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PTSD Treatment and Suicide Prevention: Clinical Practice Guidelines and Steps Toward Further Knowledge

The Department of Veterans Affairs (VA) is committed to providing care for Veterans with post-traumatic stress disorder (PTSD) and to preventing suicide among Veterans. VA has undertaken extensive efforts in the last five years to implement enhancements to mental health care, many focused on PTSD care and on suicide prevention. VA is committed to improving and enhancing access to care and the quality of care delivered, and to expanding knowledge through research.

VA develops Clinical Practice Guidelines (CPGs) in conjunction with the Department of Defense (DoD) on a wide array of health care issues, including several mental health diagnoses and problems. The CPGs are developed in a thoughtful, data-driven process, resulting in documents that guide assessment and disease management, and, when possible, prevention of disorders. The most recently revised CPG for PTSD was published in 2010, as an update from the original 2004 CPG for PTSD.

The role of CPGs is to guide clinical decisionmaking, not to dictate clinical care. VA emphasizes that patient preferences must be addressed, with the patient being a full collaborator in treatment planning and decisions. As potentially effective treatment options increase, Veterans can take an active role in deciding how each option fits with their goals, strengths, and challenges.

VA must develop providers who can deliver with clinical skill and fidelity the treatments shown most likely to be effective. To support this, the VA Office of Mental Health Services (OMHS) has taken a lead role in identifying the training needs of VA's mental health work force and developing programs to target those needs. VA has trained thousands of mental health clinicians to provide the psychotherapies rated most effective for PTSD in both the CPG and in an independent 2007 report by the Institute of Medicine: Cognitive Processing Therapy and Prolonged Exposure Therapy. VA's National Center for PTSD (NCPTSD) also delivers training for PTSD treatment providers through a national mentoring program that shares best practices in PTSD care across Veterans Integrated Service Networks (VISNs) and VA medical facilities.

The PTSD CPG must continue to evolve as knowledge progresses through research. For example, many Veterans want their family members more involved in PTSD treatment. While VA has expanded authority to allow family involvement in PTSD treatment, little empirical evidence exists to guide how clinicians may effectively adapt to these preferences. Additionally, the value of the PTSD CPG would be greatly increased by an evidence base to guide adjustments to treatment when clients present with common comorbidities, such as pain, insomnia, anger, substance use disorders, or traumatic brain injury.

Suicide prevention is integral to VA's mental health efforts. Currently, a suicide prevention CPG is under development with the DoD, and should provide invaluable clinical guidance. The 2008 recommendations of a Blue Ribbon panel of suicidology experts have contributed to development of these guidelines. The foundation for effective suicide prevention is good mental health care for PTSD and for all diagnosable mental illness and other emotional challenges. At the core of VA's program is VA's Crisis Line, a 24/7 phone line run in collaboration with SAMHSA's Lifeline, established in 2007. Veterans, or those concerned about a Veteran, can call 1-800-273-8255 and then press 1 to be connected to a VA mental health professional trained to work with those in crisis or who may be potentially suicidal. Since its founding, the Crisis Line has received over 500,000 calls and initiated over 19,000 rescues. Such rescues involve dispatching emergency personnel to the site of an imminent suicide, securing the person and any others in the area, and ensuring the person receives urgent care.

One invaluable feature of VA's Crisis Line is that staff can link to the Veteran's Electronic Health Record, if the Veteran is willing to share his or her name and social security number. This feature allows the Crisis Line responder to link the caller to mental health providers who have seen the Veteran previously and to get immediate help. In addition, VA employs Suicide Prevention Coordinators (SPCs) at every facility and large clinic to arrange immediate local response. The SPCs follow up with Veterans to ensure they continue care and receive the support they need, and to develop safety plans.

Building on the success of the call line, VA has opened a written Chat Service at www. veterancrisisline.net and a texting service, at 838255, both of which connect those seeking care directly to mental health professionals who staff Crisis Line calls. These services especially appeal to younger Veterans, for whom these communication options are familiar and preferred.

Numerous opportunities for research remain. Many relationships between suicidality and diagnosed mental illness are known, but there is much to learn, particularly about the same issues of chronicity and comorbidity that are central for PTSD care. In addition, one of the most challenging issues is that a large proportion of suicides occur in those without any known mental illness. Often such suicides occur after a primary care visit, and without any obvious warning signs that the individual is at risk for suicide. Research focused on the underlying issues for such patients, how to identify them, and what care could best prevent suicide in this group would be invaluable for VA and for the nation.

  1. Batten, S. V. et al. "Veteran Interest in Family Involvement in PTSD Treatment," Psychological Services 2009; 6:184-9.
  2. Institute of Medicine (2007). Treatment of Post-traumatic Stress Disorder: An Assessment of the Evidence. Washington, DC: The National Academies Press.
  3. VA/DoD Clinical Practice Guideline (2010). Management of Post-Traumatic Stress, Version 2.0. Washington, DC: Department of Veterans Affairs and Department of Defense.
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