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I'm pleased to reprint here a blog post from Shaili Jain, MD, a dedicated VA psychiatrist who works at the Palo Alto Veterans Medical Center — who also is a fine writer. In both capacities, she contributes to a new PLOS BLOG "Mind the Brain," of which I am editor/manager. In this post she confronts the disturbing fact that 5 veterans who are presently under VA care are still dying by suicide on a daily basis. Jain achieves the difficult balancing act of seamlessly blending her personal and scientific perspectives on this tough subject.
Preventing Veteran Suicide
Posted: September 27, 2012
The alarm clock, flashing 03:00 in green neon, signals to me that I should be fast asleep. I close my eyes and take deep breaths, trying to lull myself back into a peaceful slumber–the day ahead holds a daunting schedule with no room for yawns or fatigue. Then it appears, pops right into the forefront of my mind, a solitary question that has needled its way through my dreams, forcing me to deal with its implications. "Did you miss something with Dave?" Instantly I recognize this thought as residue from yesterday's day at work, something that had been neglected amongst the whirlwind of patient visits, typing of progress notes, writing of prescriptions, answering of emails, voice mails and texts.
In the still darkness of my bedroom, I strain to recall the details of his clinic visit. My patient Dave, a veteran, had been home from Iraq for two years, but the passage of time had not healed his psychological wounds. Through stifled tones he told me about his tormented nights and stunned days—horrifying memories, so difficult to erase, now dangerously directing his life. Tears had welled in his honey brown eyes that were dulled by the weight of war. Silence hung between us and I shifted uneasily in my chair, hesitating to reach for the Kleenex. Then, I asked the question I was duty bound to ask, "Have you had thoughts to kill yourself?" A pause, then, "No, Doc, No."
I run through a mental checklist, to make sure I had done all that his clinical condition had required, I had: increased his Sertraline dosage (a medication to treat symptoms of posttraumatic stress); prescribed a short course of sleep medication to help ease the agony of his insomnia; recommended he see his therapist weekly instead of every other week; called his therapist and shared my concerns and asked him to return to my clinic in two weeks (the time it would take for the extra Sertraline to kick in) instead of the usual month. As I had walked him to the door, I had made sure he had all the emergency numbers to call if things got worse.
It seemed, on paper at least, I had done all I was supposed to do — so then why am I tossing and turning at this ungodly hour?
My heart sinks as I realize what had been missing from my visit with Dave: the "click". The click is a feeling that is beyond rational comprehension, more intuition than fact, it can come and go in the blink of an eye and is hard to quantify or measure. The presence of the click signals to me that my patient is telling me everything I need to know, we are on the same page and we share the same hope for their recovery. The click signals a mutual trust and respect and a healthy alliance in our relationship. Treating thousands of patients, over a decade of clinical practice, has taught me that the absence of the click invariably means trouble is brewing.
Now the green neon flashes 04:00. I sigh and get out of bed knowing full well that sleep will evade me. I wait for dawn and a reasonable time for when I can call Dave to make sure he is okay.
Available Research on Veterans and Suicide
30,000 to 32,000 Americans die from suicide per year and about 20% of these Americans are veterans. It is important to make the distinction between veterans i.e. persons who have served in the military, naval or air service and are now discharged from active duty personnel i.e. persons who are still serving in the military. The distinction is important because in Army and Marine active duty personnel the statistics are different, for this population, suicide rates have nearly doubled between 2005 and 2009. A recent and thoughtful analysis of this tragic situation can be found here.
I am a psychiatrist, working for Veterans Affairs (VA), so the subject of veteran suicide is never far from my mind. There are about 5 deaths from suicide, per day, among veterans who also receive care in VA hospitals like the one where I work. More than 60% of these suicides occur among veterans who use VA services and are known to have a mental health condition. The statistics are sobering and as troops return home from the conflicts in Iraq and Afghanistan the topic of veteran suicide will, no doubt, continue to vex and distress all concerned parties.
In high income countries, like the U.S., suicide usually occurs in the context of mental illness. Hence, the key to suicide prevention is providing high quality mental healthcare for the mental health disorder that ails the person seeking help. Whilst Posttraumatic Stress Disorder (PTSD) and Traumatic Brain Injury (the signature injury of the Iraq war) are always forefront in the minds of professionals treating veterans, our care would be reductionistic if we did not thoroughly evaluate for and treat other common mental health disorders such as clinical depression, alcohol or drug addiction, bipolar disorder and schizophrenia. All of these mental health disorders are associated with an elevated suicide risk so getting the diagnosis correct is crucial. The diagnosis dictates what the treatment should be and the correct treatment increases the odds of recovery from the specific mental health disorder. This is still our best strategy for preventing suicide.
In reality there are, however, many obstacles to this strategy. For mental health treatment to be effective it often requires the steady delivery of treatment for several weeks (i.e. a certain dose of psychological treatments and psychotropic medication is often needed for a sustained recovery). Yet, studies have shown that, amongst recent returnees from the conflicts in Iraq and Afghanistan who have PTSD, for instance, such treatment courses are less likely to be completed.
Specifically with regards to psychotropic medication: Guidelines addressing the treatment of veterans with PTSD strongly recommend a therapeutic trial (i.e. taking the medication for long enough and at enough dosage to see its full effect on symptoms) of medications called selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Yet a recent study we published shows that, when compared to veterans from previous eras, recent returnees from the conflicts in Iraq and Afghanistan were less likely to complete such a therapeutic trial. Moreover, if they were clinically depressed, in addition to having PTSD, their odds of getting a therapeutic trial were diminished even further. This hints to, as yet, unexplained obstacles to engaging veterans from the recent conflicts in Iraq and Afghanistan, in mental health treatment—a disconcerting thought for clinicians who work with this population.
Another obstacle is that, despite the best efforts of an individual clinician, the reality is that conventional mental health services still fail to reach many individuals who are suicidal i.e. many of those who are suicidal are not even engaged in the healthcare system to begin with. The health disparities literature is replete with evidence demonstrating how, in our society, those most in need of psychiatric and medical care are often the least likely to get it. Social determinants such as where one lives, economic security, housing quality and employment opportunities all play a key role in the development of such inequities. These limitations have been compounded by a historic lack of coordinated suicide prevention strategies by well-meaning organizations and agencies. So this begs the question, what is the VA system doing to prevent veteran suicide?
In 2004, the VA started to focus on deficits in its mental healthcare services and developed a VA Comprehensive Mental Health Strategic Plan to address identified problems and focused suicide prevention efforts beginning in 2007. Examples of outreach efforts are a 24/7 suicide prevention hotline where 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 deal with the immediate crisis. A written Chat Service at http://veteranscrisisline.net/Default.aspx and a texting service, at 838255, both of which connect those in crisis directly to mental health professionals is also available.
In addition, screening and assessment processes have been set up through the system to assist in the identification of patients at risk for suicide. The VA electronic medical record has a suicide risk flagging system that has been developed to assure continuity of care and enhance awareness among care-givers. Each VA medical center has a suicide prevention coordinator, whose job it is to ensure the Veteran, at risk, is connected to the right services and receives adequate followed up. Those identified as high risk receive an enhanced level of care, including missed appointment follow ups, safety planning and weekly follow up visits.
The relative recency of these efforts means their actual effectiveness in reducing suicide rates remains to be fully evaluated. Speaking from the viewpoint of a physician, who has worked in a variety of hospital systems from public to private, it is hard not to be impressed by the comprehensive nature of VA's current suicide prevention efforts. Furthermore, dedicated and well trained professionals continue to come up with thoughtful and innovative ways to tackle these tough problems head on.
Yet there has only been a slight decrease in suicide in VA treated veterans in recent years and this begs the question: Why does this goal of reducing suicide rates amongst Veterans (and, indeed, the general public also) remain so elusive?
Some of these reasons lie in the state of the science of suicide research. We have a lack of knowledge regarding the fundamental biological markers that could help us predict who will commit suicide. Risk of suicide is shared by biological, but not adoptive relatives, prompting the conclusion that familiality of suicide is due to genes rather than family environment or culture. Yet, despite gargantuan efforts on the part of psychiatric researchers, there is currently no suicide gene or genetic test that would be useful in predicting risk of suicidal behavior in any particular individual.
From an epidemiological standpoint, we know several clinical factors that are associated with increasing the odds someone will commit suicide. These factors include: having a mental illness; endorsing suicidal ideation; a prior history of a suicide attempt; a recent interpersonal loss; recent discharge from a psychiatric hospital and family history of suicide.Yet, with an overall rate of 11.3 American suicide deaths per 100,000 people, it is very hard to predict who will actually commit suicide as there are many people who have these clinical risk factors (i.e. the risks are common) but relatively few of these people will actually commit suicide. In short, the predictive validity of these clinical risk factors is poor. Add to this the reality that human beings are infinitely complex (and not just a sum of their clinical risk factors) means identifying under what exact circumstances, and at what point in time, a high risk individual may actually attempt suicide is seemingly impossible.
To complicate matters further a clinician cannot simply rely on a patient's denial of suicidal ideation when assessing suicide risk. The reality is a suicidal patient may not be inclined to admit their suicidality to a mental health professional for fear they will be forced into treatment or that this will result in their suicidal plans being challenged. This complicates the dynamic between caregiver and patient and regrettably means that even the most well meaning vigilant clinicians may not be able to identify a suicidal patient.
A Time Honored Tradition
Faced with the complexities and uncertainties surrounding the issues of veteran suicide, I find myself relying heavily on a time honored tradition of medicine—the power of a strong therapeutic alliance with my patient; the importance of creating an environment where they feel they can say whatever is on their mind and making it clear that, if things are not going well, I want to know about it. Creating such an environment is no easy feat as 21st century medical practice offers no end of distraction to the practicing physician: back to back clinic schedules; an electronic medical record that dishes up a steady stream of alerts, notifications and orders that require your continued visual attention; instant messages, email, texts and phone calls that ask you to make, in real time, clinical decisions and judgments and, of course, mounds of paperwork. In such an environment, I find listening—really listening– to my patient has become one of the most powerful things I can offer. Listening creates silent spaces that can be filled with a patient's expressions of their worst fears and deepest secrets, untainted by fabrication or distortion.
The Click
In my office, I watch the clock ticking on the wall. The second it hits 8AM, I pick up the phone and call Dave's cell phone number. The phone rings and rings, my heart sinks as I fear it is heading for voice mail, then skips a beat as it is picked up,
"Hi Dave, its Dr. Jain from the Palo Alto VA"
"Oh hi Doc,
"I know yesterday was a bad day for you, so I thought I would just check in."
"I am thinking you should come back to clinic in a week instead of next week; how does that sound?"
"Yes, I think that would be a good idea."
There it is—in his voice, what had been missing from clinic, an inflection in his tone, a subtle change but somehow reassuring—the click. He is listening to me and, perhaps more importantly, he knows I am listening to him— we are a team working toward a mutually agreed upon goal. I know this does not guarantee that there will not be troubled times ahead but, for now, this is enough.
The views expressed are those of the author and do not necessarily reflect the official policy or position of the Department of Veterans Affairs or the United States Government.
In an effort to protect individual patient privacy the patient stories depicted here are composites of various real encounters brought together to illustrate the situation.


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NASA kills GEMS X-ray telescope, blames project's cost (Update)
(AP) NASA killed a new X-ray telescope mission on Thursday, two years before its planned launch.
The Gravity and Extreme Magnetism Small Explorer mission, or GEMS for short, was supposed to blast off in 2014 to study black holes and neutron stars. But external reviews found the project would likely come in considerably over budget.
GEMS was selected under a strict cost cap, NASA officials said, unlike the price-busting James Webb Space Telescope to be launched in 2018.
"That cost cap is a very important aspect of the development of the project," said Paul Hertz, director of NASA's astrophysics division. Webb "is different."
Billions over budget and years behind schedule, Webb is NASA's largest science project and considered the successor to Hubble Space Telescope. Both Webb and GEMS are managed by Goddard Space Flight Center in Maryland.
Adjusted for inflation, GEMS was supposed to hold at $119 million, not counting the rocket, but independent reviews estimated the final cost at 20 percent to 30 percent above that, Hertz said.
Hertz said in a news conference that the technology needed for the instrument took longer to develop than expected, and that drove up the price.
It will cost NASA an estimated $13 million to close out the project, Hertz said. After adding in the money already spent on GEMS, the final tab for the space agency will be $50 million.
No rocket had yet been purchased for the mission, and the telescope itself had not yet been built.
A number of existing observatories can address some of GEMS' science questions, Hertz said, including the NuStar telescope due to lift off next week from Kwajalein Atoll in the Pacific.
Explore further
Copyright 2012 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

subset: commoncrawl


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Update, 1/16/09: Here are Bethesda's replies! Thanks for your questions.
As you might have gathered from our 2008 Game of the Year Awards, we here at GameSpy are big fans of Fallout 3. Bethesda's post-apocalyptic RPG was our favorite game of last year, so it's understandable that we're more than a little excited to check out Operation Anchorage, the first piece of downloadable content for the game. Available for the Xbox 360 and PC on January 27th, Operation Anchorage will tell the tale of the liberation of Anchorage, Alaska from the invading Chinese Communist forces. What better way to find out more about the DLC than by doing an interview with the team itself?
Rather than simply ask the developers our own questions, we thought it would be more fun to let you, our readers, do our work for us. So, if you've got some hard-hitting questions for the team at Bethesda, either pose them in the comment section below or head into this forum post to post them. We'll be choosing your ten best questions and running Bethesda's replies on Friday afternoon. Please limit your questions to the Operation: Anchorage DLC, as the team isn't quite ready to discuss the other content that will be available in the coming months. Ask away!


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FY08 Phase 8.1 (DNDO)
The Department of Homeland Security Domestic Nuclear Detection Office (DNDO) is involved in developing technology to examine cargo entering into the United States. There is a need to provide operators with a capability to nominate potential contra-band that are contained in the cargo conveyances. The proposed solutions should be in a stand-alone software package that can receive the x-ray data as files over standard computer interfaces and output the results as files over the same hardware interface. Threat materials can take many shapes and therefore an emphasis should be placed on anomaly detection instead of specific shape detection. Current state of the art in detection of contraband relies on human operators which can result in a high false positive rate. The goal is to maintain human operator performance in the detection of contraband and to reduce the false positive rate of the overall process (human operator and signal processing combined). The other need is to have the signal processing greatly reduce the time required to examine a truck or cargo conveyance image. The typical average time to examine a truck x-ray image is 2 to 3 minutes.
The Department of Homeland Security Domestic Nuclear Detection Office (DNDO) is involved in developing technology to examine cargo entering into the United States, sometimes using active interrogation (AI) or Non-Invasive Interrogation (NII). Active Interrogation imposes extra demands on the neutron and gamma detection systems in the way of speed, discrimination, robustness, and spectral capabilities. These performance parameters have to be achieved within reasonable cost and manufacturability. The objective is to develop solid-state neutron detectors which are capable of operating in active (as well as passive) interrogation environments. This requires fast (nsec or less) response times, robust radiation hardened detectors capable of operating in or near the interrogation beam, be it neutron or gamma ray, high gamma rejection and/or discrimination, low cost, and reliable manufacturability. High-efficiency and low-cost per unit area is the goal, but consideration will be given to lower efficiency if accompanied with very low fabrication costs per large area units. He-3 tube technology within appropriate enclosures should be the standard with which to compare for cost and efficiency. New materials and detector systems, or new methods of improving existing candidate materials and detectors, are sought.
The proposed research should emphasize advancements in the analytical techniques and instrumentation used in determining the origin and transit route of nuclear materials. These developments need to be applicable in providing assistance to law enforcement, federal, and international agencies responsible for oversight in the proliferation of these materials and in the identification of their origin. An emphasis is being given to identifying ways to improve instrumentation and techniques for the physical, chemical, radiological or morphological analysis of nuclear or radioactive materials and any associated materials. Applications include determination of the origins, transport and use of these materials as well as prevention of their use. Acceptable studies can emphasize improvements in existing methods and instrumentation for chemical and radiological characterization, as well as the development of novel, advanced approaches. Improvements in the separation or analysis of non-nuclear material associated with nuclear materials, as well as automation, are also considered to be within the scope of this work. In addition, research studies which identify ways to improve on current utilization of "signatures" which can be used to identify source materials in the nuclear fuel cycle are encouraged. Potential topics include, but are not limited to: 1) Field radiochemistry kit for rapid analysis and positive ID of interdicted materials by alpha spectrometry 2) Chemically reactive surfaces with specific affinity for actinide sorption for micro-scale chemical separations of actinides (useful for sample isotopic analysis by TIMS / age dating of U & Pu) 3) Devices capable of sorting particles, e.g., isolation of actinide particles from dust (such as density based separation) or isolation of biological particles (pollen, etc) from U or Pu oxides 4) Field collection kits for collecting biological samples (urine, blood, hair, etc) from individuals potentially involved in the handling / transport of a radioactive material 5) Improved device for separation / isolation of oxygen from U / Pu oxides for stable isotope analysis (current methods are limited due to incomplete extraction of oxygen and interference from background of local oxygen)
In the past few years Congress and various government agencies have recognized the problem of orphaned radioactive sources worldwide. Such sources pose a security risk in the form of potential material for a "dirty bomb" or for other illicit applications. This SBIR topic seeks replacements for existing operating radioactive sources in two areas: well logging, and medical applications. Specifically, this SBIR topic seeks alternatives to the Americium-Beryllium (AmBe) sources used in the well-logging industry and any medical application where sealed radioactive sources are currently being used. However, solutions that also offer benefit as potential replacements for sealed sources used in other industries (e.g., food irradiation, industrial thickness and liquid level gauging, etc.) would be desirable. Each of these applications may be accomplished by alternate techniques (not requiring radioactive materials) or alternate sources of radiation to accomplish the tasks at hand. These alternate sources or techniques must achieve the full capabilities of the existing systems, but not require the use of a radioactive material. New ideas are sought, not simply implementations of commercial off-the-shelf retrofits. They must be financially viable, adding little extra cost in instrumentation compared to the replaced source. Their size, weight, and power requirements must not be so onerous as to prevent their use under the conditions normally envisioned for the application. Lastly, they must be sufficiently robust to withstand the temperatures, pressures, humidity, vibration, and shock encountered in the typical operating environment for the application. Concepts which cross several applications are especially desired.


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I made this page using Jenni's new Quilt Star Punch which I used like a border punch. The punch is 1.5" wide so it's a great size. I used the new JBS Modern Mercantile line designed by Lisa Dickinson as well as a piece of blue paper from Wren. The light blue dot was an exclusive from the February Mercantile Main Kit. When I got these papers out, I knew I had the most perfect picture to use with them - a photo of my son standing in front of the stained glass window at church on Easter Sunday last year. Modern Mercantile is perfect for all kinds spring and summer stuff! It reminds me of green grass, sunshine, and blue skies.
This page is going in my Project Life album as the intro to the Easter Project Life pages I made using the February Mercantile kit.
Look how well these papers go together. From Wren I've used Blueprint. From Modern Mercantile I used: Hodge Podge, Patchwork, and Miscellany. After I had glued down the border strips I sewed over each of them with coordinating colored thread. I used white along the top of each row and then went back with the matching color down the center of the star row. When I used the white, I pulled extra thread out when I rotated the page without trimming it and beginning a new row so that when I went back with the colored thread it trapped strands of white thread. I love the way that ended up - kinda messy with a bit of added texture.
To ground the picture I cut banner tails in a strip from Fancy Checks and layered a printed tag, Vintage Flag, behind the photo.
Here's an example of how I made the quilt star border using cardstock. I grabbed these sheets from my scrap pile and took the punch and punched right along the edge of the paper. Don't worry about getting the spacing just right - once you get all those layers going it doesn't look like they're supposed to be perfectly aligned, in this case anyway, and it ends up looking rather charming with the imperfections. Then you simply lay one sheet on top of the next and glue them down.
To finish off the top of the page I punched the quilt star along an extra piece of the white dotted cardstock background to create a white on white border along the top. I trimmed and tucked the happy sticker under the white punched border. The dark yellow alpha stickers (Shadow Alpha Stickers) look so good with Modern Mercantile.
Happy St. Patrick's Day and happy crafting!