Suicide

1. Suicide CorieFerestad, Michael Pretz, Steven Coop

2. International Statistics • 5 million suicides worldwide since 2000 • 10-20 times as many suicide attempts than suicide deaths • In the last 45 years, suicide rates have increased by 60 percent in some countries. • Worldwide, suicide ranks among the three leading causes of death among those aged 15-44 years. World Health Organization

3. National Statistics • Suicides (2009) • 36,909 suicides • Rate= 12 • 1.5% of all deaths • 2.4% increase from 2008 • Highest rate in 15 years • Suicide ranked 10th cause of all deaths • Suicide Attempts (2009) • 922,725 annual attempts in the US • 25 attempts for every death by suicide • Between 20 and 50 percent of people who kill themselves had previously attempted suicide. Center for Disease Control and Prevention

4. Statistics of Methods • 2009 • Firearms- 18,735 (50.8%) • Suffocation/Hanging- 9,000 (24.4%) • Poisoning- 6,398 (17.3%) • Cut/pierce- 669 (1.8%) Center for Disease Control and Prevention

5. Types of Suicides • Due to a mental illness • Rational Suicide • Euthanasia and Physician-Assisted Suicide • Passive • Active • Voluntary • Involuntary (Gearing & Worchell, 2010)

6. Special Populations and Suicide • Gender • There are four male suicides for every female suicide, but three times as many females as males attempt suicide. (79% male and 21% female) • Rate of male suicide in 2009- 19.2 • Rate of female suicide in 2009- 5 • Age • Suicide is the fourth leading cause of death for adults between the ages of 18 and 65 years in the United States. • 5-14 rate .7 – lowest • 45-54 rate 19.3- highest • Race • European Americans are most likely to commit suicide • 32% white (rate- 13.5) • 29% native american or alaska native (12.3) • 15% asian or pacific islander (6.3) • 12% Hispanic (5.3) • 12% Black (rate-5.1) • Region • Montana rate- 22.5 (219/974,989) • District of Columbia rate- 4.8 (29/599,657) Center for Disease Control and Prevention

7. Mental Disorders and Suicide • Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death. • Depression • 2/3 who commit suicide are clinically depressed • 30% of depressed people attempt suicide • Bi-Polar • 25-50% of persons with this illness make at least one suicide attempt • The suicide rate in the first year off lithium treatment is 20 times thatduring treatment • During treatment an estimated 3-20% of persons diagnosed with bipolar disorder die by suicide • Schizophrenia • 20-40% of persons with schizophrenia make suicide attempts and 10% of individuals with schizophrenia eventually complete suicide. • Suicide is the number one cause of death for young people with schizophrenia Center for Disease Control and Prevention

8. Substance Use and Suicide • Lifetime mortality due to suicide in alcohol dependence is between 2.2% and 18% • 20-35% of completed suicides are committed by individuals with alcoholism • 24% of individuals with alcohol use disorder have attempted suicide • Lifetime prevalence for suicide ideation among heroin users is between 50-60% • Approximately 1/3 attempt suicide (Gearing & Worchel, 2010)

9. Suicide Assessment • Suicide is not a disorder • It is also possible that certain types of suicide are not indicative of a mental disorder (Gearing & Worchel, 2010)

10. Assessment • Sociodemographic data • Age • Gender • Race • Culture • Ethnicity • SES • Living situation • Current and past medical history • Substance use (Gearing & Worchel, 2010)

11. Assessment 2. Identified problem/symptom history • From a diagnosis to a specific problem of living 3. Current suicidality • Ideation • Intent • Plan/Planning • Feasibility • Lethality (help differentiate between parasuicide) • Timing • Impulsivity/aggression • Hopelessness (Gearing & Worchel, 2010)

12. Assessment 4. Risk Factors • Social • Environmental • Psychiatric • Individual 5. Protective Factors • Social • Environmental • Psychiatric • Individual 6. Suicide history 7. Family/peer suicide history (Gearing & Worchel, 2010)

13. Individual Factors That Increase Risk of Suicide • Employment- unemployed and retired persons • Marital Status- being single or divorced • Religion- Protestants are at higher risk • Family History- increases risk even beyond mental disorder • Living Alone- Isolation • Gun Ownership • Physical Disease • Feelings of Hopelessness • Recent Mental Hospitalization- first few days after release • Financial Difficulty • Heaving Gambling Losses • Talking about suicide • Suicide of Others • Prior Suicide Attempt (Morrison, 2007)

14. Protective Factors • Reasons for living • Social support and connectedness • Limited access to firearms • Marital status • Religious affiliation • Ethnicity (Gearing & Worchel, 2010)

15. Suicide Ideation • Warning Signs • IS PATH WARM • I-Ideation • S-Substance Abuse • P- Purposelessness • A-Anxiety • T-Trapped • H-Hopelessness • W-Withdrawal • A-Anger • R-Recklessness • M-Mood Changes • Fifty to 75 percent of all suicides give some warning of their intentions to a friend or family member AFSP.ORG

16. Case Study • Lt. Colonel Frank Slade: • Retired Army Officer • Complete Visual Impairment • Noticeable Alcohol use • Suicide Ideation Disclaimer: The video clips you are about to view contain foul language necessary to depict a realistic life event involving suicidal ideations.

17. Level of Risk • Absences of risk – Treatment based on clinical presentation and issues present • Low Risk – Outpatient referral may be acceptable • Moderate – Outpatient referral can be reasonable and psychopharmacological treatment may be needed to supplement outpatient psychotherapy • High Risk – Observation for up to 72 hours at the ER • Severe Risk – Admission to a psychiatric hospital is typically required (Gearing & Worchel, 2010)

18. Risk Factors • Lt. Coronel Frank Slade: • Retired • Single • Isolated • Gun ownership • Visually impaired • Hopeless • Talks about suicide • Alcoholic • Major depressive disorder

19. Treatment Considerations: More than 90 percent of people who kill themselves are suffering from one or more psychiatric disorders, including: • Major depression (especially when combined with alcohol and/or drug abuse) • Bipolar depression • Alcohol abuse and dependence • Drug abuse and dependence • Schizophrenia • Post Traumatic Stress Disorder (PTSD) • Eating disorders • Personality disorders (Gearing & Worchel, 2010)

20. Treatment Algorithm for Patients with Suicidal Ideations (Anil et al., 1999)

21. Treatment Options Three Options: • Hospitalization • Psychotherapy • Prescription Medications (Demyttenaere , 2001)

22. Treatment Options Hospitalization Treatment for an Acute Suicidal Crisis • Take the person to an emergency room or walk-in clinic at a psychiatric hospital. • If a psychiatric facility is unavailable, go to your nearest hospital or clinic. • If the above options are unavailable, call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255). (Brown et al., 2005)

23. Treatment Options Psychotherapy • Research shows that when it comes to treating depression, all therapy is NOT created equal. • Study shows applying correct techniques reduce suicide attempts by 50% over 18 month period • To be effective, psychotherapy must be: • Specifically designed to treat depression • Relatively short-term (10-16 weeks) • Structured (therapist should be able to give step-by-step treatment instructions that any other therapist can easily follow) • Examples: Cognitive Behavior Therapy (CBT), Interpersonal Therapy (IPT), Dialectical Behavior Therapy (DBT) (Brown et al., 2005)

24. Treatment Options Medications Adequate prescription treatment and monitoring is critical to ensure successful treatment of underlying psychiatric disorders associated with suicidal ideations. Commonly used Antidepressants: Prozac, Zoloft, Paxil, Luvox, Effexor, Serzone Commonly used anti-anxiety meds: Ativan, Serax, Restoril, Ambien Other medications: lithium (mood stabilizer), Abilify, Clozaril and Risperdal (anti-anxiety) Only 20% of medicated patients are adequately treated with prescription medications – possibly due to: • Side effects • Lack of improvement • Fear of drug dependency • Concomitant substance use • Didn't combine with psychotherapy • Dose of medication too high/low NOTE: Most antidepressants take 4-6 weeks to reach full potential and MAY result in increased suicidal ideations resulting from increased energy prior to reduction in depressive episodes. (Demyttenaere , 2001)

25. References • American Association of Suicidology . 2012. Fact Sheet and Statistics. 2012, May 15, http://www.suicidology.org/stats-and-tools/suicide-fact-sheets. • American Foundation for Suicide Prevention. 2012. About Suicide. 2012, May 15, http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_id=04EA1254-BD31- 1FA3C549D77E6CA6AA37. • Anil, K., Gliatto, F., & Rai, M. Evaluation and Treatment of Patients with Suicidal Ideation. Am FamPhysician. 1999 Mar 15;59(6):1500-1506 • Brown et al, Journal of the American Medical Association, 2005 • Center for Disease Control and Prevention. 2012. Suicide Prevention. 2012, May 15, http://www.cdc.gov/ViolencePrevention/suicide/index.html. • Demyttenaere K, et al, Journal of Clinical Psychiatry, 2001. • Gearing, R. & Worchell,D. (2010). Suicide Assessment and Treatment: Empirical and Evidence Based Practices. New York, NY. Springer Publishing Company. • Morrison, J. (2007). Diagnosis Made Easier: Principles and Techniques for Mental Health Clinicians. New York, NY: The Guilford Press • World Health Organization. 2012. Data and Statistics. 2012, May 15, http://www.who.int/research/en/.