Welcome!

1. Welcome! The QPR Suicide Triage Training Program Instructor:

2. QPR Suicide Triage Training Agenda • Introductions • Scope of the problem • Introduction to risk factors • Mental illness and suicide • Suicide Risk Rating Exercise • Lunch • Introduction to the QPR Triage protocol • Role plays and practice

3. Source of the QPR Suicide Triage Training Program • The QPR Suicide triage training program is derived from the QPRT Suicide Risk Management Inventory and training program used by thousands of healthcare professionals. • The foundation materials are identical and at the end of training you will know about suicide than most healthcare professionals. • Note: where you see or hear the word “patient” remember that the person you are trying to help out of a crisis may, or may not be, your patient.

4. Training goals • Describe the scope of the problem • Address social policy/impact on practice • Relationship of mental illness and substance abuse to suicide • Current status of suicide risk assessment • Learn how to determine immediate risk of suicide and what safety measures can be taken to reduce risk

5. General approach for today… • Emphasis is knowledge gain and skill acquisition verses interesting statistics • Teach a tested suicide risk assessment documentation protocol • Address strategies for immediate suicide risk reduction

6. From the Surgeon General “Suicide is our most preventable form of death.”

7. Why now? • National movement has begun… • National Strategy for Suicide Prevention • Public health is marketing “suicide is preventable” • Public expectations that suicide is a preventable form of death are rising

8. How big is the problem?Global Violence-Related Deaths • 1 million people die by suicide • 10-20 million attempt • Leading cause of death in 1/3 of all countries • 54% of all violence-related deaths • Global rates are climbing, esp. men More die by suicide each year than from all armed conflicts around the world

9. American Numbers(averaged over past 10 years) • 31,000 + die each year (39,000 in 2010) • Rate: 12 -15 per 100,000/Year • 105+ per day now (1 commercial jet per day) • One person every 15-20 minutes • Of these deaths • 4 X male completions to female • 3 X females to male attempts Suicide is no respecter of age, race, religion, social or economic status; its an equal opportunity mode of death.

10. Scope of the problem USA • Range: ideations, attempts, deaths • 31,483 completed suicides in US (2003) • US suicide rates are trending down, not rising • Exceptions: AI/NA youth are rising • Rates vary widely by race, gender, geography, ethnicity, but all deaths have commonalities Am. Journal of Public Health, McKeown, 2006

11. Big picture adult numbers • Think, plan, attempt, die • 10 million adults think about suicide each year • 1.2 million plan a method (gun, MVA, etc) • 750,000 attempt (minimum count). • Approximately 30,000 die • Suicide is 11th cause of death overall - 3rd for young people (rate has almost tripled since 1950s – unexpected upturn 2003-2004. - first for young people in some states source: National Co morbidity study, CDC and NIMH

12. American Numbers(averaged over past 10 years) • 31,000 + die each year • Rate: 11-12 per 100,000/Year • 80+ per day (1 commercial jet every other day) • One person every 15-20 minutes • Of the 31,000 deaths • 4 X male completions to female • 3 X females to male attempts Suicide is no respecter of age, race, religion, social or economic status; its an equal opportunity mode of death.

13. States with highest rates for past decade (not ordered) The following states have completed suicide rates above 15/100,000 Nevada - New Mexico – Montana – Wyoming – Colorado – Alaska – Idaho What do these states have in common?

14. States with the lowest rates for the past decade The following states (and DC) have completed suicide rates below 9/100,000 Rhode Island - California - Connecticut - District of Columbia - New Jersey – Massachusetts - New York What do these states have in common?

15. Would access to care save lives? • Over 90% of all people who die by suicide are suffering from a major psychiatric illness or substance abuse disorder, or both. • More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease, COMBINED. • Effective, accessible, competent care could save thousands of lives.

16. Intention and Suicide “There are ways of killing yourself without killing yourself.” Tony Manero, Saturday Night Fever, on the “suicide” of his friend. ILTB = Intentional life threatening behavior

17. Need for surveillance data • We really do not know the full scope of suicidal behaviors, self-inflicted injuries, risk-taking activities that lead to premature morbidity and mortality. • New! National Violent Death Surveillance System is now in place in 17 states and is collecting critical data on 50,000 violent deaths per year, including suicide. We do know where those identified end up…. In our care and we must do the best we can to keep them safe.

18. Suicide Attempt “Any potentially self-injurious action, with a nonfatal outcome, for which there is evidence, either explicit or implicit, that the individual intended to kill himself or herself.” From Carol, Berman, Maris, et. Al., Journal of Suicide and Life-Threatening Behavior, 1996

19. Lethality of Suicide Attempts Suicide attempts vary in lethality. Death can be an impossible result of some action, or almost a certainty. Smith et. al., The Menninger Foundation, scales from 1 to 10 (good inter rater reliability). Examples: 0.0 Death is an impossible result of “suicidal behavior,” e.g., light scratches to the skin Wounds that do not require suturing. Swallowing paper clips, coins, 10 or fewer aspirins or clearly ineffective acts which are shown to others.

20. Lethality of Attempt Scale • 3.5 Death is improbable so long as first aid is administered by victim or other agent. No effort to hide attempt. Rescue is likely. • 5.0 Death is a 50-50 probability directly or indirectly. Severe cutting with sizable blood loss. Hanging efforts with chance of discovery high. Vague drug overdose. • 7.0 Death is the probable outcome unless there is immediate and vigorous first aid or medical attention. Large doses drugs with fifth of whisky and suicide note. Hanging attempt, with patient found cyanotic. • 10.0 Death almost certain. Use of shotgun. Drowning self at midnight in a lake. Survival is accidental.

21. Suicide Attempts • Most don’t die in their attempt • Youth: 100 -200 attempts per 1 completion • Elder: 4 attempts per 1 completion • Average: 25 attempts per 1 completion • 5 million Americans have attempted (est.) • Reporting problem - under reporting - unknown (don’t ask, don’t tell)

22. Suicide and Homicide • More homicides or suicides per year in the US? • Is there any overlap between homicide and suicide?

23. Facts you Need to Know If a man calls, take him seriously, he may have a gun in his hand.. • Boys, teenaged boys, young men 18-25 • Highest tally of total death: men in middle years • Old white males are the highest risk group - 79% use a firearm (lethal planners) • They know how to do it and plan carefully • They avoid rescue “If a woman calls about a man, take her even more seriously.”

24. Our Older Veterans • 70% of older males are vets • Vet status adds suicide risk independent of any other problem • Of all psych problems, depression is self- or other reported in 50% of the suicides at time of death • Of these, only 22% were in care, 78% were not - ID and Rx MDD = saved lives!

25. Cold Sober Suicide Where alcohol and other drugs on board contribute to greatly to suicide risk in younger people, among men over 65 only 9% had a BAC greater than .8 Source:National Violent Death Surveillance System

26. Annie get your gun… In late life a firearm is the #1 method used by women….36% of all suicides, OD second. Now imagine a trend line into the future for our women warriors….

27. Facts you need to know… • Suicide risk rises with age for white males, not for men of color • Responsibility for one or more children is a powerful protective factor against suicide in women (Sweden) • Contact with a healthcare provider does not confer protection…. and neither does recent psychiatric hospitalization. • Most suicides occur with weeks to months of last contact AND risk rises after discharge!

28. Suicide Prevention is Violence Prevention DOMESTIC VIOLENCE, SUICIDE AND HOMICIDE * DV victims make more suicide attempts (20 to 26%). * Violent families contribute to youth suicide. * Violent people have a history of self-destructive behavior (30%). * Double suicides are often motivated by the couples fear of separation and the fantasy that they can remain together in death. * Abusive men who kill their wives and lovers usually do so in response to the woman’s attempt to leave.

29. Intimate Partner Violence • Males who threaten suicide in an intimate partner violence situation are at greater risk for murder-suicide. WSDVFR finding: “Abusers were suicidal in 35% of domestic violence fatalities overall (this includes cases where no homicide occurred), and in 31% of the cases in which a homicide was committed.” US AIR FORCE: • Suicide rate down 33%, • Homicide rate down 52% • Serious DV rate down 54% Suicide Prevention IS violence prevention!

30. Survivors of Suicide • 6 blood relatives directly affected by each suicide • 1 of every 62 of us is a survivor • This number does not include colleagues, co-workers, friends, team or school mates and ex spouses • One suicide every 18 minutes = 6 new survivors • Suicide risk is greater in survivors (e.g., 4-fold increase in children when a parent dies by suicide) • If 30,000+ Americans die by suicide each year leaving 180,000 blood relative survivors, how many have died by suicide since 9/11, and how many new survivors are there?

31. GOOD NEWS! • Research, medicine and political will are building • Stigma, funding, and lack of awareness remain • Leadership has emerged: NIMH, CDC, National Council for Suicide Prevention • U.S. Air Force success story is out • The majority of Americans believe we should fund more research and believe many suicides are preventable (SPANUSA research)

32. End Module Questions

33. Suicide Risk and Risk Management What you need to know….

34. Suicide Risk Assessment • Prediction is complex and difficult • Prognosis vs. prediction • Challenge of a low probability event • Behavior is threshold sensitive • Behavior is context sensitive • Behavior relationship sensitive • Summation of risk factors not helpful • Screening tools can get you in trouble (prediction is best done in reverse)

35. ENVIRONMENTAL RISK FACTORS Attempts Completions Seasonal Variations Unknown Jan-Feb, March Peak Weekly Unknown High Midweek Geography High on both Same War Unknown Inverse Unemployment: Chronic Unknown No Association Sudden Direct Direct * Source: Harvard School of Public Health, 1998

36. SUICIDE CRISIS EPISODE Risk Imminent Crisis Peaks Crisis Begins RISK LEVEL Crisis Diminishes Hazard Encountered Stable Stable Years Days Hours Days Years Plus or minus three weeks

37. THE LETHAL TRIAD UPSET PERSON FIREARM ALCOHOL When these three are present-the risk of violence is high.

38. The Many Paths to Suicide Cause of Death Acute (proximal) Risk Factors: triggers/last straw Fundamental (distal) Risk Factors Biological Crisis in Relation Poison Genetic Load Sex GLTB Loss of Freedom Gun Race Age Personal/Psychological Increasing Hopelessness Contemplation of Suicide as Solution Hanging Fired/ Expelled Values Religion Beliefs Drugs or Alcohol Culture Shock/ Shift Child Abuse Loss of Parent WALL OF RESISTANCE Illness Autocide Model for Suicide Environmental Urban vs. Rural Major Loss Geo-graphy Jumping Season of year ? ? • All “Causes” are real. • Hopelessness is the common pathway. • Break the chain anywhere = prevention.

39. Wall of Resistance to Suicide Duty to others Others? Counselor or therapist Fear Good health Medication Compliance Responsibility for children Job Security or Job Skills Support of significant other(s) Difficult Access to means Positive Self-esteem A sense of HOPE Religious Prohibition Calm Environment AA or NA Sponsor Pet(s) Best Friend(s) Safety Agreement Treatment Availability -- Sobriety -- Protective Factors

40. Nature of the suicide • Psychic suffering (Psycheache) • Hopelessness • Unbearable mental anguish • Cognitive constriction • Grossly impaired problem solving ability • Feeling a burden to others • Thwarted belongingness • Acquired capacity for self-injury

41. BASIC CONCEPTS ABOUT SUICIDE • Suicide is always multi-determined. • Suicide prevention must involve multiple approaches. • Most suicidal people do not want to die. • Suicidal people want to find a way to live. • Ambivalence exists until the moment of death. • The final decision rests with the individual. • Reduce risk factors and you reduce risk. • Enhance protective factors and you reduce risk.

42. The Relationship of Mental Illness and Substance Abuse to Suicide…

43. Preventing suicide is largely about identifying and treating mood disorders, alcoholism and co-occurring disorders • WHO aims to target: - Mood disorders - Schizophrenia - Alcoholism World evidence for treatment effectiveness suggests suicide rates can be substantially reduced in all these categories… if we can find them before they die

44. Is Suicide Primarily: “Mental Health Territory?” • Lifetime Suicide risk for Schizophrenic, Affective and Addiction Disorders: Method: review of 83 mortality studies: • Schizophrenia…………4% • Affective Disorders……6% • Addiction Disorders…...7% Inskip HM: Br J Psych 1998

45. Epidemiology: Interesting but not clinically useful… Suicide rates vary across cultures, racial groups, age groups, time and by geography. Major risk factors: Mental disorders, hopelessness, impulsive and/or aggressive tendencies, history of trauma or abuse, major physical illnesses, previous suicide attempt, family history of suicide, etc. (see NSSP for complete lists of risk and protective factors) What you need to know: 90-95% of all completed suicides have an Axis I disorder…BUT – most people with these illnesses DO NOT die by suicide.

46. General Neurobiology of Suicide • Reduced serotonin function in suicide, especially in suicides of high lethality or with considerable planning • Depletion of essential neurotransmitters (including dopamine and serotonin) may be the common clinical pathway for suicidal thinking, feeling and behaviors • Genetic studies inconclusive to date • Familial patterns of suicide suggest biological factors may influence risk. From Joseph Coyle, MD, Harvard Medical School, 1997

47. Specific neurobiological changes in severe suicidal depression • Loss of gray matter • Impaired prefrontal cortical response to serotonin release • Dopamine deficit • Serotonin hypofunction in the PFC correlates to higher suicidal intent and planning and lethality of suicide attempt

48. MDD AND SUICIDE • Lifetime risk: 2- 6% (lifetime risk) • 98 % of completers are seriously depressed • Most die while off medication. • Adherence to meds is essential to safety. • For severe, agitated and suicidal depressions, electroconvulsive therapy may be the best choice. • Family/patient education: MMD is a potentially fatal illness and death is a possible result of not following medical advise. • Benzodiazepines are often underutilized (more later)

49. Pharmacotherapy for depression • PET scan depicts a depressed patient’s brain prior to treatment, after successful treatment , scan reveals greatly increased activity in the prefrontal cortex

50. Warning, do not use the brain on the left to make a life or death decision….