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Clinical Practice Guideline Updated for Service Members and Veterans at Risk for Suicide

Image of military personnel engaged in conversation. U.S. Air National Guard Chaplain Derick Wakefield speaks with an airman about suicide prevention at the I.G. Brown Training and Education Center on McGhee Tyson Air National Guard Base, Tennessee, on Aug. 27, 2023. (U.S. Air National Guard photo by Master Sgt. Jonathan Young)

[Editor’s note: This article deals with mental health issues and treatment. If you or someone you know is having a mental health crisis, call the 988 National Suicide and Crisis Lifeline and press “1”, or text 838255, or chat for the dedicated Veterans Crisis Line and Military Crisis Line. For Spanish, press “2”.]

For adults who served or current active duty military at high risk of suicidal thoughts or actions, new guidance for clinicians can streamline the help they need.

Updated clinical practice guidelines, otherwise known as CPGs, from the Department of Defense and the Department of Veterans Affairs are an essential tool in assessing and managing patients and offer evidence-based recommendations for health care providers, according to Isabella Alvarez, nurse administrator coordinator, DOD program management for VA-DOD clinical practice guidelines.

A joint VA-DOD working group announced in May 2024 the release of the revised guideline, “The Assessment and Management of Patients at Risk for Suicide (2024),” to aid in critical decision points, Alvarez said. The VA-DOD Evidence-Based Practice Working Group was chartered by the VA-DOD Health Executive Committee in 1998.

The document updates the 2019 CPG based on a 2022 decision by the working group on the need to incorporate expanded evidence in this clinical area.

The guideline is intended for use across the VA and the Military Health System for service members, beneficiaries, and veterans who choose or need to be treated within their respective health care systems. The CPG is also available for community providers and others in the health care team involved with the assessment and management of adult patients at acute risk for suicide.

The updated CPG is based on information gathered by the working group and other mental health care experts from a variety of disciplines.

These experts systematically reviewed both current clinical evidence and epidemiological evidence, the latter on how often and why suicidal behaviors occur in particular populations. The CPG “provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation,” according to a provider summary.

Significant Revisions

The 2024 version contains a number of significant revisions that offer tangible strategies for practitioners by providing a roadmap and resources for how to apply them to service members, beneficiaries, and veterans, including:

  • Updated algorithm of assessment and management
  • Critical outcomes of suicide attempts and deaths by suicide included in the studies reviewed
  • Eight new recommendations, with 12 reviewed and replaced from 2019, three amended, and one with no change
  • More rigorous application of the Grading of Recommendations Assessment, Development and Evaluation method of measuring quality of evidence and strength of recommendations in health care
  • Updated routine care for suicide prevention section
  • Updated research priorities section

The algorithm represents a simplified clinical management flow of patients at heightened risk for suicide and helps foster efficient decision-making by providers. Model A helps identify those who are high risk; Model B helps providers assess the state of the patient’s mood and risk; and Model C aids providers in their management of adult patients at very serious risk of suicidal thoughts and actions.

“It’s very encouraging to note a significant increase in high-quality studies on suicide prevention and intervention since the last CPG was produced in 2019,” said Kate McGraw, who holds a doctorate in clinical psychology, and is chief of the Defense Health Agency’s Psychological Health Center of Excellence.

“These new studies allowed us to fine-tune recommendations based on more evidence than we had during the last CPG” in 2019, said McGraw, pointing to the grading methodology used. “These changes resulted in updated decision algorithms, and the development of eight new recommendations.”

The body of research on suicide risk-management, suicide prevention, interventions, and postvention in the aftermath of a death by suicide continues to grow. The new CPG includes updated recommendations on these key topics:

  • Universal screening
  • Screening tool selection
  • Dialectal behavior therapy, a type of talk psychotherapy
  • Infusion of the anesthetic drug ketamine to temporarily halt suicidal thinking

The CPG also provides advice on acute warning signs, predictive analytics, risk stratification, and risk management, including lethal means safety, and post-acute care, among other recommendations.

Patient Summary of Care

For DOD or VA patients, the CPG includes a summary of care and straightforward advice.

The advice includes getting help as the first step in a mental health crisis. “Your safety and improving your symptoms are the priorities. The goal is to decrease symptoms and lessen thoughts of hurting yourself, while planning for times when concerning thoughts happen,” according to the summary.

It notes there are “different interventions like talk therapy, medications, and decreasing access to lethal means that have been shown to help decrease the drivers and behaviors that could lead to harming oneself.” The summary briefly and simply explains the terms talk therapy, skill and strategies development in an individual or group setting, and the use of medication to reduce symptoms, as well as a combination of options.

The CPG also includes how and why patients need and get help, including reaching out through phone calls, email communications, and home visits. The best treatment may include patients and providers working together to develop a safety plan or crisis management response plan to help patients cope in the future, according to the CPG’s document for patients.

A pocket flow chart guide is also available for use by mental health intake personnel and treatment and management professionals.

McGraw called the 2024 CPG a “valuable resource for everyone on the team: providers, patients, family members, non-provider professionals, line leaders, and for civilian communities that support our military and veterans.”

The CPG’s clinical support tools “serve as more concise resources to support all members of the team who may be called upon to prevent a service member or veteran death by suicide,” she noted.

Additional Resources

For anyone experiencing a mental health crisis, needing immediate assistance, or simply wanting to talk, confidential help is available 24/7/365.

 

Resources

 

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Last Updated: June 10, 2024
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