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This Issue: Ensuring High-Quality Care | Table of Contents: Fall 2018 | Download this issue

A Chat with Our Experts

Seeking new ways to alert physicians to Veteran suicide risk

Dr. Hal Wortzel is a forensic neuropsychiatrist at the VA Rocky Mountain Mental Illness Research and Education Clinical Center in Denver. <em>(Photo by Shawn Fury)</em>
Dr. Hal Wortzel is a forensic neuropsychiatrist at the VA Rocky Mountain Mental Illness Research and Education Clinical Center in Denver. (Photo by Shawn Fury)

Dr. Hal Wortzel is a forensic neuropsychiatrist at the VA Rocky Mountain Mental Illness Research and Education Clinical Center in Denver. (Photo by Shawn Fury)

Dr. Hal Wortzel is a forensic neuropsychiatrist at the VA Rocky Mountain Mental Illness Research and Education Clinical Center (MIRECC) in Denver. He serves as director of neuropsychiatric consultation services and codirector of the VA Suicide Risk Management Consultation Program. Dr. Wortzel is also an associate professor of psychiatry, neurology, and physical medicine and rehabilitation at the University of Colorado.

His research is focused on suicide prevention in the Veteran population, especially as it relates to Veterans who experience posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI).

VARQU spoke with Wortzel about his research into suicide prevention, and more specifically, his thoughts on using a suicide-specific diagnosis code in Veterans' medical records.

The overall suicide rate for Veterans is 5 percent greater than for non-Veterans, according to the latest VA National Suicide Data Report. Why are Veterans at a greater risk for suicide?

Unfortunately, it's the case that suicide rates and recent numbers aren't terribly encouraging when we talk about the population at large. This is a growing problem across our community—for Veterans and non-Veterans. Why are the numbers looking a little bit worse for Veterans? It starts with whatever is driving the increase in the general population.

There are a lot of factors driving suicide risk in the general population—things like depression, life stressors, and substances of abuse. And of course, all those things also impact our Veterans. Then, we must superimpose Veteran-specific aspects that might increase the risk above what everyone else is facing.

For many of our Veterans, that involves circumstances directly stemming from their military service—exposure to combat, PTSD, various injuries that might result in TBI, or chronic pain. Also, the added psycho-social stressors that come with military service can increase suicide risk. Most of us don't have to contend with deploying for service and being gone for months, if not years, and coming back to kids we haven’t gotten a chance to spend a lot of time with. Or coming home to a significant other who has had to take on a different role in our absence. To better understand all the unique aspects that increase Veteran suicide risk, we must superimpose them on top of the stressors that people in the general population deal with.

In an article published in Psychiatric Practice, researchers proposed that physicians should use a suicide-specific diagnosis code in Veterans' medical records. Can you explain what a diagnosis code is?

In the world of psychiatry and mental health, we have the Diagnostic and Statistical Manual of Mental Disorders (DSM). The diagnostic manual outlines the criteria for all the diagnoses we use: whether it’s major depression, PTSD, bipolar disorder, or schizophrenia.

The DSM has evolved over many years now in the spirit of making sure that we are all using these terms in the same way. If I say someone is depressed, then all other mental health professionals will know what I mean. And that wasn't always the case. If you go back long enough, people would use these terms in their own idiosyncratic fashion, and it wasn't always clear what they meant. The DSM has evolved so that we have a shared language that will facilitate communication, and, by virtue of better communication, enhance patient care.

The idea of the suicide-specific diagnosis doesn't necessarily begin with these authors. If you look at the DSM5, which is the most current version of the diagnostic manual, there is a proposed—not ready for prime time—research diagnosis for suicide. In the DSM though, suicide risk is really based on historical behaviors, rather than anticipating future risk or behaviors.

Why would including a suicide-specific diagnosis in the medical record be helpful?

If there was a perfect diagnosis that would help us determine future risk—who would or would not attempt suicide—if that was predictive in terms of future suicide behaviors, that of course would be helpful in identifying who is at risk to help us support and bolster care for those individuals. I think that is the justification for these proposed diagnoses: It is going to call-out risk more effectively in the medical record and thereby help ensure that appropriate treatment plans are in place.

In an editorial written in response to that article, you and your colleagues wrote that there could be some unintended consequences to putting a suicide-specific diagnosis in the medical record. Why is that?

Going back to where we started this conversation, suicide rates are alarming for all populations. As a society, as medical providers, and mental health professionals, we are still unable to predict who will or will not go on to die by suicide. It is a unique challenge to come up with a diagnosis and concrete criteria for a behavior that we don't really know how to effectively predict.

The literature out there suggests that when we try to predict, we end up with a lot of false positives. In order words, most people we identify as being at high, chronic risk for suicide, probably won't go on to die by suicide. And there are unfortunately many people who are not identified as being at risk, who die by suicide. So, the problem here is prediction, and we can't do it well. It is exceedingly difficult to create criteria that then facilitate that process in a way that potentially justifies achieving the status of a diagnosis.

You also mention that requiring a suicide-specific diagnosis in the medical record could put providers in a difficult position. Can you explain?

One of the arguments in favor of these diagnoses was that the addition of this type of diagnosis in the medical record would be helpful to providers by reflecting their consideration of suicide risk. And presumably it would offer protection against claims that they were negligent in considering suicide, or accepting that risk.

And although that is probably not untrue, from the medical-legal perspective, our concern was more the opposite end of things—when that diagnosis did not appear in records. So, when you start talking about the ways that clinicians can be held liable for malpractice, one of the leading causes is diagnostic error: The idea that if you misdiagnose someone or don't offer a diagnosis when it is applicable, could lead to a finding of negligence.

Right now, because there isn't a suicide-specific diagnosis, you can't be held negligent for not offering a diagnosis. Once we create and routinely start using that diagnosis, it potentially becomes a problem if, and when, that diagnosis doesn't feature in an individual's record. It creates the risk, that retrospectively, legal advocates will make the argument, "Well, obviously someone who died by suicide warranted a suicide-specific diagnosis." And, by virtue of that not being there, you are guilty of diagnostic error and negligence as a consequence.

But we know that, unfortunately, roughly half of individuals who die by suicide haven't been recognized as being at risk. And that doesn't mean that all the providers those people saw were negligent. There are a number of reasons why people don't present as being at risk—they may not share their risk, and sometimes, it’s the case that people take active steps to hide their risk, for any number of reasons, such as stigma, or concern about consequences—for example, what will this mean for my job?

Is dying by suicide an impulsive act?

Although it may appear as though dying by suicide is an impulsive act, this is rarely the case. What is true is that thoughts of suicide can come and go. Sometimes life events trigger a sudden spike in suicidal desire, which can then lead to individuals deciding to act on those ideas or impulses. In other words, if someone saw their doctor on Tuesday and didn't have any thoughts of suicide or intent to harm themselves, and they died by suicide two days later, that doesn't mean they weren't being truthful when they saw the provider. It may mean that life happened and something triggered an acute crisis that no one could have predicted or anticipated.

Now, there are people for whom suicide is a more contemplative act that evolves over days, weeks, months, and even years. And that's a different circumstance. But for people who become acutely suicidal because of unpredictable life circumstances, this kind of diagnostic issue could become dangerous for clinicians who potentially face legal outcomes, if these diagnoses were to exist.

In your editorial, you mentioned using red flags in the electronic medical record. Can you tell me what those are?

There is a lot of suicide-specific programming within the VA that is fairly unique. One element of that is the use of risk flags that populate the electronic medical record. There are a number of flags that can exist in the medical record, but there is one specifically that is supposed to communicate to providers perceived high risk for suicide.

The advantage is, if for example, a Veteran was on the road and went to an emergency room where no one knew him or her, the existence of that flag would indicate to new providers that we should be checking in about this person. We should be assessing the Veteran for suicide risk, thoughts about suicide, and obviously, identifying any changes or spikes in risk and entering that in the record.

You've written a lot about the importance of creating suicide risk assessments and patient safety plans. Can you explain their significance?

The exchange of articles with Joiner, et. al., was intended as a healthy debate about these issues to create an important dialogue. So, both of those articles appeared in a Law and Psychiatry column that I edit. Even though we have differing perspectives on these issues, I think we are all in agreement that these are important dialogues to have—and that risk assessment remains an important thing to have. I say this because some of this has come up in the context of a body of literature that highlighted clinicians' fairly poor ability to predict suicide. With some even going so far to say, "If we are so bad at predicting suicide, why are we spending all this time doing risk assessments?"

Our answer to that question is, risk assessment matters not because we are good predictors, but because if we do risk assessment in a patient-centered way that is thoughtfully integrated with the rest of the mental health assessment, it can contribute to building therapeutic relationships. It can identify things that are not only important to suicide risk management, but for achieving mental health and life goals more generally.

For example, one of the items in a safety plan involves identifying things that you can do to distract yourself when you are in crisis. Or, identifying people you can reach out to help distract you when you are not doing well. Of course, these things are important for navigating a suicide crisis, but they also turn out to be really important for living happy and fulfilled lives.

Suicide aside, there are many individuals struggling with emotions who would benefit from tools that are not only helpful in terms of suicide risk, but in achieving their treatment goals and life goals more generally. If you are having a bad day, it can be important to have people you can reach out to cheer you up. Or, have the ability to do things that make you feel better. With the focus on suicide we sometimes tend to talk about these things in that context—in isolation. What I am trying to say is that we need to bring that dialogue back into the mental health world, more broadly. And make sure that we are not carving out suicide and its risk assessment and management from all the other things that are part of a comprehensive mental health treatment plan.

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