Some insights for daily clinical practice can be taken from completed research studies and translated into practice. These include increasing evidence of sleep disturbances as warning signs for suicide and suicide-related behaviors, growing concerns related to the overprescription of opioid analgesics in patients with PTSD and other psychiatric diagnoses, and increased emphasis on restriction of access to firearms in those at risk for suicide.
Sleep disturbances have been previously identified as a risk factor for suicide.59-62
Ribiero et al,62
in a cross-sectional and longitudinal correlational study of young adults in the military, found that self-reported insomnia symptoms were associated with suicidal ideation even after controlling for depression, hopelessness, PTSD diagnosis, anxiety symptoms, and drug and alcohol abuse. When only depression and hopelessness were controlled, insomnia symptoms were uniquely predictive of suicide attempts in the month after assessment. Complaints of insomnia or other sleep disturbances in otherwise healthy soldiers, reservists, or veterans may signal the need for taking a careful history and screening for depression, substance misuse, and PTSD. These complaints may also serve as opportunities for referring those potentially needing more intensive treatment.
Opioid analgesic prescription in the United States continues to increase dramatically in parallel with rising rates of opioid misuse, unintentional overdose, and death.63-67
Unintentional overdose deaths, primarily with opioids, now outnumber traffic fatalities in many states. Individuals with psychiatric illness are overrepresented among those receiving opiate prescriptions and those taking overdoses.66
This same trend has been seen in former military personnel.
A 2012 VHA study68
analyzed the association between opioid prescription and clinical outcomes in Iraq and Afghanistan veterans with and without psychiatric disorders. Seal et al68
found that individuals with a PTSD diagnosis were almost 3 times as likely as veterans without a psychiatric diagnosis to be prescribed opioid analgesics. Iraq and Afghanistan veterans with a PTSD diagnosis who were prescribed opioids were significantly more likely to have opioid-related accidents and overdoses, alcohol and nonopioid drug-related accidents and overdoses, and self-inflicted and violence-related injuries.68
Similar to larger US practice trends,67
opioids were dispensed despite the presence of comorbid alcohol use and concomitant use of benzodiazepines.
Caution should be used in prescribing opioids for all patients with chronic, noncancer pain. The State of Washington has developed helpful guidelines for opioid prescribing69
for patients with chronic, noncancer pain that incorporate dosing guidelines and screening tools to address high-risk use and psychiatric illness and that provide recommendations for when to refer patients for specialty-level care. These guidelines69
seem temporally associated with a decrease in opiate dosage equivalents per patient, a reduction in the number of patients prescribed daily doses exceeding guidelines, and a decline in opioid-related deaths.70
Finally, 2 evidence-based strategies27
to consider for upstream suicide prevention (ie, before patients engage in a suicide attempt) include (1) improving primary care physician recognition and treatment of depression and (2) restricting access to lethal means in those at risk for suicide.27
Previous research suggests that patients who die by suicide are more likely to have visited a primary care physician within 1 month of their death than a mental health clinician.71
Programs developed to improve primary care clinicians' recognition and treatment of depression have resulted in decreased suicide rates.72-74
For a more extensive review of suicide risk management and depression in primary care, see the August 2011 issue of Mayo Clinic Proceedings.75
The second strategy focuses on restricting access to firearms since they are the means of choice for almost 70% of soldiers dying by suicide.33,35,58
Veterans are more likely to own firearms and are significantly more likely than the general population to die by firearms suicide.76
All veterans with psychiatric illness should be asked about firearms access and encouraged to deposit weapons in safe storage or remove them altogether from the home if an individual is experiencing increased psychiatric symptoms77
(eg, severe anxiety or hopelessness) or elevated chemical abuse that could raise the risk of suicidal action.78
There is a well-developed research literature on the increased risk of suicide in states and homes with increased rates of firearm ownership.79-82