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The Complex Science of

Suicide PreventionJim Thompson MD CCFP(EM) FCFP

Adjunct Associate Professor, Department of Public Health Sciences, Queens University

Research Medical Consultant, Canadian Institute for Military & Veteran Health Research (CIMVHR)j.thompson@queensu.ca

PHS/CIMVHR Seminar, Queens University, 08 January 2020

By “Veterans” I mean former military members living in life after release from service, regardless of type of military service. This presentation does not focus on the in-service phase of life.

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This Seminar• Prevalence of suicidal thoughts and behaviours in Canada’s military Veteran

population.• The evidence base for suicide prevention remains incomplete and

complicated.• Suicide prevention is in a pre-paradigm phase – many theories, none fully

encompassing.• Move beyond lists of risk and protective “factors” to integrative

frameworks.• Break downs silos between mental health, physical health and chronic

pain.• We need to listen to social scientists.• Suicide as a population well-being problem: Deploying integrated well-

being approaches to suicide prevention.

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Suicide Prevention in Military Veterans

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A challenging public health problem in all nations

Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans.

J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Suicidality in Military Veterans• Suicidal Ideation prevalent 3 times in CAF Regular Force Veterans

released from service in 2012-15 than in the general population.• Higher suicide mortality risk in CAF Veterans released from service

during 1976-2012 compared to the general population:• Male Veterans: 1.4 times• Female Veterans: 1.8 times• Male Veterans compared to female Veterans: 3.5 times

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• Simkus et al. 2017 Veteran Suicide Mortality Study: 1976 to 2012. Charlottetown (PE): Veterans Affairs Canada, Research Directorate Technical Report; November 30, 2017. https://www.veterans.gc.ca/eng/about-vac/research/research-directorate/publications/reports/vsms-2017

• VanTil, L. D., et al. (2018). Veteran suicide mortality in Canada from 1976 to 2012. Journal of Military, Veteran and Family Health 4(2): 110-116. https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh.2017-0045

• Thompson et al. Group identity, difficult adjustment to civilian life and suicidal ideation in Canadian Armed Forces Veterans: Life After Service Studies. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/full/10.3138/jmvfh.2018-0038

• Smith, J. A., et al. (2019). A historical examination of military records of US Army suicide, 1819 to 2017. JAMA Network Open 2(12): e1917448-e1917448.

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Suicide Attempts in Ideation Deniers

US Army soldiers who denied lifetime suicidal ideation in a population survey:• Followed for 45 months to identify administrative records of suicide

attempts.• 67% of attempts occurred among those who denied ideation in the

survey.

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Bernecker, S. L., et al. (2019). Predicting suicide attempts among soldiers who deny suicidal ideation in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Behaviour research and therapy 120: 103350.

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The Measurement Challenges

1. Nomenclature:

2. How do we know that a suicide was prevented?3. How do we know that someone died of suicide?4. Unique ethical problems in doing suicide research.

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Goodfellow, B., et al. (2019). International Study of Definitions of English-Language Terms for Suicidal Behaviours: protocol of an opinion survey. BMJ Open. 9(7): e025770.

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Health Canada Suicide Task Force Report 1987:

“There are many unanswered questions about suicide, and a multitude of conflicting theories. The role of environmental influences and mental disorders, the existence and nature of predisposing genetic or biochemical factors, and the parallel issues of proper and productive treatment and prevention -the questions are complex. Suicide is an action; it is not an illness. Identifying the chain of causal and triggering factors, which may in any case be highly individual, and deriving from this an overall prevention and treatment strategy is perhaps one of the most vexing problems facing professionals in the health sciences.”

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Well-Being

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More than just psychological well-being

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Well-Being Framework

Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Suicide Prevention Guidelines for Military & Veteran Populations

Evidence to guide guidelines is limited

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Sareen, J., et al. (2018). Report of the 2016 Mental Health Expert Panel on Suicide Prevention in the Canadian Armed Forces. Journal of Military, Veteran and Family Health 4(1): 70-89.Sall, J., et al. (2019). Assessment and management of patients at risk for suicide: synopsis of the 2019 US Department of Veterans Affairs and US Department of Defense clinical practice guidelines. Annals of Internal Medicine 171(5): 343-353.

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Suicide Prevention Guidelines –Military & VeteransLines of Effort1. Communicate, engage, educate2. Support resilient CAF members/Veterans3. Strengthen through families & community4. Timely access to effective health care5. Promote well-being through transition to post-service life6. Align business practices to manage risk and stress7. Improve through research and lessons learned

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Canadian Armed Forces and Veterans Affairs Canada. Joint Suicide Prevention Strategy. Ottawa: Government of Canada. ISBN 978-0-660-20443-7. 2017. https://www.canada.ca/en/department-national-defence/corporate/reports-publications/caf-vac-joint-suicide-prevention-strategy.html

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Lack of evidence is not evidence that something does not work

Sall et al. 2019: “Despite a preponderance on the national suicide prevention stage of strategies for community-based intervention, evidence for the benefits of such interventions is lacking.”

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Sall, J., et al. (2019). Assessment and management of patients at risk for suicide: synopsis of the 2019 US Department of Veterans Affairs and US Department of Defense clinical practice guidelines. Ann Int Med 171(5): 343-353.

Caine, E. D. (2019). "Seeking to Prevent Suicide at the Edge of the Ledge." Ann Int Med 171(5): 374-375.Hogan, M. (2019). "Veteran suicide: not just a VA Issue; it's a US issue." Ann Int Med, 171(5): 372-373.

But: “these guidelines are restricted in their view; they emphasize randomized trials but neglect findings that broadly based suicide prevention is possible, as shown by sustained reductions in such countries as Denmark, Finland … and the United Kingdom” (Caine)

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Community-Based Peer Support• Upstream suicide prevention.• Two main themes:• Support for community-based suicide

prevention• Promote evidence-based culture

• Beyond “call 911” or “get them to the Emergency Department”

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Thompson J, Meehan M, Heber A, Belanger S, Pedlar D. Leading by Example: May 2019 Ottawa Workshop on Community-Based Suicide Prevention in Canadian Veterans and Public Safety Personnel. Kingston, ON: Canadian Institute for Military and Veteran Research. Technical Report. 2019. https://cimvhr-cloud.ca/reports/leadByExample-report-2019-12-04.pdf

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Emerging Evidence for Upstream Prevention

A study of community centre based peer support with clinical guidance

Men approaching retirement

“Participants experienced significant increases in attitudinal sources of meaning in life, psychological well-being, life satisfaction, retirement satisfaction, and general health, and decreases in depression, hopelessness, loneliness, and suicide ideation.”

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Heisel, M. J., et al. (2019). Meaning-centered men’s groups: Initial findings of an intervention to enhance resiliency and reduce suicide risk in men facing retirement. Clinical gerontologist: 1-19.

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Knowledge Translation – How?“In comparison with the Resilience Retreat (n = 24), ASIST training (n = 31) was not associated with a significant impact on all outcomes of the study based on intention-to-treat analysis. There was a [statistically insignificant] trend toward an increase in suicidal ideation among those who participated in the ASIST in comparison to those who were in the Resilience Retreat. Conclusions: The lack of efficacy of ASIST in a First Nations on-reserve sample is concerning in the context of widespread policies in Canada on the use of gatekeeper training in suicide prevention.”

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Sareen, J., et al. (2013). Gatekeeper training for suicide prevention in First Nations community members: a randomized controlled trial. Depression and Anxiety 30(10): 1021-1029.

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No Widely Accepted Suicide Theory

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Still in a pre-paradigm phase

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Still in a Pre-paradigm Phase

•We reviewed 17 suicide theories & frameworks:• Durkheim 1897• Psychodynamic theorists 1920-1938• Integrative: Shulman 1978 to O’Connor 2018

• Suicide causation is understood to be multifactorial, complex, varying individually, and due to interacting factors rather than linear causal chains.

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Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Four Decades of Study in Military Veterans

“Data from a 1983 prospective study of suicide in a cohort of 4800 psychiatric inpatients were reanalyzed using logistic regression, which is more appropriate for a binary outcome. The results were the same as in the previous study: too few of the subsequent suicides were identified and there were too many false positives to make this procedure useful.”

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Pokorny, A. D. (1993). Suicide prediction revisited. Suicide and Life-Threatening Behavior 23(1): 1-10.

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Far from a Perfect ScienceRives (1999) Summary of principles for Emergency Department assessment of suicidal patients:• Focus on mental illness diagnosis and treatment, especially

depression and alcoholism.• Risk assessment uncertain.• No discussion of contributing well-being factors.Belsher et al. (2019) systematic literature review:• “suicide prediction models produce accurate overall classification

models, but their accuracy of predicting a future event is near zero”

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Rives, W. (1999). Emergency department assessment of suicidal patients. Psychiatric Clinics 22(4): 779-787.Belsher, B. E., et al. (2019). Prediction models for suicide attempts and deaths: a systematic review and simulation. JAMA psychiatry 76(6): 642-651.

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Common to all suicide theories

1. It’s not just all about mental illness or “depression”.2. Heterogeneity in life course trajectories to suicide.3. Multiple causal factors interlinked in nonlinear ways that vary

person to person.4. Individuals vary in vulnerability to becoming suicidal: stress-

diathesis.5. Waxing and waning over time in response to well-being

influences.

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Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Move Beyond Lists of “Risk Factors”

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The future lies I think in integrative models

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Multicausality

From Nancy Krieger’s 1994 paper on the “spider web” metaphor for multicausality: “… modern epidemiology often seems more concerned with intricately modelling complex relationships among risk factors than with understanding their origins and implications for public health. Reflecting this trend, graduate students in epidemiology are far more likely to be taught about study design and data analysis than they are about how to generate epidemiologic hypotheses about the societal dynamics of health and disease.”

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Krieger, N. (1994). Epidemiology and the web of causation: has anyone seen the spider? Social science & medicine 39(7): 887-903.

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Stuck in Monocausal ThinkingKendler (2019):“Despite ample evidence to the contrary, monocausal thinking continues to influence our field, for example, in the popular but improbable view that we can, with a few key advances, move easily from descriptive to etiologically based diagnoses.”

Chang et al (2016):“currently known biological factors are weak predictors of future suicidal behaviors…”

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Kendler, K. S. (2019). From Many to One to Many—the Search for Causes of Psychiatric Illness. JAMA psychiatry.Chang, B., et al. (2016). Biological risk factors for suicidal behaviors: a meta-analysis. Translational psychiatry 6(9): e887.

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Not such risky factors after allRibeiro et al. (2016): “Prior self-injurious thoughts and behaviours confer risk for later suicidal thoughts and behaviors. However, they only provide a marginal improvement in diagnostic accuracy above chance.”Franklin et al. (2017): “prediction was only slightly better than chance for all outcomes; no broad category or subcategory accurately predicted far above chance levels; predictive ability has not improved across 50 years of research; studies rarely examined the combined effect of multiple risk factors; risk factors have been homogenous over time, with 5 broad categories accounting for nearly 80% of all risk factor tests; and the average study was nearly 10 years long, but longer studies did not produce better prediction.

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Ribeiro, J., et al. (2016). "Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies." Psychological medicine 46(2): 225-236.Franklin, J. C., et al. (2017). "Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research." Psychological bulletin 143(2): 187.

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DepressionA majority who die by suicide had depression prior to death, but:1. The great majority with depression do not become suicidal or die by

suicide.2. Many who die by suicide did not have a mental illness.

Franklin et al. (2017) found that depression is not a strong risk indicator for suicide.So, is suicidal depression a unique form of ”depression”?If so, does that make well-being factors even more significant, in addition to finding treatments specific for acute suicidality?

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Franklin, J. C., et al. (2017). Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychological bulletin 143(2): 187.Black, S. A., et al. (2011). Prevalence and risk factors associated with suicides of army soldiers 2001–2009.Military Psychology 23(4): 433-451.

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Figure 14. Female Veteran smoothed hazard function for risk of dying by suicide by component (Regular Force vs. Reserve Force Class C service only), 1976 to 2012 releases.

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Simkus K, et al. 2018 Veteran Suicide Mortality Study. Charlottetown (PE): Veterans Affairs Canada, Research Directorate Technical Report; 4 December, 2018. https://www.veterans.gc.ca/eng/about-vac/research/research-directorate/publications/reports/veteran-suicide-mortality-study2018

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Health Canada Suicide Task Force Report 1987:

“Studies of common personal characteristics and traits are reported, as are studies of family relationships ·and structure. There are job-related factors as well as findings in terms of social disorganization. Physical illness can be a factor. Of major importance in many suicides is mental disorder. Drug and alcohol abuse are also common factors. Findings concerning the role of stress are discussed, as well as such biological factors as seasonal variation, the menstrual cycle and socio-biochemical and genetic determinants. Some psychoanalytic contributions are briefly noted. The necessity for a 'multidimensional approach' in understanding the causal chain is clearly illustrated…”

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Big Data, Machine Learning, Precision RiskPossible advantages:

• Might help us to do suicide prevention like heart disease prevention.

• Can look upstream at heterogenous pathways to suicide.

Yellow flags:• Garbage in, garbage out.

• We still do not have a universally accepted suicide paradigm.

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Kessler, R. C. (2019). "Clinical Epidemiological Research on Suicide-Related Behaviors—Where We Are and Where We Need to Go." JAMA psychiatry.Kessler, R. C., et al. (2019). "Suicide prediction models: a critical review of recent research with recommendations for the way forward." Molecular psychiatry: 1-12. Gradus, J. L., et al. (2019). "Prediction of sex-specific suicide risk using machine learning and single-payer health care registry data from Denmark." JAMA psychiatry.Fazel, S. and L. O’Reilly (2019). "Machine Learning for Suicide Research–Can It Improve Risk Factor Identification?" JAMA psychiatry. [Comment on Gradus et al.]Fonseka, TM … Sid Kennedy (2019). "The utility of artificial intelligence in suicide risk prediction and the management of suicidal behaviors." Australian & New Zealand Journal of Psychiatry 53(10): 954-964.

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Silos in Health Care

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Importance of:

Chronic physical health conditions and chronic painandSocial Identity

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Why so Little Attention to Physical Health and Chronic Pain?

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Important determinants of mental health problems, and suicidality

Thompson JM, Zamorski M, Sweet J, VanTil L, Sareen J, Pietrzak RH, Hopman W, MacLean MB, Pedlar D. Roles of physical and mental health in suicidal ideation in Canadian Armed Forces Regular Force veterans. Can J Pub Health. 2014;105(2):E109-E115. https://link.springer.com/article/10.17269/cjph.105.4217

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Canadian Veterans:Life After Service Studies

LASS 2010, 2013, and 2016:• Canadian Armed Forces

Veterans. • Released from 1998. • Living in the general Canadian

population. • Two types of studies:

• A. Surveyed within years after release, large sample sizes.

• B. Also income studies, whole population data.

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*Veteran = ex-military, regardless of type or length of service.

Tweel M et al. Veterans Affairs Canada Research Directorate Publications: Annotated Bibliography 1997-2018. Charlottetown, PE: Veterans Affairs Canada. Research Directorate Technical Report. 2019. https://cimvhr.ca/vac-reports/data/reports/Tweel%20M%202019%20Research%20Directorate%20Annotated%20Bibliography.pdf

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Health: Chronic conditions prevalence

32LASS 2013, CAF Veterans released 1998-2012.

Thompson JM, VanTil L, Zamorski MA, Garber B, Dursun S, Fikretoglu D, Ross D, Richardson JD, Sareen J, Sudom K, Courchesne C, Pedlar D. Mental health of Canadian Armed Forces Veterans – Review of Population Studies. J Mil Veteran Fam Health. 2016;2(1):70-86.

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Comorbidity of Physical and Mental Health Conditions

Percent of Population

Adjusted Odds RatioNo

LimitationsSome

LimitationsHigh

Limitations

No Health ConditionsMental onlyPhysical only Both Physical and Mental

33%2%

59%7%

<1%<1%71%28%

17%1%

38%23%

1.009*** (3-30)

25*** (12-52)73*** (34-157)

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***p<0.001

Odds of having activity limitations four times higher in those with both physical and mental

health conditions than either one alone.

Thompson JM, Pranger T, Sweet J, VanTil L, McColl MA, Besemann M, Shubaly C, Pedlar D. Disability Correlates in Canadian Armed Forces Regular Force Veterans. Dis Rehab. 2014.

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Chronic Pain Common in Military VeteransCAF Regular Force and Class C Reserve Veterans released in 1998-2015:

• 41% had chronic pain or discomfort, double the Canadian general population (age-sex adjusted).• 63% with chronic pain had diagnosed mental

health conditions.• Of those with mental health conditions:• 91% also had a chronic physical health

condition.• 62% had chronic pain.• 57% had activities reduced by chronic pain.

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VAC Info Brie. LASS 2016 CAF Veterans released 1998-2015. https://www.veterans.gc.ca/eng/about-vac/research//research-directorate/info-briefs/chronic-painVanTil LD, Sweet J, Poirier A, McKinnon K, Sudom K, Dursun S, Pedlar D. Well-Being of Canadian Regular Force Veterans, Findings from LASS 2016 Survey. Charlottetown (PE): Veterans Affairs Canada Research Directorate; 2017 Jun 23. Technical Report. Available from: http://publications.gc.ca/pub?id=9.839366&sl=0

Credit: Department of National Defence

Two different self-report pain measures:1. LASS 2010 (64%):

Asked directly if they had pain or discomfort.2. LASS 2013 (36%) and LASS 2016 (41%):

Used HUI module, asked indirectly if they did not have pain or discomfort. Comparable to general population.

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Connection to Suicidality

Suicidal ideation associated with poorer physical health status measured 3 different ways

Independently of the stronger association with chronic diagnosed mental health conditions

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Thompson JM, Zamorski M, Sweet J, VanTil L, Sareen J, Pietrzak RH, Hopman W, MacLean MB, Pedlar D. Roles of physical and mental health in suicidal ideation in Canadian Armed Forces Regular Force veterans. Can J Pub Health. 2014;105(2):E109-E115. https://link.springer.com/article/10.17269/cjph.105.4217

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Social Identity Might be a Key

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I was not taught social identity theory in medical school

Hatcher, S. and O. Stubbersfield (2013). Sense of belonging and suicide: a systematic review. The Canadian Journal of Psychiatry 58(7): 432-436.

Thompson JM, Lockhart W, Roach MB, Atuel H, Bélanger S, Black T, Castro CA, Cox D, Cooper A, de Boer C, Dentry S, Hamner K, Shields D, Truusa, TT. Veterans’ Identities and Well-being in Transition to Civilian Life – A Resource for Policy Analysts, Program Designers, Service Providers and Researchers. Veterans Affairs Canada. Research Directorate Technical Report. 01 June 2017. https://cimvhr.ca/resource-reports

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Identity Challenges in Transitions:Major Life Transitions are all about Identity Shifts• Personal identity:• Our cores, the Self: Who am I?• How we are unique and differ from others: What am I?

• Social Identity:• How we are like some, and different from others: Where do I belong?• Formed by (1) memberships in social groups and (2) value attached to those

memberships.• We have many social identities, always changing.• Enable us to have good well-being.• Need to integrate old and new social identities as we adapt in transition to

the new culture.• Success: Adopt the norms, values and beliefs of the groups.

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Identities Across the Life Course

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Thompson JM, Lockhart W, Roach MB, Atuel H, Bélanger S, Black T, Castro CA, Cox D, Cooper A, de Boer C, Dentry S, Hamner K, Shields D, Truusa, TT. Veterans’ Identities and Well-being in Transition to Civilian Life – A Resource for Policy Analysts, Program Designers, Service Providers and Researchers. Veterans Affairs Canada. Research Directorate Technical Report. 01 June 2017. https://cimvhr.ca/resource-reports

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Weak Group Identity is Associated with Difficult Adjustment & Suicidal Ideation

Group IdentityPer Cent of Population

DifficultAdjustment

Suicidal Ideation

Strong SoLCB & Part of a group 46% Reference Reference

Strong SoLCB & Not part of a group 3% 7* 23*

Weak SoLCB & Part of a group 35% 3* 7*

Weak SoLCB & Not part of a group 16% 11* 34*

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Unadjusted Odds Ratios

Thompson et al. Group identity, difficult adjustment to civilian life and suicidal ideation in Canadian Armed Forces Veterans: Life After Service Studies. J Mil Vet Fam Res. 2019.

Postmes, T., et al. (2019). Social identification and depression: A meta-analysis. European journal of social psychology 49(1): 110-126.

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Difficult adjustment and Weak sense of community belonging Improve over time

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LASS 2016, All CAF Regular Force Veterans(Cross-sectional)

Veterans Adapt over Time after Release

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Determinants of Well-being in the Health Domain – and of Suicidality

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Haslam, S. A., et al. (2019). Group life shapes the psychology and biology of health: The case for a sociopsychobio model. Social and Personality Psychology Compass 13(8): e12490.

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An Ecological, Life Course, Whole-of-Community Approach to Suicide Prevention

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Look upstream from the precipice

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The Move to Integrative Models

Kenneth Shulman (1978):

Argued for integrative models in suicide risk assessment, rather than lists of risk and protective factors

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Shulman K. Suicide and parasuicide in old age: a review. Age Ageing. 1978;7(4):201–9. https://doi.org/10.1093/ageing/7.4.201

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Caine et al. (2018) – Ecological Model of Suicide Prevention

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Caine ED. Forging an agenda for suicide prevention in the United States. Am J Public Health 2013;103:822–9. Caine, E.D., Reed, J., Hindman, J., & Quinlan, K. (2018). Comprehensive, integrated approaches to suicide prevention: practical guidance. Injury Prevention, 24(Suppl 1), i38-i45.

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Life Course, Well-being Framework for Suicide Prevention

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Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Suicide Influences Across the Life Course

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Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Suicide Pathway Influences

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• Targets for suicide prevention activities.

• Use this diagram to think through what you and your agency can do to help prevent Veteran suicides.

Thompson JM, Heber A, VanTil L, Simkus K, Carrese L, Sareen J, Pedlar D. Life course well-being framework for suicide prevention in Canadian Armed Forces Veterans. J Mil Vet Fam Res. 2019. https://jmvfh.utpjournals.press/doi/abs/10.3138/jmvfh.2018-0020

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Wrap-up: So what are we to do?

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Getting suicide prevention right

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Whole of Community, Across the Life Course“Suicide prevention efforts have tended to be one-by-one initiatives rather than comprehensive efforts that bring together communities, state agencies, health systems and diverse stakeholders to work in a synergistic fashion that pushes forward multiple efforts simultaneously. Suicide is not a singular problem, or a specific medical diagnosis. Rather it serves as a final common pathway for an array of elements reflecting personal, family, community and societal stresses and turmoil—typically expressed one individual at a time. While the final moments of action—killing oneself—predominantly have drawn past attention from medical and mental health professionals, it is timely to integrate the person level with what can be done in both health systems and beyond their walls across entire communities, and far upstream, so that it is possible to alter life trajectories.”

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Caine, E.D., Reed, J., Hindman, J., & Quinlan, K. (2018). Comprehensive, integrated approaches to suicide prevention: practical guidance. Injury Prevention, 24(Suppl 1), i38-i45.

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Putting it all Together

Suicide prevention requires both:1. Access to mental health care for

assessment and treatment of:• Mental illness• Acute suicidality

2. Support for good well-being in all the domains• Across the life course and• When suicidality develops

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Prevention, Intervention, and Postvention

For

Individuals, Vulnerable Subpopulations, andWhole Populations

By

The Whole Community

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Engage the Community “Support an evidence-based culture in community suicide prevention:”• “Research findings need to be transparent and

freely available in lay language. Mechanisms for open and free sharing of research knowledge are essential in advancing suicide prevention work.”• “Help groups to develop data collection. Foster

participation in whole-of-community data collection.”

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Thompson J, Meehan M, Heber A, Belanger S, Pedlar D. Leading by Example: May 2019 Ottawa Workshop on Community-Based Suicide Prevention in Canadian Veterans and Public Safety Personnel. Kingston, ON: Canadian Institute for Military and Veteran Research. Technical Report. 2019. https://cimvhr-cloud.ca/reports/leadByExample-report-2019-12-04.pdf

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Three Centres of ExcellenceFunded by Veterans Affairs Canada

Canadian Institute for Military & Veteran Health Research• Based at Queens University and the Royal Military College of Canada, Kingston• 10 years of progress• Network of 45 Canadian universities

Center of Excellence on Post Traumatic Stress Disorder (PTSD) and Related Mental Health Conditions

• Based at the Royal Ottawa Mental Health Centre, Ottawa• Announced 2018

Center of Excellence on Chronic Pain• Based at McMaster University, Hamilton• Announced 2019

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OP IDENTITY: Transition tactics for you and your village

I Identity awareness and etiquetteD Do seek out new social groupsE Embrace transitioners into your social groupN Normalize transition challengesT Tell a positive life storyI Ideal stereotypes are positive and realT Think to ask: What recognition works for you?Y You aren’t alone: The power of positive peers

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What one thing can every one of us do, every day?

Thompson JM, et al. Veterans’ Identities and Well-being in Transition to Civilian Life – A Resource for Policy Analysts, Program Designers, Service Providers and Researchers. Veterans Affairs Canada. Research Directorate Technical Report. 01 June 2017. https://cimvhr.ca/resource-reports

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Thank you

Have a good day, and good year

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