Homeless Vets

I have known and worked with way too many homeless veterans of various U.S. wars. But the one I remember best is a Vietnam veteran I call Jake. He became a patient of mine in the mid-1980s when I ran a clinic for the homeless in my hometown of Richmond, Virginia. I wrote about him in a chapter titled “Homeless Ghosts” from my 2016 medical memoir, Catching Homelessness: A Nurse’s Story of Falling Through the Safety Net. Even though our system of care for homeless veterans has improved since the 1980s, homelessness, post-traumatic stress disorder (PTSD), and suicide remain prevalent at alarming rates for our veterans. Below, I include the VA suicide prevention hotline, followed by an excerpt of my story of Jake.

*Where to Call for Help:
The Department of Veterans Affairs maintains a hotline for veterans in crisis that operates 24 hours a day. Call 1-800-273-8255 and press 1. Online, visit veteranscrisisline.net/chat, or send a text message to 838255.*

“Since I was seeing Jake regularly for wound care, over the next several months I got to know him better. He wasn’t talkative, but began offering more information, at least about his current life. There was something about the daily ritual of foot care and wound cleaning that nudged him to talk. I learned to modulate my questions with his moods, knowing when to gently probe and when to back off, when to be silent as he brooded. It was like falling into step beside him.

Jake told me about his pet crow named Blackie, how smart Blackie was, and what a good companion because she listened and didn’t talk back. “She had a hurt wing when I found her but she let me splint it. Healed up crooked but she’s real strong.” Insomnia and nightmares plagued him, so he stayed up most nights reading paperback novels by flashlight. Mysteries were his favorite as long as they didn’t involve much killing. He didn’t like sleeping outside because it reminded him of the war, so he stayed in his car, or in a vacant garage he’d found near the Hollywood cemetery on the edge of the river. He liked the quiet of the cemetery and was able to sleep better there. The ceiling of the garage had old glow-in-the-dark stars and he could see his way around at night by their light. Jake had been homeless off and on ever since he was discharged from the U.S. Army ten years ago: “I tried going home but it didn’t work out.” I didn’t press for details. His face closed down as he said it. Jake had a classic case of the recently named Post Traumatic Stress Disorder—PTSD. It had older names, including battle fatigue and shell shock. During the Civil War it had been called nostalgia or homesickness.

I knew about PTSD, but only in an abstract, clinical sense. At the time, I didn’t realize I would develop it myself. I wish I had known then what I know now about PTSD, how it festers and flares inside while leaving no visible scars. Maybe I could have done more to help Jake. Maybe I could have seen that his PTSD was more destructive than his leg wound.

What I would never know first hand was what it was like to be a chronically homeless war veteran. The media people liked to focus on this segment of the homeless population, the long-term disabled homeless, the large number of Vietnam vets who were on the streets. After the Vietnam War was finally over, people in the U.S. wanted to forget about it, but the presence of homeless vets on the streets wouldn’t allow them to.” pp. 89-91

Spring Blue(s)

Photo credit: Josephine Ensign, 2015

Why do spring and depression go together? The seasonality of illness is fascinating and is proof that our environment matters quite a lot to our individual and collective/public health. In temperate regions of the world, injuries and drownings go up in the warmer months, and deaths from influenza and carbon-monoxide poisoning go up in the colder months. These make sense. But when we think of depression and suicide risk, most of us would guess that these peak in the fall and winter months–what with decreased hours of sunlight and the stresses of some of the major holidays. In the U.S., September is National Suicide Prevention Month and October is National Depression Awareness Month, and many news reports continue to falsely link higher rates of depression and suicide with fall and early winter.

Yet studies worldwide find that depression and suicide rates peak in late spring and early summer. High pollen counts, increased hours of sunshine, higher temperatures, and even an increase in thunderstorms (ah–that Shakespearean pathetic fallacy!) have been linked to higher rates of depression and suicide. Within psychology and sociology circles, this seasonal link is theorized to be from the fact that people generally have increased social pressures and interactions in the spring, which can increase stress. (see “The Season of Renewal and Suicide” by Brian Palmer, Slate, 12-7-12).

The most current statistics from the CDC on the leading causes of death in the U.S. (for 2013), list suicide (intentional self-harm) as the tenth leading cause of death, with the total number of deaths by suicide as 41,149. (Suicide is the second leading cause of death for young people ages 15-24 years.) This continues the upward climb of suicide deaths in our country since the start of the Great Recession, with the largest increase being in people 45-64 years of age (peak wage-earning years.) With the possible exception of unintentional injuries, such as motor vehicle accidents, suicide is our most preventable form of mortality. And suicide deaths have serious impacts on the family members, friends, co-workers, and care providers who knew and loved the people who killed themselves. Note: they did not ‘commit’ suicide as is still too commonly used; suicide is not a crime or a sin–it is a preventable travesty. Using the term ‘commit suicide’ adds to the already debilitating stigma of mental illness.

So what are interventions that work to help prevent deaths by suicide?

1) Train healthcare providers to screen for depression, drug/alcohol use, bullying at school (for young people), history of adverse childhood events (especially sexual abuse), and suicidal ideation and attempts. In primary care screening for depression and suicide risk (as well as intimate-partner violence), a standard question is “Do you have access to a firearm?” This screening question seems so obvious, as access to a lethal weapon is an important part of the overall risk assessment. Over half of all deaths by suicide are by firearms. But now in Florida that healthcare screening question is illegal for physicians and nurses to ask their patients. (See James Hamblin’s 8-11-14 article in The Atlantic, “The Question Doctors Can’t Ask.” ) And other (mostly Southern, no surprise) states have similar legislative ‘healthcare gag orders’ pending.)

2) Educate the general public about the warning signs of severe depression, problematic drug/alcohol use, and suicide–and give them the proper tools to be able to intervene effectively. Reinforce the fact that talking about suicide in a supportive way does not encourage suicide (just as talking about sex or drug use with adolescents does not encourage them to have sex and use drugs.) An excellent (free and 24/7) resource is the National Suicide Prevention Hotline at 1-800-273-TALK (8255). They can connect people with local crisis centers and assistance.

3) Implement a community-wide public mental health promotion (and depression/suicide prevention) program. One such model program that is cost-effective and that could be replicated in the U.S., is New Zealand’s All Right? Wellbeing Campaign, a Healthy Christchurch project that is being led by the Mental Health Foundation and the Canterbury District Health Board. As they state, “All Right is a social marketing campaign designed to help us think about our mental health and wellbeing. It’s about helping people realise that they’re not alone, encouraging them to connect with others, and supporting them to boost their wellbeing.” Although targeted at earthquake recovery efforts in the Christchurch area, this public mental health campaign could be most effective at building community resilience before major disasters occur.

My students and I stumbled across the work of the All Right? Wellbeing Campaign while we were in Christchurch last year studying community health. I wrote about it in a series of blog posts, including “New Zealand Postcards: The Allrighties” 2-3-14. Some of our health-focused students ‘brought this home’ to Seattle and started the student-led “What’s Up UW?” community for promoting social and emotional wellbeing.

From the All Right? Wellbeing Campaign, Christchurch, New Zealand.