Alan Q. Radke, M.D., M.P.H. State Medical Director Minnesota Department of Human Services

1. SUICIDE PREVENTION EFFORTS FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS:ROLES FOR THE STATE MENTAL HEALTH AUTHORITY Alan Q. Radke, M.D., M.P.H. State Medical Director Minnesota Department of Human Services

2. ACKNOWLEGEMENT • NASMHPD Medical Directors’ Council • Suicide Prevention Resource Center • Suicide Prevention Action Network USA • National Suicide Prevention Lifeline • National Mental Health Association • Department of Veterans Affairs • SAMHSA/CMHS

3. CONSIDERATIONS • Suicide prevention strategies for individuals with SMI • Person-centered prevention approach • SMI population heterogeneity

4. SCOPE • Understanding the characteristics & dynamics of individuals with SMI who attempt or die by suicide; • Considering improvements to suicide prevention activities through the SMHA; • Applying person-centered approaches to suicide prevention; • Adopting a conceptual model for use by the SMHA to improve care.

5. EPIDEMIOLOGY • 32, 439 deaths by suicide in the U.S. in 2004. • Eleventh cause of death in the U.S. • 1 person every 16.2 minutes dies by suicide. • 324,000 treated in ED for deliberate self-harm. • 90,000 hospitalized following a suicide attempt.

6. EPIDEMIOLOGYContinued • Between 811,000 and 1.8 million suicide attempts per year. • 1 out of 65 Americans is a “survivor”. • Over 90% of individuals who die by suicide have a significant psychiatric illness. • $25 Billion impact to the U.S. economy for deaths and injuries associated with suicidal behavior.

7. FOCUS POPULATION • Individuals with Serious Mental Illness. • Recurrent Major Depression • Schizophrenia and Other Psychotic Disorders • Bipolar Disorder • Borderline Personality Disorder • 17.5 Million adults in the U.S. have SMI.

8. SUICIDE RISKPERSONS WITH SMI People with SMI have a higher risk of suicide attempt and death by suicide. • Suicide Attempts: • 30% - Major Depression • 25 to 50% - Bipolar Disorder; and • 20 to 40% - Schizophrenia • Deaths by Suicide: • 3 to 20% - Bipolar Disorder; and • 10% - Schizophrenia

9. CONSUMER & SURVIVORPERSPECTIVES • Consumers call for: • Better training; • Enhanced treatment for shame and humiliation; • Address concerns of possible long term disability; • Nurturing spiritual concerns; • Creating creative, meaningful connections with others; and • Developing peer support groups.

10. CONSUMER & SURVIVORPERSPECTIVES • Survivors call for: • Better education on available resources; • Enhanced treatment for grief; • Open communication with providers; and • Developing peer support groups.

11. National Response Methods • Surgeon General’s Call. • DHHS’ National Strategy for Suicide Prevention • NASMHPD recommendation to SMHA and position statement on mental health promotion and mental illness prevention

12. Service Delivery Systems • The National Suicide Prevention Lifeline (1-800-273-TALK) • Suicide Prevention Task Forces • Emergency Departments • Inpatient Care • Primary Care • Risk Factors & Management

13. CONCLUSIONS AND RECOMMENDATIONS 1: Suicide is a serious, but preventable public health threat that requires high profile recognition at the state level, and a high priority on the state health agenda.

14. CONCLUSIONS AND RECOMMENDATIONS 1.1: The Governors of each state should appoint a state advisory council to advance suicide prevention.

15. Conclusions and Recommendations Continued 2: Persons with SMI carry a significantly elevated risk for suicidal behaviors. The SMHA has responsibility for providing mental health services to people with SMI, and in that position, is ideally positioned to lead suicide prevention efforts for this sub-population. Access to effective mental health services for people with SMI can prevent substantial morbidity and mortality associated with suicide attempts and deaths by suicide.

16. Conclusions and Recommendations Continued 2.1: SMHA, working closely with other principles on the state suicide prevention advisory council, ensure suicide prevention programs and practices are in place for persons with SMI.

17. Conclusions and Recommendations Continued 3: Suicidal individuals with SMI can benefit from a robust continuum of care that extends beyond the boundaries of the traditional physical health and mental health care systems. Crisis hotlines have been shown to provide effective services to individuals seriously contemplating suicide and are available to all regardless of geographical barriers, timely access or ability to pay.

18. Conclusions and Recommendations Continued 3.1: The public mental health system should support and collaborate with crisis hotlines to ensure individuals at risk for suicide, including those who have made a suicide attempt, can readily access high quality crisis support services.

19. Conclusions and Recommendations Continued 4: Poor communication and lack of information sharing between social service agencies, law enforcement, justice, education, physical health care providers and mental health care providers and others hinders suicide prevention efforts for persons with SMI.

20. Conclusions and Recommendations Continued 4.1: The SMHA and the SHA should lead efforts improve collaboration, information sharing and surveillance between and among systems of care for all persons and promote use of standard terminology.

21. Conclusions and Recommendations Continued 5: Inadequate continuity of care, especially after discharge from emergency departments and inpatient psychiatry units contributes to significant suicide-related morbidity and mortality.

22. Conclusions and Recommendations Continued 5.1: The SMHA, in collaboration with the SHA, should initiate policies and practices that promote improved continuity of care for suicidal individuals following discharge from emergency departments and inpatient psychiatric hospitalizations.

23. Conclusions and Recommendations Continued 6: Suicide risk often goes undetected, even though suicidal individuals frequently seek and receive medical care in primary care settings. Screening of persons with depression and substance abuse in primary care settings can identify individuals at elevated risk for suicide and expedite their referral for definitive evaluation and treatment.

24. Conclusions and Recommendations Continued 6.1: The SMHA, in collaboration with the SHA, should require screening for suicide risk at all primary care appointments for those individuals who exhibit risk factors such as depression or substance abuse.

25. Conclusions and Recommendations Continued 7: Individuals who have access to lethal means of suicide have been shown to have higher rates of suicide.

26. Conclusions and Recommendations Continued 7.1: The SMHA, in collaboration with the SHA, should develop and implement strategies to reduce access to lethal means of suicide.

27. Conclusions and Recommendations Continued 8: Members of the general public, and especially consumers and their families, are unaware of suicide’s toll on society and the heightened risk of suicide carried by many consumers. Increasing awareness of suicide among consumers and their families and reducing the social stigma, shame and humiliation associated with being a consumer are key elements of comprehensive suicide prevention.

28. Conclusions and Recommendations Continued 8.1: The SMHA, in collaboration with the SHA, should strengthen psycho-educational programs in communities and for at-risk populations. Objectives should include eliminating stigma associated with mental illness, care seeking, and recovery from a suicide attempt.

29. Conclusions and Recommendations Continued 9: Specific treatments for certain mental illnesses can significantly reduce suicidal behavior. Access to these treatments inadequate and must be improved.

30. Conclusions and Recommendations Continued 9.1: The SMHA, in collaboration with the SHA, should develop and promote new models for providing evidence-based services over the life course for those who have attempted suicide, particularly for those who have made multiple or medically serious suicide attempts.

31. Conclusions and Recommendations Continued 9.2: The SMHA should implement strategies to provide training of mental health services providers in evidence-based practices that reduce rates of suicidal behaviors among people with SMI.

32. Conclusions and Recommendations Continued 10: Funding for suicide prevention, intervention and research is disproportionately low when compared to other serious health threats. Increased public and private funding is necessary to make systematic improvements to the health care and social service systems that serve those at the highest risk for suicide, persons with SMI.

33. Conclusions and Recommendations Continued 10.1: NASMHPD should increase its efforts to advance suicide prevention through its work in the state and federal policy arenas.

34. BOTTOM LINE • People with SMI are a high risk population • Fragmented, discontinuous system of care • SMHA must be the leader • Proactive suicide prevention

35. QUESTIONS AND CONCERNS