Suicide in America

1. Suicide in America “Suicide is a national public health problem.” David Satcher, M.D. Surgeon General of the United States

2. How Big is the Problem? • World Health Organization -1999: one million died by suicide - by 2020: 1.5 million will die by suicide - in the top 10 causes of death in every country • International Association for Suicide Prevention: - 814,000 per year in 1999 - 60% increase is past 5 years • Everyone agrees even these conflicting numbers are conservative

3. American Numbers2002 Data • 31, 655 in 2002 • Rate: 11.0 per 100,000 • 87 per day (one commercial jet every other day) • One person every 17 minutes • Of the 31,655 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.

4. 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

5. 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)

6. 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.

7. 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.

8. 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.

9. 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)

10. Survivors of Suicide • 6 blood relatives directly affected by each suicide • 4.4 million Americans since 1975 • 1 of every 62 of us is a survivor (4.4 million) • This number does not include colleagues, co-workers, friends, team or school mates and ex spouses • If there is a suicide every 18 minutes, there are 6 new survivors every 18 minutes • Suicide risk is greater in survivors (e.g., 4-fold increase in children when a parent dies by suicide) • 175,000 new survivors in 1999 --- the pain gets around ---

11. QPR for Suicide Prevention So long as suicide remains a mystery, we have no responsibility to prevent it. But once we begin to understand suicide, we must act boldly in good faith to save lives. The QPR Institute Staff and Faculty

12. 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.

13. 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)

14. ENVIRONMENTAL FACTORS Attempts Completions Seasonal Variations Unknown January through May 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

15. 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

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

17. Putting it all Together…. • The following slides conceptualize: - the relationship of risk factors to suicide - the role of events precipitating crises - the role of hopelessness - the selection of a means of suicide - the role of protective factors in suicide

18. The Many Paths to Suicide Cause of Death Proximal Risk Factors “Triggers or Final Straws” Fundamental 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.

19. 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

20. Saving Lives * When we reduce risk factors, we reduce suicide risk. * When we increase protective factors, we reduce suicide risk. How do we do this? To save lives we must do both! Examples?

21. NEUROBIOLOGY OF SUICIDE • Familial patterns of suicide suggest biological factors may influence risk. • Low HIAA has been found in severe suicidal depressions. • Research suggest reduced serotonin function in suicide, especially in suicides of high lethality or with considerable planning. • Increasing evidence depletion of essential neurotransmitters, including dopamine and serotonin, may be the common clinical pathway for suicidal thinking, feeling and behaviors. • Life history, culture, attitude and various forms of psychopathology, probably outweigh potential genetic determinants. From Joseph Coyle, MD, Harvard Medical School, 1997

22. MDD AND SUICIDE • Lifetime risk roughly 2- 6% (lifetime risk) • 98 % of completed suicides are seriously depressed(aggressive rx is indicated). • Most suicide attempts take place when person is off antidepressant medication. • Compliance/adherence is essential to safety. • For severe, agitated and suicidal depressions, electrocon-vulsive therapy may be the best choice. • Patient education: death is a possible result of discontinuing medications. • Benzodiazapines are often under used in anxious/agitated suicidal depressions.

23. BIPOLAR DISORDER & SUICIDE • #1 cause of death, 1-2% per year. • 30 studies 9-46% x = 19%. • Attempts • Major Depressive Disorder = 20% • Bipolar Disorder = 25%-50% • General Population = 1% • Highest risk windows • Early in illness • In denial phase • During mixed states • While experiencing depressive mania • Lithium has pronounced anti-suicide effect. • Lithium works best for those who won’t take it. • Lithium appears to decrease aggression and impulsivity. • Psychotherapy and mood stabilizers prevent suicide better than mood stabilizers alone. K. R. Jamison, 1997 John Hopkins University

24. SUICIDE AND SCHIZOPHRENIA M.T. Tsuang, MD, Harvard Medical School, 1998 • Ten to 15% complete suicide. • High-risk years: ages 15 to 40 • Clozapine responders often realize they have lost 20 to 30 years of life, resulting in acute depression, despair and elevated suicide risk. • Negative symptoms for schizophrenia lead to hopelessness and increased risk. • Finland National Study (1997) - 7% of all suicides met DSM-IV criteria for schizophrenia (N=92). Of these 92, 64 were also depressed. • Twenty to 40% make a suicide attempt.

25. Suicide and Schizophrenia Cont. • Inadequate pharmacotherapy contributes to higher suicide rates for schizophrenics. • Major risk factors: young age, early stage of illness, substance abuse present, college education, multiple episodes of psychosis, living alone, historyof previous attempt. • Improving on medications is the most dangerous time. • Suicides occur after discharge and in the first year of follow-up from index illness.

26. SUBSTANCE ABUSE AND SUICIDE • Lifetime risk for alcoholics: 7%. • Fifteen percent to 25% of all suicides by alcoholics. • Major risk factors: male, long-term drinker, comorbid psychiatric disorder. • Highest risk group: depression and alcoholism. • Links to suicide: poor judgment, impulsiveness, aggressiveness; loss of job, health, home, money. • State variable (intoxication) associated with at least 50% of all suicides. • Alcohol myopia. Sources: NIMH, Dying for a Drink, BMJ Oct 2001

27. FIVE ACUTE SUICIDE RISK FACTORS • Severe psychic anxiety/turmoil • Incessant rumination • Global insomnia • Delusions of gloom and doom • Recent alcohol use (with or without alcoholism) • Jan Fawcett, M.D., 1997 (replicated in 2003 with 76 inpatient deaths)

28. DISEASE MANAGEMENT MODEL FOR SUICIDAL PATIENTS PSYCHIATRIC COMORBID TRANSIENT ILLNESSPSYCHOLOGICAL STATES Schizophrenia Agitation Depressive Disorder Perturbation Bipolar Disorder Psychic Pain Panic Disorder Hopelessness Substance Abuse Disorder Dopamine Deficit Personality Disorder Serotonin Deficit Comorbid Physical Illness Alcohol Myopia WALL OF RESISTANCE SUICIDAL BEHAVIORS

29. Common Chemical Pathways for Suicidal Acts? Alcohol in the bloodstream Low serotonin levels Impaired dopamine function

30. Implications for prevention • WHO 2001 effective depression RX = 52%. If 50% of depressives got good care the rate impact would be a 7.8% reduction from 15.1/100,000 to 13.9/100,000 (thousands of lives) • If alcohol-related disorders were found and treated with 30% effectiveness (WHO), rate would drop 2.6% - from 15.1 to 14.6/100,000 • Schizophrenia (78% effective) = 15.1 to 13.7 • Personality disorders (no Rx effectiveness estimates)

31. Needed? • Numbers of lives saved is not “particularly impressive.” • Best case outcome for Rx of all disorders: 15.1 to 12.0 • To save lives we cannot focus more broadly - find the folks (gatekeeper training) - reduce stigma and link untreated illness to suicide - improve Rx effectiveness - not rely only on drugs (e.g. SSRIs have questionable effect and do not address psychosocial variables • Reduce exposure to serious stressors that lead to gene changes and vulnerability to psychiatric illness

32. MALPRACTICE Duty Dereliction Direct Causation Damages The Best Defense The Worst Defense Sloppy Work Loses

33. NATURE OF CLAIM • Where did the suicide occur? • Outpatient? • Should have been in the hospital. Inpatient? • Should have been monitored more closely. After discharge? • Should not have been discharged. On escape status? • Should not have escaped or should have been found sooner. After outpatient termination? • Questionable termination. T. Guthiel, MD, 1997

34. MALPRACTICE ERRORS • Type 1: Failure to detect risk • Type 2: Substandard care • Type 3: Postvention failure “An uninformed family is a potentially litigious one -especially if not comforted after the suicide.”

35. Avoid suicide malpractice every time! • Get appropriate training and keep records of same • Routinely query about suicide risk • Document your risk assessment • Carry out a “best practices” treatment plan • Team up and chart • Document why you did what you did, and why you didn’t do something even your mother would think you should do.

36. CURRENT THINKING ON SUICIDE AND RISK • The greater the number of losses, the greater the risk. • Personally humiliating events. • No good evidence for sexual orientation as an independent risk factor for suicide. • Treatment prevents suicide. • Eve Morscicki, NIMH, 1997

37. CURRENT STATUS OF SUICIDE RISK ASSESSMENT • National Survey: Almost all clinicians rely on clinical interview (Jobes, Eyman & Yufi, 1995). • No known test will predict suicide. • Beck Hopelessness Scale. • Screening inventories. • Risk detection is job one. • 75% of suicides see a physician within a week to a month before their death.

38. CURRENT STATUS OF SUICIDE RISK ASSESSMENT • Current methods produce large numbers of false positives. • No known method to identify those few who complete suicide. • Summation of risk factor approach: -not clinically useful -too nonspecific to be helpful -inefficient and weak in predicting individual suicide • 67% - 91% of completers made no previous attempt (Coe, 1963 & Dorpat, 1960).

39. End Module Always do better on the competency quiz that the lawyer who is suing you…..

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