddressed symptoms of PTSD can become more severe over time, it is important to try and help your loved one find helpful resources to begin the healing process. Do not be afraid to ask your loved one about their experiences and be open to actively listening. You are not expected to "fix" anything, just allow your loved one space to talk openly without fear of judgment or criticism. Ask your doctor or mental health professional for a recommendation or referral to someone who specializes in treating PTSD. If you or a loved one are struggling
with PTSD, contact the Substance Abuse and Mental Health
Services Administration (SAMHSA) National Helpline at
1-800-662-4357 for information on support and treatment
facilities in your area. Children and
PTSD Yes, children can have PTSD. However, a child can have a very different reaction to a traumatic event than an adult. Some of the possible symptoms include:
Below is a checklist of problems or symptoms that people with PTSD can exhibit. Remember, you must seek a professional for an accurate diagnosis of PTSD. This checklist is provided only as a tool to help you talk with your doctor or treatment provider about your concerns and develop an action plan for successful recovery. I have repeated, disturbing memories, thoughts,
or images of a stressful experience from the
past. I suddenly act or feel as if a stressful
experience were happening again (as if you were
reliving it). I have physical reactions (e.g., heart pounding,
trouble breathing, or sweating) when something
reminds me of a stressful experience from the
past. I have repeated, disturbing dreams of a
stressful experience from the past. I feel very upset when something reminds me of a
stressful experience from the past. I avoid thinking about or talking about a
stressful experience from the past or avoid having
feelings related to it. I avoid activities or situations because they
remind me of a stressful experience from the
past. I have trouble remembering important parts of a
stressful experience from the past. I feel emotionally numb or unable to have loving
feelings for people close to me. I have lost interest in things that I used to
enjoy. I feel as if my future will somehow be cut
short. I feel irritable. I feel distant or cut off from other people. I have trouble falling or staying asleep. I have angry outbursts. I am “super alert” or watchful. I feel jumpy or easily startled. I have difficulty concentrating. Source:
save.org/about-suicide/mental-illness-and-suicide/post-traumatic-stress-disorder-ptsd/ Shame Drives
Suicidal Ideation Among Veterans With PTSD Every day, approximately 20 veterans die by suicide and up to 14% of veterans report current suicidal ideation. Veterans suffer disproportionately from mental health disorders, including PTSD, depression, and substance abuse. Up to 15% of veterans have PTSD, and those diagnosed with this disorder have high rates of suicidal behavior and suicide. Emotional responses to trauma have been shown to play an important role in PTSD and may increase the risk for suicidal behavior. Given the high rate of suicide among veterans, there is a pressing need to identify risk factors for suicidal behavior. Katherine C. Cunningham, PhD, from the Durham Veterans Affairs Medical Center and the VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, North Carolina, and colleagues investigated the role of that shame plays in PTSD and suicidal ideation. They used the Mississippi Scale for Combat-Related PTSD to gauge PTSD severity, the Personality Assessment Inventory to evaluate suicidal ideation, and the Internalized Shame Scale to assess shame among 189 men and 12 women who were veterans, with a mean age of 40 years. Whites made up 48.3% of the study population, blacks made up 44.8%, Native Americans 2%, white Hispanics 3%, and others 2%. PTSD and shame together accounted for
a significant degree of the variance in suicidal ideation.
However, although shame had significant effects on both
suicidal ideation and PTSD, and PTSD had an indirect effect
on suicidal ideation via shame, shame did not have an
indirect effect on suicidal ideation via PTSD symptoms. The
authors suggest that these findings indicate that shame
drives the relationship between PTSD and suicidal
ideation. Left
behind after suicide Every year in the United States, more than 45,000 people take their own lives. Every one of these deaths leaves an estimated six or more "suicide survivors" — people who've lost someone they care about deeply and are left with their grief and struggle to understand why it happened. The grief process is always difficult, but a loss through suicide is like no other, and the grieving can be especially complex and traumatic. People coping with this kind of loss often need more support than others, but may get less. There are various explanations for this. Suicide is a difficult subject to contemplate. Survivors may be reluctant to confide that the death was self-inflicted. And when others know the circumstances of the death, they may feel uncertain about how to offer help. Grief after suicide is different, but there are many resources for survivors, and many ways you can help the bereaved. What makes suicide different The death of a loved one is never easy to experience, whether it comes without warning or after a long struggle with illness. But several circumstances set death by suicide apart and make the grief process more challenging. For example: A traumatic aftermath. Death by suicide is sudden, sometimes violent, and usually unexpected. Depending on the situation, survivors may need to deal with the police or handle press inquiries. While you are still in shock, you may be asked whether you want to visit the death scene. Sometimes officials will discourage the visit as too upsetting; at other times, you may be told you'll be grateful that you didn't leave it to your imagination. "Either may be the right decision for an individual. But it can add to the trauma if people feel that they don't have a choice," says Jack Jordan, Ph.D., clinical psychologist and co-author of After Suicide Loss: Coping with Your Grief. You may have recurring thoughts of the death and its circumstances, replaying the final moments over and over in an effort to understand — or simply because you can't get the thoughts out of your head. Some suicide survivors develop post-traumatic stress disorder (PTSD), an anxiety disorder that can become chronic if not treated. In PTSD, the trauma is involuntarily re-lived in intrusive images that can create anxiety anda tendency to avoid anything that might trigger the memory. Stigma, shame, and isolation. Suicide can isolate survivors from their community and even from other family members. There's still a powerful stigma attached to mental illness (a factor in most suicides), and many religions specifically condemn the act as a sin, so survivors may understandably be reluctant to acknowledge or disclose the circumstances of such a death. Family differences over how to publicly discuss the death can make it difficult even for survivors who want to speak openly to feel comfortable doing so. The decision to keep the suicide a secret from outsiders, children, or selected relatives can lead to isolation, confusion, and shame that may last for years or even generations. In addition, if relatives blame one another — thinking perhaps that particular actions or a failure to act may have contributed to events — that can greatly undermine a family's ability to provide mutual support. Mixed emotions. After a homicide, survivors can direct their anger at the perpetrator. In a suicide, the victim is the perpetrator, so there is a bewildering clash of emotions. On one hand, a person who dies by suicide may appear to be a victim of mental illness or intolerable circumstances. On the other hand, the act may seem like an assault on or rejection of those left behind. So the feelings of anger, rejection, and abandonment that occur after many deaths are especially intense and difficult to sort out after a suicide. Need for reason. "What if" questions may arise after any death. What if we'd gone to a doctor sooner? What if we hadn't let her drive to the basketball game? After a suicide, these questions may be extreme and self-punishing — unrealistically condemning the survivor for failing to predict the death or to intervene effectively or on time. Experts tell us that in such circumstances, survivors tend to greatly overestimate their own contributing role — and their ability to affect the outcome. "Suicide can shatter the things you take for granted about yourself, your relationships, and your world," says Dr. Jordan. Many survivors need to conduct a psychological "autopsy," finding out as much as they can about the circumstances and factors leading to the suicide, in order to develop a narrative that makes sense to them. While doing this, they can benefit from the help of professionals or friends who are willing to listen — without attempting to supply answers — even if the same questions are asked again and again. Sometimes a person with a disabling or terminal disease chooses suicide as a way of gaining control or hastening the end. When a suicide can be understood that way, survivors may feel relieved of much of their what-if guilt. It doesn't mean someone didn't love their life. The grieving process may be very different than after other suicides. A risk for survivors. People who've recently lost someone through suicide are at increased risk for thinking about, planning, or attempting suicide. After any loss of a loved one, it's not unusual to wish you were dead; that doesn't mean you'll act on the wish. But if these feelings persist or grow more intense, confide in someone you trust, and seek help from a mental health professional. Support from other survivors Research suggests that suicide survivors find individual counseling (see "Getting professional help") and suicide support groups to be particularly helpful. There are many general grief support groups, but those focused on suicide appear to be much more valuable. "Some people also find it helpful to be in a group with a similar kinship relationship, so parents are talking to other parents. On the other hand, it can be helpful for parents to be in a group where they hear from people who have lost a sibling — they may learn more about what it's like for their other children," says Dr. Jordan. Some support groups are facilitated by mental health professionals; others by laypersons. If you go and feel comfortable and safe — feel that you can open up and won't be judged — that's probably more important than whether the group is led by a professional or a layperson. Lay leaders of support groups are often themselves suicide survivors; many are trained by the American Foundation for Suicide Prevention. For those who don't have access to a group or feel uncomfortable meeting in person, Internet support groups are a growing resource. You can join a support group at any time: soon after the death, when you feel ready to be social, or even long after the suicide if you feel you could use support, perhaps around a holiday or an anniversary of the death. Getting professional help Suicide survivors are more likely than other bereaved people to seek the help of a mental health professional. Look for a skilled therapist who is experienced in working with grief after suicide. The therapist can support you in many ways, including these:
Immediately after the suicide, assistance from a mental health professional may be particularly beneficial if you experience any of the following:
A friend in need Knowing what to say or how to help after a death is always difficult, but don't let fear of saying or doing the wrong thing prevent you from reaching out to suicide survivors. Don't hold back. Just as you would after any other death, express your concern, pitch in with practical tasks, and listen to whatever the person wants to tell you. Here are some special considerations: Stay close. Families often feel stigmatized and cut off after a suicide. If you avoid contact because you don't know what to say or do, family members may feel blamed and isolated. Whatever your doubts, make contact. Survivors learn to forgive awkward behaviors or clumsy statements, as long as your support and compassion are evident. Avoid hollow reassurance. It's not comforting to hear well-meant assurances that "things will get better" or "at least he's no longer suffering." Instead, the bereaved may feel that you don't want to acknowledge or hear them express their pain and grief. Don't ask for an explanation. Survivors often feel as though they're being grilled: Was there a note? Did you suspect anything? The survivor may be searching for answers, but your role for the foreseeable future is simply to be supportive and listen to what they have to say about the person, the death, and their feelings. Remember his or her life. Suicide isn't the most important thing about the person who died. Share memories and stories; use the person's name ("Remember when Brian taught my daughter how to ride a two-wheeler?"). If suicide has come at the end of a long struggle with mental or physical illness, be aware that the family may want to recognize the ongoing illness as the true cause of death. Acknowledge uncertainty. Survivors are not all alike. Even if you are a suicide survivor yourself, don't assume that another person's feelings and needs will be the same as yours. It's fine to say you can't imagine what this is like or how to help. Follow the survivor's lead when broaching sensitive topics: "Would you like to talk about what happened?" (Ask only if you're willing to listen to the details.) Even a survivor who doesn't want to talk will appreciate that you asked. Help with the practical things. Offer to run errands, provide rides to appointments, or watch over children. Ask if you can help with chores such as watering the garden, walking the dog, or putting away groceries. The survivor may want you to sit quietly, or perhaps pray, with him or her. Ask directly, "What can I do to help?" Be there for the long haul. Dr. Jordan calls our culture's standard approach to grief the "flu model": grief is unpleasant but is relatively short-lived; after a stay at home, the bereaved person will jump back into life. Unfortunately, that means that once survivors are back at work and able to smile or socialize again, they quickly get the message that they shouldn't talk about their continuing grief. Even if a survivor isn't bringing up
the subject, you can ask how she or he is coping with the
death and be ready to listen (or respect a wish not to talk
about it). Be patient and willing to hear the same stories
or concerns repeatedly. Acknowledging emotional days such as
a birthday or anniversary of the death — by calling or
sending a card, for example — demonstrates your support
and ongoing appreciation of the loss. PTSD and Suicide:
How Emergency Department Clinicians Can Intervene Trauma is a well-documented risk factor for suicidal thoughts and behaviors (LeBouthillier, McMillan, Thibodeau, & Asmundson, 2015). A diagnosis of posttraumatic stress disorder (PTSD) is one of the strongest predictors of both recent and lifetime suicide attempts, with a comorbid diagnosis of depression and PTSD further amplifying the risk for suicide (Bryan, 2016). Research also indicates that individuals diagnosed with PTSD who, at some point, experience suicidal ideation (SI) have an increased likelihood of transitioning to a suicide attempt compared to those who are diagnosed with other psychiatric disorders (Nock et al., 2009). Therefore, providers who treat clients with a trauma history and/or those diagnosed with PTSD are urged to continually monitor and assess for SI using well-validated assessment measures. PTSD often includes somatic problems that motivate patients to seek treatment in either primary care or emergency department (ED) settings (Greene, Neria, & Gross, 2016; Onoye et al., 2013). Given this, one place that mental health clinicians may be able to successfully identify and intervene for those most at risk for suicide is in EDs. From 2001 to 2016, rates of ED visits for nonfatal self-harm, a primary risk factor for suicide, increased by 42% (Stone et al., 2018). In addition, it was estimated that as many as one in ten individuals who died by suicide had been seen in an ED during the prior two months (Bowers et al., 2018). This observation highlights EDs as a crucial setting for suicide assessment and prevention. As ED psychiatric services are frequently required to assess a high number of patients and provide a clinical opinion about their future risk for suicide, the need for reliable and valid suicide assessment protocols is critical. Risk Factors Associated with Suicide Assessment Instruments Identifying standardized instruments that can reliably and validly assess suicidal behavior has been a focus of research for decades (Cochrane-Brink, Lofchy, & Sakinofsky, 2000; Cull & Gill, 1988; Jobes & Drozd, 2004; Russ, Kashdan, Pollack, & Bajmakovic-Kacila, 1999; Yufit & Lester, 2005). A recent systematic review suggests that researchers developing these instruments have typically focused on identifying and validating risk factors and sets of suicidal predictors in order to assess a person’s risk of suicide (Runeson et al., 2017). These risk factors have been reported to cluster into two domains: socio-demographic factors and clinical factors (Bisconer & Gross, 2007; Large et al., 2011). Some of these factors include: a history of deliberate self-harm, hopelessness, male gender, substance use, unemployment, feelings of guilt or inadequacy, social isolation, depressed mood, a family history of suicide, and a diagnosis of bipolar disorder or schizophrenia (Cull & Gill, 1988; Large et al., 2011; Links & Hoffman, 2005; Ruiz, 2001; Russ et al., 1999; Stack & Wasserman, 2005). Researchers have identified clients seen in inpatient settings as a subpopulation that presents with slightly different risk factors for suicide compared to those who are seen in outpatient clinical settings (Large et al., 2011). A history of a suicide attempts was the strongest predictor of death by suicide among inpatients. Moderate predictors include depressed mood, a family history of suicide, being prescribed an antidepressant medication, a diagnosis of schizophrenia, and feelings of hopelessness, worthlessness, inadequacy, or guilt (Large et al., 2011). Interestingly, weak predictors for in-patient suicide included a higher number of previous psychiatric admissions and a suicide attempt at the time of admission (Large et al., 2011). Additionally, this meta-analysis identified no demographic factor as significantly associated with inpatient suicide (Large et al., 2011). Moreover, physical illness, co-morbid substance abuse, the presence of hallucinations, delusional beliefs, or treatment with antipsychotic medication were also not significantly associated with suicide for patients receiving inpatient care (Large et al., 2011). These research findings underscore the difficulty of relying on a singular assessment tool to detect all of the varied risk factors when determining suicide risk. Although, these research findings suggest that specific socio-demographic factors and clinical factors contribute to an individual’s risk for suicide, setting also influences an individual’s potential risk. It is clear that each of these factors must be thoroughly considered when designing, selecting, and utilizing an assessment tool that will help a clinician predict an individual’s risk of suicide. Selection of an Assessment Instrument Ideally, each high-risk patient seen in a hospital setting should be assessed with a clinical interview in addition to a measure that can reliably and validly detect factors that may place them at an increased risk for suicide. Overall, current research is clear that assessment instruments should never be a substitute for a clinical interview, as interviews can address multiple areas of a patient’s life that may be contributing to their increased risk for suicide (Links & Hoffman, 2005; Podlogar et al., 2016; Stone et al., 2018). Assessments should be used to augment a clinical interview and the results should be used to inform the clinician’s decision to hospitalize or discharge the patient. Some of the most widely accepted instruments used to detect risk of suicide include the Beck Anxiety Inventory (BAI; Beck & Steer, 1993a), the Suicide Probability Scale (SPS; Cull & Gill, 1988), the Adult Suicidal Ideation Questionnaire (ASIQ; Reynolds, 1991), the Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001), the Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1993c), the Beck Hopelessness Scale (BHS; Beck & Steer, 1993b), and the Beck Depression Inventory II (BDI-II; Beck, Steer, & Brown, 1996). Research at a psychiatric hospital evaluated the ability of the SPS, ASIQ, BSS, BHS, BDI-II, and the BAI to distinguish between patients who were admitted for suicidal behavior and patients admitted for other reasons (Bisconer & Gross, 2007). Results indicated that the BAI, BHS, and BSS, while face valid for suicidal behaviors, did not perform as well as the SPS, ASIQ, and BDI-II. Additionally, while the SPS and ASIQ were specifically designed to assess suicide behaviors, results suggested that the BDI-II was the overall best predictor of suicide risk compared to the SPS and ASIQ (Bisconer & Gross, 2007). In addition, Baryshnikov et al. (2018) used the BDI, BHS, and the BAI to identify which scale best detected risk for suicide by inpatients in context with the patient’s personality characteristics as measured by the BIG-5 Inventory (McCrae & John, 1992). Results of their study revealed that suicidal inpatients with high levels of neuroticism and extroversion were best identified using the BHS (Baryshnikov et al., 2018), Moreover, having a low level of perceived social support increased the predictive validity of the BHS with these patients, helping to explain both state and trait variations of hopelessness as it relates to risk for suicide (Baryshnikov et al., 2018). These results suggest that an individual’s personality traits also influence the usefulness of a suicide risk assessment measure. The PTSD and Suicide Screener (PSS; Briere, 2013) is a less known, 14-item self-report measure that is designed to quickly screen for PTSD and suicide risk. This screener contains two scales: the PTSD Risk (PR) and the Suicide Risk (SR). The SR contains four items that assess for suicide risk. The PSS is effective as a quick indication that a patient may be experiencing SI. However, its limitations include the nuanced ways that SI is experienced among individuals, which may not be fully captured in fourteen questions. Results of these studies highlight a major limitation of existing assessment measures; relying on single-construct measures such as PTSD, depression, hopelessness, historical factors, or level of overt suicidal intent to determine an individual’s risk of suicide (Hawes, Yaseen, Briggs, & Galynker, 2017). It is evident that single-construct assessment measures are not able to adequately capture all of the nuanced ways that setting, sociodemographic, cultural, and personality characteristics influence a person’s risk for suicide. This may also help to explain why, to date, there is no singular assessment instrument that demonstrates predictive validity for death by suicide (Runeson et al., 2017). An additional limitation of using a single construct assessment measures is missing data. Research shows that when participants skip suicide risk screening items it does not occur completely at random (Podlogar et al., 2016). Selective nondisclosure by inpatients can be intentional and is likely to predict a subpopulation of respondents who have some level of elevated risk, based on the information they do not endorse (Podlogar et al., 2016). Missing data could lead a psychologist to mistakenly discharge an inpatient if they do not identify and address the specific items that the patient skipped. In general, these limitations highlight the need for hospitals to use suicide risk protocols that encompass multiple assessment instruments in order to capture all of the unique factors that could contribute to a patient’s increased risk for suicide. Future Directions for Risk of Suicide Assessment Instruments To address the lack of multi-factor assessment instruments, recent suicide risk assessments have turned to a multi-informant approach for assessing a patient’s risk for suicide. The Modular Assessment of Risk for Imminent Suicide (MARIS) was developed to assess a patient’s short-term suicide risk following hospital discharge (Hawes et al., 2017). This assessment instrument combines both the patient’s self-report and the clinician’s evaluation of the patient’s risk for suicide into one singular score (Hawes et al., 2017). Interestingly, the patients’ self-report does not contain items overtly referring to their suicidal history, ideation, or intent but the clinician’s portion of the assessment does (Hawes et al., 2017). It is the combination of these two scores that define an inpatient’s short-term risk for suicide (Hawes et al., 2017). Results of Hawes et al. (2017) suggests that the MARIS demonstrated adequate predictive validity for detecting high-risk psychiatric inpatients who will engage in suicidal behavior during the four to eight weeks following hospital discharge. This research identified the use of multi-informant approaches as a promising area for future directions within the field of suicide risk assessment instruments. Conclusion As clinicians, our ethical principles dictate that we do our best when assessing patients who express SI and intent (APA, 2013; Bongar, 1991). Assessment instruments that measure risk of suicide include the BAI, SPS, ASIQ, PHQ-9, BSS, BHS, BDI-II, and the PSS. Overall, results indicate that using single factor assessment measures are problematic due to the varied and nuanced ways that patients’ characteristics influence a variety of risk factors that increase their risk for suicide. Recent advances in suicide risk assessment measures have demonstrated predictive validity for multi-informant approaches, making these a prominent area of future research. These types of approaches are aligned with APA guidelines that outline the usefulness of both a clinical interview and an assessment battery to adequately evaluate a patient’s risk for suicide. While death by suicide remains a national public health concern in the U.S., EDs have a unique opportunity to identify and intervene for those most at risk, in part through the creation of valid and reliable assessment measures. References American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Baca-García, E., Diaz-Sastre, C., García Resa, E., Blasco, H., Conesa, D. B., Saiz-Ruiz, J., & de Leon, J. (2004). Variables Associated With Hospitalization Decisions by Emergency Psychiatrists After a Patient’s Suicide Attempt. Psychiatric Services, 55(7), 792–797. https://doi-org.paloaltou.idm.oclc.org/10.1176/appi.ps.55.7.792 Baryshnikov, I., Rosenström, T., Jylhä, P., Koivisto, M., Mantere, O., Suominen, K., …Isometsä, E. T. (2018). State and trait hopelessness in a prospective five-year study of patients with depressive disorders. Journal of Affective Disorders, 239, 107–114. https://doi-org.paloaltou.idm.oclc.org/10.1016/j.jad.2018.07.007 Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The Scalefor Suicide Ideation. Journal of Consulting and Clinical Psychology, 47(2), 343–352. Beck, A. T., & Steer, R. A. (1993a). Manual for Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation. Beck, A. T., & Steer, R. A. (1993b). Manual for Beck Hopelessness Scale. San Antonio, TX: Psychological Corporation. Beck, A. T., & Steer, R. A. (1993c). Manual for Beck Scale for Suicidal Ideation. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for Beck Depression Inventory II. San Antonio, TX: Psychological Corporation. Bisconer, S. W., & Gross, D. M. (2007). Assessment of suicide risk in a psychiatric hospital. Professional Psychology: Research and Practice, 38(2), 143–149. Bongar, B. M. (1991). Risk management: Prevention and postvention. In The suicidal patient: Clinical and legal standards of care. (pp. 163–204). Washington, DC: American Psychological Association. Bongar, B., & Sullivan, G. (2013). Inpatient management and treatment of the suicidal patient. In The suicidal patient: Clinical and legal standards of care., 3rd ed. (pp. 201–239). Washington, DC: American Psychological Association. Bowers, A., Meyer, C., Hillier, S., Blubaugh, M., Roepke, B., Farabough, M., … Vassar, M. (2018). Suicide risk assessment in the emergency department: Are there any tools in the pipeline? The American Journal Of Emergency Medicine, 36(4), 630–636. Briere, J. (2013). PTSD and Suicide Screener. Retrieved from https://search-ebscohost- com.paloaltou.idm.oclc.org/login.aspx?direct=true&db=mmt&AN=test.6505 Bryan, C. J. (2016). Treating PTSD Within the Context of Heightened Suicide Risk. Current Psychiatry Reports, 18(8), 73. Chu, J. P., Goldblum, P., Floyd, R., & Bongar, B. (2010). A cultural theory and model of suicide. Applied and Preventive Psychology, 14, 25–40. Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013). A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) measure. Psychological Assessment, 25(2), 424–434. Cochrane-Brink, K. A., Lofchy, J. S., & Sakinofsky, I. (2000). Clinical rating scales in suicide risk assessment. General Hospital Psychiatry, 22, 445– 451. Colucci, E., & Martin, G. (2007). Ethnocultural aspects of suicide in young people: a systematic literature review part 1: Rates and methods of youth suicide. Suicide & Life-Threatening Behavior, 37(2), 197–221. Cull, J. G., & Gill, W. S. (1988). Suicide Probability Scale (SPS) manual. Los Angeles: WPS. Fisher, L. B., Overholser, J. C., Ridley, J., Braden, A., & Rosoff, C. (2015). From the outside looking in: Sense of belonging, depression, and suicide risk. Psychiatry: Interpersonal and Biological Processes, 78(1), 29–41. Greene, T., Neria, Y., & Gross, R. (2016). Prevalence, Detection and Correlates of PTSD in the Primary Care Setting: A Systematic Review. Journal Of Clinical Psychology In Medical Settings, 23(2), 160–180. Hawes, M., Yaseen, Z., Briggs, J., & Galynker, I. (2017). The Modular Assessment of Risk for Imminent Suicide (MARIS): A proof of concept for a multi-informant tool for evaluation of short-term suicide risk. Comprehensive Psychiatry, 72, 88–96. Heron, M. (2016). National Vital Statistics Reports: Deaths–Leading Causes for National Vital Statistics Reports, pp. 1–92. Jobes, D. A., & Drozd, J. F. (2004). The CAMS approach to working with suicidal patients. Journal of Contemporary Psychotherapy, 34, 73–85. Kroenke, K., Spitzer, R.L., Williams, J.B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613. Large, M., Smith, G., Sharma, S., Nielssen, O., & Singh, S. P. (2011). Systematic review and meta-analysis of the clinical factors associated with the suicide of psychiatric in-patients. Acta Psychiatrica Scandinavica, 124(1), 18–19. LeBouthillier, D. M., McMillan, K. A., Thibodeau, M. A., & Asmundson, G. J. G. (2015). Types and number of traumas associated with suicidal ideation and suicide attempts in PTSD: Findings from a U.S. nationally representative sample. Journal of Traumatic Stress, 28(3), 183–190. Leung, C.-M., Lee, S., Lee, D. T. S., Yan, C. T. Y., So, J., Ungvari, G. S., … Xiang, Y.-T. (2018). Suicide after hospital contact for psychiatric assessment in Hong Kong: A long-term cohort study. Psychiatry Research, 264, 266–269. Links, P. S., & Hoffman, B. (2005). Preventing suicidal behaviour in a general hospital psychiatric service: priorities for programming. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 50(8), 490–496. Louzon, S. A., Bossarte, R., McCarthy, J. F., & Katz, I. R. (2016). Does suicidal ideation as measured by the PHQ-9 predict suicide among VA patients? Psychiatric Services, 67(5), 517–522. McCrae, R. R., & John, O. P. (1992), An introduction to the Five-Factor Model and its applications. Journal of Personality, 60, 175-215. doi:10.1111/j.1467-6494.1992.tb00970.x Morrison, L. L., & Downey, D. L. (2000). Racial differences in self-disclosure of suicidal ideation and reasons for living: Implications for training. Cultural Diversity and Ethnic Minority Psychology, 6, 374– 386. doi:10.1037/1099-9809.6.4.374 Nock, M. K., Hwang, I., Sampson, N., Kessler, R. C., Angermeyer, M., Beautrais, A., … Williams, D. R. (2009). Cross-national analysis of the associations among mental disorders and suicidal behavior: Findings from the WHO World Mental Health Surveys. Plos Medicine, 6(8), e1000123. Onoye, J., Helm, S., Koyanagi, C., Fukuda, M., Hishinuma, E., Takeshita, J., & Ona, C. (2013). Proportional differences in emergency room adult patients with PTSD, mood disorders, and anxiety for a large ethnically diverse geographic sample. Journal Of Health Care For The Poor And Underserved, 24(2), 928–942. Podlogar, M. C., Rogers, M. L., Chiurliza, B., Hom, M. A., Tzoneva, M., & Joiner, T. (2016). Who are we missing? Nondisclosure in online suicide risk screening questionnaires. Psychological Assessment, 28(8), 963–974. Rogers, J. R., & Russell, E. J. (2014). A framework for bridging cultural barriers in suicide risk assessment: The role of compatibility heuristics. The Counseling Psychologist, 42(1), 55–72. https://doi-org.paloaltou.idm.oclc.org/10.1177/0011000012471823 Ruiz, P. (2001). The Harvard Medical School Guide to Suicide Assessment and Intervention (Book Review). American Journal of Psychiatry, 158(10), 1758. Runeson, B., Odeberg, J., Pettersson, A., Edbom, T., Jildevik Adamsson, I., & Waern, M. (2017). Instruments for the assessment of suicide risk: A systematic review evaluating the certainty of the evidence. PLoS ONE, 12(7), 1–13. Russ, M. J., Kashdan, T., Pollack, S., & Bajmakovic-Kacila, S. (1999). Assessment of suicide risk 24 hours after psychiatric hospital admission. Psychiatric Service, 50, 1491–1493. Stack, S., & Wasserman, I. (2005). Race and Method of Suicide: Culture and Opportunity. Archives of Suicide Research, 9(1), 57–68. Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan, K., Holland, K. M., … Crosby, E. (2018). Vital signs: Trends in state suicide rates – United States, 1999-2023 and circumstances contributing to suicide – 27 states, 2015. MMWR. Morbidity And Mortality Weekly Report, 67(22), 617–624. Tran, T., Luo, W., Phung, D., Harvey, R., Berk, M., Kennedy, R. L., & Venkatesh, S. (2014). Risk stratification using data from electronic medical records better predicts suicide risks than clinician assessments. BMC Psychiatry, 14, 76. U.S. Department of Veterans Affairs. (2016). Suicide among veterans and other Americans 2001–2014. Retrieved from http://www.mentalhealth.va.gov/docs/2016 suicidedatareport.pdf Yufit, R. I., & Lester,
D. (2005). Assessment, treatment, and prevention of suicidal
behavior. Hoboken, NJ: Wiley. National Center for
PTSD Just Released COVID Coach App Suicide and
PTSD For Immediate Help, Call 24/7
How Common Is Suicide? No matter how rare it is, suicide is always very tragic. It is hard to say exactly how many suicides occur.
Overall, men are more likely to die by suicide than women. For example, from 1999-2010, the average suicide rate among U.S. males was 19.4 out of every 100,000, compared to 4.9 out of every 100,000 females. The difference in suicide rates between men and women is also true among Veterans. Does Trauma Increase a Person's Suicide Risk? Going through a trauma may increase a person's suicide risk. For example, there is evidence that childhood abuse and sexual trauma may increase a person's suicide risk. Among Veterans, some studies have found that combat trauma is related to suicide, while other studies have not. In this research, combat trauma survivors who were wounded more than once or put in the hospital for a wound had the highest suicide risk. This suggests suicide risk in Veterans may be affected by how intense and how often the combat trauma was. Does PTSD increase a person's suicide risk? Why is suicide risk higher in trauma survivors? It may be because of the symptoms of PTSD or it may be due to other mental health problems, like depression. Studies show that suicide risk is higher in persons with PTSD. Some studies link suicide risk in those with PTSD to distressing trauma memories, anger, and poor control of impulses. Further, suicide risk is higher for those with PTSD who have certain styles of coping with stress, such as not expressing feelings. Research suggests that for Veterans with PTSD, the strongest link to both suicide attempts and thinking about suicide is guilt related to combat. Many Veterans have very disturbing thoughts and extreme guilt about actions taken during times of war. These thoughts can often overwhelm the Veteran and make it hard for him or her to deal with the intense feelings. Can PTSD Treatment Help? A person can benefit from cognitive behavioral treatments (CBT) for PTSD if suicidal thoughts are able to be managed on an outpatient basis. For example, a study of female rape survivors who received such treatment found that as PTSD symptoms decreased during treatment, suicidal thoughts also became less common. This effect lasted for 5-10 years after treatment ended. More research is needed, but having a good relationship with a mental health provider can help persons with PTSD make the best treatment decisions. Given the link between PTSD and suicidal thoughts/behaviors, if you have PTSD and are involved in mental health treatment, your suicide risk will likely be regularly assessed. If the provider learns that immediate risk for suicide is high based on his/her assessment, they will make appropriate treatment decisions to ensure safety. If the immediate risk for suicide is not high and suicide risk can be managed safely on an outpatient basis, the provider may suggest treatment for PTSD. What Can I Do? I am suicidal If you are ever thinking about suicide and feel unsafe:
Everyone feels down from time to time. If you have thoughts about hurting yourself, seek professional help. Many people who have thoughts of suicide also struggle with depression or with drinking or drug problems. There are many places to get help. See Get Help in a Crisis for resources. Someone I know is suicidal You may come in contact with a family member, friend, or coworker who is thinking about suicide. When someone tells you they have these thoughts, you may feel scared and unsure what to do. It is even harder if the person tells you in secret and you feel pressure not to tell others. If someone you know is thinking about suicide, this is a serious matter. It can be very hard to gauge the level of danger. A mental health professional is the best person to decide how much danger there is.
Someone I know has died by suicide It is very upsetting when someone you know dies by suicide. Getting over the shock and distress will be especially hard if you felt close to them, if you saw the event, or if you have your own mental health issues. Grieving the loss of a loved one is a natural process. It may take several months to feel "normal" again after someone you know dies by suicide. Due to the traumatic nature of suicide, you may go through what's known as "traumatic grief." If you are feeling intense grief or guilt several months after the suicide, contact a mental health provider for help. Many people feel guilty about not having prevented the suicide. Be aware, though, that suicide is never your fault. Suicide is complex with many factors that contribute. It can also be difficult to cope when
a loved one has made a suicide attempt. You can access
education products for family members of Veterans who have
made a suicide attempt, including a Family Resource Guide
and information about how to talk to a child about a suicide
attempt. Some materials are also available in Spanish.
Although these products were created with military families
in mind, resources and information included in them may be
useful for non-military families as well. The
Connection Between PTSD and Suicide In the United States, more than 48,000 people commit suicide each year. Although women attempt suicide more so than men, men are more likely to die by suicide.1? People who have experienced a traumatic event and/or have post-traumatic stress disorder (PTSD) may be more likely to attempt suicide. Trauma, PTSD, and Suicide In a survey of 5,877 people across the United States, it was found that people who had experienced physical or sexual assault in their life also had a high likelihood of attempting to take their own life at some point:2?
There Is Hope: Seeking Help Experiencing a traumatic event and/or developing PTSD can have a tremendous impact on a person's life. The symptoms of PTSD can make a person feel constantly afraid and isolated. In addition, depression is common following a traumatic event and among people with PTSD.6? escape from their symptoms, leading them to contemplate suicide. It is important to realize that even
though it may feel as though there is no hope,
recovery
and healing is possible. If
you are having thoughts of ending your life or if you know
someone who is having these thoughts, it is important to
seek help as soon as possible. PTSD
and Suicide Post-traumatic Stress Disorder happens when an individual experiences a horrifying ordeal that involves physical harm or the threat of physical harm. The physical harm or threat could have happened to the individual with PTSD, or the individual could have witnessed it happen to a loved one or a stranger. PTSD was first brought to public attention in relation to war veterans but a variety of traumatic events can cause PTSD including:
Not everyone who goes through a traumatic event will develop PTSD and it is unclear why some people develop PTSD and some do not. Symptoms PTSD symptoms typically start soon after the traumatic event occurs, but symptoms can also occur months or years later. Symptoms can come and go over a course of years, or they can be consistent. If symptoms last more than 4 weeks, interfere with your work or home life, or cause you a great amount of anguish, you might have PTSD. Below are the 4 types of symptoms of PTSD:
Who can get PTSD? Anyone at any age can get PTSD. This includes war veterans and survivors of physical and sexual assault, abuse, accidents, disasters and many other traumatic events. Not everyone with PTSD has been through a dangerous event. Some people get PTSD after a friend or family member experiences danger or harm. The sudden, unexpected death of a loved one can also cause PTSD. Why do some people get PTSD and other people do not? Not everyone who lives through a traumatic event gets PTSD. In fact, most will not get the disorder. Many factors play a part in whether a person will get PTSD. Some of these are risk factors that make a person more likely to get PTSD. Other factors, called resilience factors, can help reduce the risk of the disorder. Some of these risk and resilience factors are present before the trauma and others become important during and after a traumatic event. Risk factors for PTSD include:
Resilience factors that may reduce the risk of PTSD include:
Researchers are studying the importance of various risk and resilience factors. With further researcher, it should become possible to predict who is likely to get PTSD, how resilience can be learned and prevent it. How is PTSD detected? The PTSD diagnosis can be made by a medical doctor, or mental health professionals such as a psychologist, social worker, or psychotherapist. The diagnosis is made after the doctor talks with the person who has symptoms of PTSD. To be diagnosed with PTSD, a person must have all of the following for at least 1 month:
How is PTSD treated? The main treatments for people with PTSD are cognitive behavioral therapy (CBT), medications, or a combination of the two. There are several parts to CBT, including: Exposure therapy. This therapy helps people face and control their fear. It exposes them to the trauma they experienced in a safe way. It uses mental imagery, writing, or visits to the place where the event happened. The therapist uses these tools to help people with PTSD cope with their feelings. Cognitive restructuring. This therapy helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about what is not their fault. The therapist helps people with PTSD look at what happened in a realistic way. Stress inoculation training. This therapy tries to reduce PTSD symptoms by teaching a person how to reduce anxiety. Like cognitive restructuring, this treatment helps people look at their memories in a healthy way. Everyone is different, so a treatment
that works for one person may not work for another. It is
important for anyone with PTSD to be treated by a mental
health care professional who is experienced with PTSD. Some
people with PTSD need to try different treatments to find
what works for their symptoms. If someone with PTSD is going
through an ongoing trauma, such as being in an abusive
relationship, both of the problems need to be treated. Other
ongoing problems can include panic disorder, depression,
substance abuse and feeling suicidal. Coping
With Suicidal Thoughts With PTSD For more mental health resources, see our National Helpline Database. Each year, more than 48,000 people in the United States die by suicide.1? Research shows that people with post-traumatic stress disorder, or PTSD, are at a higher risk to attempt suicide or have suicidal thoughts.2? The reasons for this are divided into studies on PTSD and suicide. It may be the PTSD itself causes a higher risk for suicidal thoughts or suicide or it may be that other existing psychiatric conditions, such as depression or anxiety, increase the risk. Given this, if you've experienced a traumatic event or have PTSD, it's important to be alert for suicidal thoughts and develop ways of coping with them. Catching and addressing these thoughts early on can prevent them from spiraling into a suicide attempt. There are several coping strategies that can help defuse suicidal thoughts, but don't wait for a crisis situation to try them. Look them over now and come up with a plan for the next time you experience suicidal thoughts. It's ideal if you can work with a therapist in developing such a plan Here are some suggestions to cope with suicidal thoughts. Stay Away From Weapons A suicide attempt will be more likely to occur if you have the means readily available to you, such as guns, knives, or other weapons, or unnecessary medications in your home.3? Remove these from your environment; take steps to remove your access (locking the items and giving someone the key) or go somewhere you won't have access to those means. There’s no single cause of depression, according to research. Brain chemistry, hormones, genetics, life experiences and physical health can all play a role.4? Go Someplace Safe Identify several places you can go where you would be less likely to hurt yourself, such as public places like the mall, a coffee shop or restaurant, a busy park, a community center, or a gym. Once there, immerse yourself in that environment. Pay attention and be mindful of all the sights and sounds around you. Doing this will help put some distance between you and your suicidal thoughts. Talk to Someone Supportive Social support can be a wonderful way of coping when you're in a crisis. Call a family member or friend. Let them know you need someone to talk to and would like their support. Change your environment by asking them if you can spend some time with them. Talk to a Therapist Some therapists have ways for their patients to contact them outside of the session if they're in crisis. If you have a therapist and you have a system like this in place, you should contact your therapist when you're experiencing suicidal thoughts. Your therapist can help you assess the seriousness of the situation, as well as assist you in coming up with ways of coping with those thoughts. Caution: In finding a therapist know that most therapists, even psychiatrists, have received no training in suicidality and in many states, no training is necessary to receive a liense. The ideal therapist is a trained therapist and one who does continuing education every 6 years of less to know what is current. - Editor Challenge Suicidal Thoughts When people feel down and depressed, it's common to have thoughts that are consistent with those moods. As our moods change, so will our thoughts. Therefore, even though things may feel hopeless, this may just be a consequence of your mood and not necessarily how things really are. Is it not possible that your mood might change? Is there really no hope for the future? Have you felt like this before, and if so, did things eventually get better? Ask yourself questions like these to challenge your thoughts of hopelessness. Be Mindful of Your Thoughts Another way of coping with suicidal thoughts is with mindfulness. Take a step back from your thoughts and watch them. Imagine your thoughts as clouds drifting across the sky. Try not to look at your thoughts as good or bad, but simply as thoughts or objects in your mind. Taking a mindful approach to thoughts of suicide or hopelessness can defuse them, limiting the power they have over your actions and mood. Manage Your Mood A number of coping strategies can be helpful in managing your mood. For example, expressive writing or self-soothing coping strategies may help lessen the intensity of your sadness or anxiety. By improving your mood, you may also improve your thoughts, reducing your risk of suicide. Go to the Emergency Room If these coping strategies aren’t working to lessen suicidal thoughts, call the police or a mental health crisis line, or go to your local emergency room. This can be scary, but it's most important for you to stay safe and alive. Find a Therapist If You Don't Have One Finally, if you don't have a therapist and are experiencing suicidal thoughts, it's important to get a psychiatric evaluation, as well as a therapist. Suicidal thoughts are a sign that you
may some immediate need help with your symptoms. You can
find PTSD treatment providers in your area through the
National
Center for PTSD. "I
can't turn my bain off": PTSD and burnout threaten
medical workers The coronavirus patient, a 75-year-old man, was dying. No family member was allowed in the room with him, only a young nurse. In full protective gear, she dimmed the lights and put on quiet music. She freshened his pillows, dabbed his lips with moistened swabs, held his hand, spoke softly to him. He wasn’t even her patient, but everyone else was slammed. Finally, she held an iPad close to him, so he could see the face and hear the voice of a grief-stricken relative Skyping from the hospital corridor. After the man died, the nurse found a secluded hallway, and wept. A few days later, she shared her anguish in a private Facebook message to Dr. Heather Farley, who directs a comprehensive staff-support program at Christiana Hospital in Newark, Del. “I’m not the kind of nurse that can act like I’m fine and that something sad didn’t just happen,” she wrote. Medical workers like the young nurse have been celebrated as heroes for their commitment to treating desperately ill coronavirus patients. But the heroes are hurting, badly. Even as applause to honor them swells nightly from city windows, and cookies and thank-you notes arrive at hospitals, the doctors, nurses and emergency responders on the front lines of a pandemic they cannot control are battling a crushing sense of inadequacy and anxiety. Every day they become more susceptible to post-traumatic stress, mental health experts say. And their psychological struggles could impede their ability to keep working with the intensity and focus their jobs require. Although the causes for the suicides last month of Dr. Lorna M. Breen, the medical director of the emergency department at NewYork-Presbyterian Allen Hospital, and John Mondello, a rookie New York emergency medical technician, are unknown, the tragedies served as a devastating wake-up call about the mental health of medical workers. Even before the coronavirus pandemic, their professions were pockmarked with burnout and even suicide. On Wednesday, the World Health Organization issued a report about the pandemic’s impact on mental health, highlighting health care workers as vulnerable. Recent studies of medical workers in China, Canada and Italy who treated Covid-19 patients found soaring rates of anxiety, depression and insomnia. To address the ballooning problem, therapists who specialize in treating trauma are offering free sessions to medical workers and emergency responders nationwide. New York City has joined with the Defense Department to train 1,000 counselors to address the combat-like stress. Rutgers Health/RWJ Barnabas Health, a New Jersey system, just adopted a “Check You, Check Two” initiative, urging staff to attend to their own needs and touch base with two colleagues daily. “Physicians are often very self-reliant and may not easily ask for help. In this time of crisis, with high workload and many uncertainties, this trait can add to the load that they carry internally,” said Dr. Chantal Brazeau, a psychiatrist at the Rutgers New Jersey Medical School. Even when new Covid-19 cases and deaths begin to ebb, as they have in some places, mental health experts say the psychological pain of medical workers is likely to continue and even worsen. “As the pandemic intensity seems to fade, so does the adrenaline. What’s left are the emotions of dealing with the trauma and stress of the many patients we cared for,” said Dr. Mark Rosenberg, the chairman of the emergency department at St. Joseph’s Health in Paterson, N.J. “There is a wave of depression, letdown, true PTSD and a feeling of not caring anymore that is coming.” Screw all of you now I see exactly why the only thing left to do is suicide. — a Facebook post by a St. Louis paramedic in April After Kurt Becker, a paramedic firefighter in St. Louis County, saw that post, which included a profanity-laced screed of frustration and despair over the job, he sent a copy to the man’s therapist with a note saying, “You need to check this out.” “I’m reading this, and I’m ticking off each comment with, ‘stress marker,’ ‘stress marker,’ ‘stress marker,’ ” said Mr. Becker, who manages a 300-person union district. (The writer is in treatment and gave permission for the post to be quoted.) ImageKurt Becker, a paramedic firefighter in St. Louis County, has been urging his union members to seek therapy during the pandemic. Kurt Becker, a paramedic firefighter in St. Louis County, has been urging his union members to seek therapy during the pandemic.Credit...Whitney Curtis for The New York Times The paramedics are part of a “warrior culture,” Mr. Becker said, which sees itself as a tough, invulnerable caste. Asking for help, admitting fear, is not part of their self-image. Mr. Becker, 48, is himself the grandson of a bomber pilot and son of a Vietnam veteran. But his local has been hit by a dozen suicides since 2004, and he has become an advocate for the mental health of its members. To maintain his equilibrium, he works out and sees a therapist. Recently, he has been getting more requests than usual for the union’s peer-support team and its roster of clinicians who understand the singular experiences of emergency medical workers. “The virus scares the hell out of our guys,” he said. “And now, when they go home to decompress, instead, they and their spouses are home schooling. The spouse has lost a job, and is at wit’s end. The kids are screaming. Let me tell you: The tension level in the crews is through the roof.” Many besieged health care workers are exhibiting what Alynn Schmitt McManus, a St. Louis-based clinical social worker, calls “betrayal trauma.” “They feel overwhelmed and abandoned” by fire chiefs who, she said, rarely acknowledge the newly relentless demands of the job. Many paramedics, she added, are “aggressive and depressed. They are so committed to the work, they are such good human beings, but they feel so compromised now.” Brendan, who asked for his last name to be withheld to protect his privacy, is a 24-year-old paramedic firefighter who works 48-hour shifts on the tough north side of St. Louis. His unit has been so busy running calls that he goes for long stretches without showering, eating or sleeping. He is terrified he might infect his fiancée and their daughter. “We got a letter from our chief saying that there’s a national shortage of gloves, gowns, masks and goggles because the public is taking them,” he said. “Then we walk into Walmart and see that 90 percent of the people have better masks than we do.” With no end in sight to the crisis, Brendan sought out a therapist. “We are a lot quicker to be angry with each other,” he said. “Any little thing sends us over the edge. But among the older guys in their late 30s and 40s, it’s not OK to talk about things. So all anyone talks about is alcohol.” “They were coming in very sick and deteriorating so fast. I was carrying a lot inside me, and I was very sad when I came home. I was feeling like I wasn’t doing a good job. My mother-in-law is a nurse, and she saw I needed help so she connected me with a therapist.” — Kristina, a nurse at Long Island Jewish Medical Center in Queens Therapists around the country, many affiliated with the Trauma Recovery Network, which includes a large New York team, have been lining up to offer free treatment to medical workers. But the number of requests for help has been modest. “People are nervous that if they pause to get treatment, they’ll crash, ”said Karen Alter-Reid, a psychologist and the founder of the Fairfield County Trauma Response Team in Connecticut, who has treated disaster-relief workers at school shootings and hurricanes. The reasons to offer front-line workers specialized trauma therapy now are both to forestall destructive symptoms from settling in long-term, and to patch up depleted people so they can keep doing their jobs with the intensity demanded of them. Since mid-March, Dr. Alter-Reid’s group has been treating dozens of emergency medical technicians, doctors and nurses. What distinguishes this pandemic as a traumatic experience, she said, is that no one knows when it will end, which protracts anxiety. Medical teams, she noted, keenly miss the familial, visceral contact. They are used to hugs, backslaps, and sharing beers after a rough shift. Now, safety strictures have shut all that down. Through Zoom group therapy, the crews have been regaining some semblance of solidarity as they unburden with each other, unmasked, through a computer screen, hearing everyone talk about similar struggles: Living away from families, to keep them safe. The smell of disinfectant in their clothes and hair. The clumsy haz-mat gear. In the sessions, Dr. Alter-Reid instructs them to tap on their desktops. The tapping is integral to her technique, a well-studied trauma treatment called eye movement desensitization and reprocessing. As they tap, which can sound like group drumming, she asks them to recall a challenging case when they each prevailed, and to share it. Through these sessions, she tries to help them subdue memories of fear, failure and death so they can summon their innate resilience: Remember what you can do. I have nightmares that I won’t have my P.P.E. I worry about my patients, my co-workers, my family, myself. I can’t turn my brain off. — Christina Burke, an I.C.U. nurse at Christiana Hospital, Newark, Del. A nagging detail sticks in Christina Burke’s mind like a burr. Not only is hers the last face that patients see before they die, but because of her mandatory mask, all they glimpse are her eyes. Her identity as a compassionate nurse feels diminished. She longs to lift up her mask and reveal her full self to patients. At 24, Ms. Burke has already worked in an intensive care unit for three years. She has loved the connections she made with patients and their families, but those experiences are now largely gone. “I can’t imagine one of my relatives on their last breath with a stranger,” said Ms. Burke, who is close to her own family but hasn’t been able to visit them for two months. One recent day, overcome with sleeplessness and despondency, she contacted Bridget Ryan, a member of the hospital’s peer support program. In Ms. Ryan’s office, she tearfully unloaded. Christina Burke (right), an I.C.U. nurse at Christiana Hospital, and her peer counselor Bridget Ryan both cried during a counseling session. Christina Burke (right), an I.C.U. nurse at Christiana Hospital, and her peer counselor Bridget Ryan both cried during a counseling session.Credit...Erin Schaff/The New York Times A March study in JAMA Psychiatry looked at the psychological impact of the epidemic on health care workers in 34 Chinese hospitals, reporting that nurses, especially women, carried the heaviest burdens. They had elevated rates of anxiety, depression and insomnia. The prevalence of burnout and suicide among medical professionals has been widely studied. As the pandemic invaded the West Coast earlier this year, Stanford psychologists gathered focus groups in their medical system to explore how to shore up mental health. Researchers flagged workers’ limited capacity to manage Covid-19; their fears of contaminating family members; the moral code-bending decisions about when to use limited, life-saving resources. But much distress could be headed off if hospital leadership created a proactive, supportive culture that included ways for workers to express concerns and feel heard, the researchers wrote in JAMA. ChristianaCare, a four-state health system, began assembling such a protocol five years ago. The program provides group support and daily inspirational texts. Twice a week, doctors and staff meet senior leaders. It set up designated “oasis” rooms, outfitted with low lights, massage chairs and meditation materials, where stressed workers take a breather. “We’re trying to provide them with psychological first aid,” said Dr. Farley, an emergency medicine physician who directs ChristianaCare’s Center for WorkLife Wellbeing. Peer counselors are quickly available. “No one else understands what we’re going through,” Ms. Burke, the I.C.U. nurse, said. “It doesn’t sound like much, but that program has changed the world for us.” At the end of her meeting with Ms. Ryan, the two women, both in surgical masks, shared a social-distance-defying hug. Ms. Burke said she emerged refreshed. For the first time in two months, she slept through the night. To address safety fears, ChristianaCare offers disposable scrubs, which workers tear off at the end of a shift. It also has a gratitude program, in which former patients return to thank their healers. At a time when so many Covid-19 patients are dying, such exchanges, said Dr. Farley, reconnect demoralized staff to “why we do what we do.” Dr. Farley and her team check on hospital crews, pushing carts loaded with hand lotion, anti-fog lens cleaner, protein bars, chocolate and solace. Every time, Dr. Farley said, “There is someone crying with me, and it’s 3 a.m. They’re exhausted. They need this.” I see all these people coming in to the hospital now who are really sick, and I’m wondering, could this be me one day? There are a lot of unknowns. And the anxiety is amplified, knowing what happened in my household. — Dr. Andrew Cohen, an emergency medicine physician at St. Joseph’s University Medical Center, Paterson, N.J. When Dr. Andrew Cohen, 45, is working his shift at the hospital’s emergency department, he is fine. He has the thick emotional skin characteristic of his high-octane profession. He dons his gear, turns his adrenaline up to a quiet, steady hum and focuses on saving lives. But hours before the shift starts, he becomes foggy, anxious, hesitant. And as soon as it ends, he performs a cleansing ritual that even he labels “over the top.” That is because he has discovered, in a brutal manner, that he cannot leave the job behind. For nearly a decade, Dr. Cohen and his wife shared their home with her parents, a practicing pulmonologist and a retired nurse, who often babysat for the Cohens’ children, now 8 and 11. But in March, both in-laws became ill with Covid-19 and were admitted to the hospital within a day of each other. Dr. Cohen’s mother-in-law, Sharon Sakowitz, 74, died first. On the day of her funeral, the hospital called the Cohens: now the father-in-law’s organs were shutting down. The Cohens rushed to the hospital. Dr. Barry Sakowitz, 75, died that morning. A few hours later, they buried Mrs. Sakowitz. Still mourning, Dr. Cohen wonders, “Did I bring this virus into my house?” As he prepares to go to work, “My son says, ‘Daddy, be very, very careful,’ and I know what he’s thinking.” The guilt threatens to swamp him. What if he is the third person in this household to die? After the shift, Dr. Cohen photocopies his notes, so there’s no risk he leaves with paper that might have coronavirus on it. He cleans his stethoscope, pens, goggles, face shield and the bottom of his sneakers with antimicrobial wipes. He does a surgical hand wash, up to his elbows. He changes into a clean set of scrubs, putting the dirty ones in a plastic bag, and walks through the hospital parking lot. Sitting in his car, he sprays the bottom of his shoes with Lysol. At home, he removes his sneakers and scrubs, leaving them in a box in the garage, and heads to the shower. Only after will he allow himself to embrace his family. How long will Dr. Cohen march through this meticulous ritual? When will fear loosen its grip? “We’ve always been told to
suck it up and move on,” he said. He wonders: When his
own emotional crash comes, when colleagues start unraveling,
“Will there be people there to help us?” Clinician's
Trauma Update - 2/21, Issue 51 Treatment Repeated ketamine infusions safe and effective for PTSD Few medications have demonstrated effectiveness for treating PTSD. A previous study by investigators at the Icahn School of Medicine at Mount Sinai found that a single, intravenous (IV) infusion of the anesthetic agent ketamine led to a substantial decrease in PTSD severity within 24 hours (see the June 2014 CTU-Online). In the current study, these investigators assessed the safety and efficacy of repeated ketamine infusions in 30 individuals with PTSD. Unclear benefit of cannabis for individuals with PTSD Cannabis is frequently used by Veterans with PTSD, and PTSD is increasingly considered an eligible diagnosis in US medical cannabis programs. However, the safety and efficacy of medical cannabis for PTSD is unknown. A prospective, observational study of Colorado residents assessed the effects of dispensary-provided cannabis in individuals with PTSD. Loss of PTSD diagnosis tied to best functional outcomes A prior study of women Veterans found that found that loss of diagnosis, assessed using the CAPS-IV, was an optimal benchmark for improved functioning and quality of life in PTSD (see the April 2016 CTU-Online). A team led by investigators at the University of Melbourne in Australia has now replicated the study in a predominantly male Veteran sample. Head injury from interpersonal violence does not impact PTSD treatment response Head injuries may occur during a traumatic event, raising the possibility that any resulting cognitive symptoms could interfere with treatment response. Investigators from the National Center for PTSD assessed the influence of head injury on recovery from PTSD and depression following CPT. First study of therapist-assisted, web-based PE Web-based interventions for PTSD could offer symptom relief with fewer barriers to access than traditional in-person treatments. Investigators at the National Center for PTSD developed and tested Web-PE, first in a small RCT and then in an uncontrolled trial. Additional evidence supports benefits of consultation following CPT training A study reported in CTU-Online in 2018 found that therapists who received weekly consultation following CPT training obtained better patient outcomes than therapists attending training alone. In order to understand the factors leading to better outcomes, investigators from the National Center for PTSD used data from that study to examine relationships among therapist self-efficacy, treatment fidelity, and patient outcomes. Examining the impact of video visits on retention of MST survivors in treatment for PTSD New research led by investigators at VA Ann Arbor Healthcare System examined MST survivors’ dropout from PE and CPT when delivered in person versus via clinical video technology (CVT). Delivering treatment through CVT can address barriers such as logistical challenges that may lead to treatment dropout. Using CPT worksheets to assess fidelity shows promise Fidelity to a psychotherapy protocol is typically assessed using audio or video review of therapy sessions. In an effort to develop a more efficient method, a team led by investigators at the National Center for PTSD took a novel approach: assessing therapists’ fidelity by rating the worksheets that patients complete in CPT. Take Note Virtual reality exposure treatment for PTSD A team led by investigators at the University of Amsterdam reviewed RCTs of virtual reality exposure therapy (VRET) and augmented reality exposure therapy for PTSD, then conducted a meta-analysis on the 11 studies of VRET. Read the article. TMS for PTSD Investigators at the University of Calgary carried out a systematic review and network meta-analysis of 10 RCTs of transcranial magnetic stimulation (TMS) for PTSD. Read the article. MDMA-assisted psychotherapy for PTSD A team led by investigators at
Peterborough City Hospital in the UK conducted a systematic
review and meta-analysis of 4 RCTs of MDMA-assisted
psychotherapy for PTSD. Read
the article. Federal
Legislation Ignores PTSD Toll on Civilians -
11/14/21 Federal laws explicitly addressing post-traumatic stress disorder (PTSD) have overwhelmingly focused on the needs of military personnel and veterans, according to a new analysis published in the Journal of Traumatic Stress. (Editor: Is 2009 data. Is this still pertinant? 6/24/21) The study, authored by Jonathan Purtle, DrPH, an assistant professor at the Drexel University School of Public Health, is the first to examine how public policy has been used to address psychological trauma and PTSD in the U.S., providing a glimpse of how lawmakers think about these issues. Purtle found that in federal legislation introduced explicitly to address PTSD, an overwhelming majority of the language – more than 90 percent of the mentions of PTSD in these bills – showed efforts were targeted exclusively at military personnel. More than 90 percent of mentions of PTSD in the bills were likewise intended to address consequences of combat exposure. This emphasis does not match with the frequency of PTSD in the U.S. population. “Although trauma and PTSD are serious issues affecting military populations, the raw number of people affected by PTSD includes substantially more civilians simply because the civilian population is so much larger,” said Purtle. As an example, Purtle pointed to the specific language of the bill that created National PTSD Awareness Day. The text of that resolution describes PTSD as a “wound of war” that affects people in the military and does not acknowledge that PTSD exists among civilians. Many types of traumatic events can cause PTSD, including violent injury, car accidents, surviving life-threatening diseases, sexual assault and natural disasters, as well as combat exposure. One-time and chronic exposure to traumatic events can also cause traumatic stress, involving some symptoms common in PTSD, without matching the full pattern of diagnostic criteria for PTSD. Purtle also found that, just as lawmakers appeared to respond to PTSD as primarily a military concern, they applied the concept of traumatic stress (other than PTSD) as a concern affecting civilians. About 75 percent of the bill sections about traumatic stress that did not mention PTSD were targeted to civilians’ needs. For example, a number of bills were introduced to address the mental health needs of U.S. civilians after the terrorist attacks of September 11, 2001, but these bills did not explicitly mention PTSD. “It’s almost as if lawmakers didn’t want to suggest that PTSD was also a disorder among civilians,” Purtle said. “This gives a sense of how elected officials at the federal level might think about the dimensions of this problem, and shows that it doesn’t match up with what’s known about who gets PTSD.” Although most civilian-targeted bills Purtle examined did not explicitly mention PTSD, their policies addressing trauma among civilians may still help individuals experiencing PTSD. Civilians with PTSD, as well as military members and veterans, may also benefit from policies addressing PTSD and trauma that were established through state and local legislation or via non-legislative administrative policies. These other policies were outside the scope of Purtle’s analysis, and have not yet been studied. This study specifically included only federal legislation introduced to Congress between 1989 and 2009. The emphasis on military personnel in
legislation addressing PTSD may reflect the history of the
disorder, which first became known through cases in military
members and veterans following combat experiences. The
federal government’s role in providing medical care for
veterans could also contribute to the legislation’s
heightened emphasis on military PTSD in contrast to civilian
PTSD.
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