Suicide: Risk assessment& treatment.

1. Suicide: Risk assessment& treatment. By: Sara E. Johnson, LMSW August 17, 2013

2. This is not an easy field to be in, nor an easy topic to talk about… It’s a bigger problem than most people can ever know. What motivates me is that it “takes a village.” Just imagine what it is like for a person who is suffering right now. If not us (to take action) who…if not now, when? — Conference participant 1

3. Definitions • SuicideDeath caused by self-directed injurious behavior with any intent to die as a result of the behavior. • Suicide attemptA non-fatal self-directed potentially injurious behavior with any intent to die as a result of the behavior. A suicide attempt may or may not result in injury. • Suicidal ideationThinking about, considering, or planning for suicide. 2

4. suicide Suicide is the tenth leading cause of death in the U.S in 2010/2011. Intentional self-harm (suicide): 38,364 3 • That’s 105 suicides a day.

5. Statistics • Someone dies by suicide every 15 minutes. In 2007, more than 34,000 Americans took their own lives. • Suicide is the third leading cause of death among 15- to 24-year-olds. • The fourth leading cause among 25- to 44-year-olds • The eighth leading cause among 45- to 64-year-olds. • Death rates are highest for people between the ages of 45 and 54 (about 17 per 100,000). • Women in the 45 to 54 age group are at greater risk for suicide • Men over the age of 75 are at greatest risk. 2

6. Populations

7. American Indian/Alaskan Native • During 2005–2009, the highest suicide rates were among American Indian/Alaskan Native males with 27.61 suicides per 100,000 and Non-Hispanic White males with 25.96 suicides per 100,000. • Of all female race/ethnicity groups, the American Indian/Alaskan Natives and Non-Hispanic Whites had the highest rates with 7.87 and 6.71 suicides per 100,000, respectively. • The Asian/Pacific Islanders had the lowest suicide rates among males while the Non-Hispanic Blacks had the lowest suicide rate among females. 2

8. American Indian/Alaskan Native • • When compared with other racial and ethnic groups, American Indian/Alaska Native youth have more serious problems with mental health disorders related to suicide, such as anxiety, substance abuse, and depression.4 • • Mental health services are not easily accessible to American Indians and Alaska Natives, due to: • Lack of funding. • Culturally inappropriate services. • Mental health professional shortages and high turnover. 3

9. Children • Children ages 10 to 14 — 0.9 per 100,0005 • Adolescents ages 15 to 19 — 6.9 per 100,0005 • Young adults ages 20 to 24 — 12.7 per 100,0005 • As in the general population, young people were much more likely to use firearms, suffocation, and poisoning than other methods of suicide.5 • Adolescents and young adults were more likely to use firearms than suffocation, children were dramatically more likely to use suffocation.6 • Nearly five times as many males as females ages 15 to 19 died by suicide.6 • Just under six times as many males as females ages 20 to 24 died by suicide.6

10. Geriatrics • Of every 100,000 people ages 65 and older, 14.3 died by suicide in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population. 6 • Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000.6 • Suicide rates increase with age. Elderly people who die by suicide are often divorced or widowed and suffering from a physical illness. The percentage of elderly people who die by suicide is greater than the percentage of elderly people in the population.7

11. Suicide Attempts • More people survive suicide attempts than actually die .1 • There is one suicide for every 25 attempted suicides.3 • In 2011, 487,700 people were treated in emergency departments for self-inflicted injuries.1 • More than 1 million people reported making a suicide attempt in the past year.2 • More than 2 million adults reported thinking about suicide in the past year.2 • Most people who engage in suicidal behavior never seek health services.2

12. Cost • In the United States, the annual economic, indirect cost of mental illnesses is estimated to be $79 billion ($63 billion in lost productivity, $12 billion in mortality costs, and $4 billion in productivity losses for incarcerated individuals and for the time of those who provide family care). The Suicide Prevention Resource Center (SPRC) has calculated the financial cost of each completed and attempted suicide at $4,000 and $9,000 per case, respectively.* *Source: National Strategy for Suicide Prevention, Harris & Barraclough, 1997.8

13. How People Attempt.

15. Fire arms • Suicidal people act impulsively. • 5 minutes is the time passed between the time a person decided to complete suicide and when they actually attempted suicide. 9 • A fire arm allows for quick, immediate, and permanent solution to a temporary thought.

16. Behaviors that may indicate a risk to harm self. • Performing poorly at work or school • Acting recklessly or engaging in risky activities—seemingly without thinking. • Showing violent behavior such as punching holes in walls, getting into fights or self-destructive violence; feeling rage or uncontrolled anger or seeking revenge. • Looking as though one has a “death wish,” tempting fate by taking risks that could lead to death, such as driving fast or running red lights • Giving away prized possessions. • Hopelessness • Impulsive and/or aggressive tendencies • History of trauma or abuse

17. Major physical illnesses • Previous suicide attempt • Family history of suicide • Job or financial loss • Loss of relationship • Easy access to lethal means* • Local clusters of suicide • Lack of social support and sense of isolation • Stigma* associated with asking for help • Lack of health care, especially mental health and substance abuse treatment. • Cultural and religious beliefs, such as the belief that suicide is a noble resolution of a. • personal dilemma • Exposure to others who have died by suicide (in real life or via the media and Internet).

18. Diagnoses that are at higher risk • Ninety percent of people who die by suicide have a mental disorder at the time of their deaths. 10 • Mental disorders, particularly mood disorders, schizophrenia, anxiety disorders and certain personality disorders. • The suicide rate of people with major depression is eight times that of the general population; there also is a strong association between trauma and suicide (attempts and completions). 7 • Alcohol and other substance use disorders • Based on data about suicides in 16 National Violent Death Reporting System states in 2009, 33.3% of suicide decedents tested positive for alcohol, 23% for antidepressants, and 20.8% for opiates, including heroin and prescription pain killers.2

19. Treatment for non-emergancy situations • Psychotherapy. • Cognitive behavior therapy for suicide attempters CBT- for suicide attempters. • Dialectical behavioral therapy DBT for patients with borderline personality disorder and recurrent suicidal ideation and behaviors. 10 • Medications. • Antidepressants, antipsychotic medications, anti-anxiety medications and other medications for mental illness can help reduce symptoms, which can help you feel less suicidal. • What is the only medication approved by the FDA that is shown to help reduce the risk of suicide in schizophrenic patients? Clozapine • True or false is there data supporting suicide reduction in patients taking Lithium? False10 • Addiction treatment.. • Family support and education.

20. What is a crisis? • The person is threatening, talking about, or making specific plans for suicide. 10

21. What to listen for. • A person may not come out and say they are suicidal, or want to die. Listen for statements that are indirect. Such as: • “I just want the pain to end.” • “I can’t see any way out.” • “Maybe my family would be better off without me.” • Things would be easier if I wasn’t around.” • “At least they would get the insurance money.”

22. What to do in a crisis. • Stay with the person. Do not leave the person alone. If they are over the phone do not hang up or put them on hold unless you are able to confirm that there is another trained professional on the other line, or in person. • Safety first! Remove all weapons-sharps, fire arms, ect. • Get the person to an emergency facility, such as a psychiatric hospital or emergency room. • Call 911 • Call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for assistance. • If at a place of employment follow there policy and procedures. • Avoid pleading and preaching to them with statements such as, “You have so much to live for,” or “Your suicide will hurt your family.” 10

23. Talking about “it” is not going to give them suicidal thoughts. • Don’t be afraid to be direct. • Don’t be afraid to ask questions. • Common questions you can ask. • How are you coping with what's been happening in your life? • Do you ever feel like just giving up? • Are you thinking about dying? • Are you thinking about hurting yourself? • Are you thinking about suicide? • Have you thought about how you would do it? • Do you know when you would do it? • Do you have the means to do it?

24. Get details. Asking about suicidal thoughts or feelings won't push someone into doing something self-destructive. In fact, offering an opportunity to talk about feelings may reduce the risk of acting on suicidal feelings. 11 FACT: Most people feel uncomfortable talking about suicide. 2

25. Follow up • Check back in with the person. • How are they doing? • What supports can you assist in finding? • Safety plan • “Being given a treatment plan and not being a partner in the treatment planning doesn’t work; plus…we need a recovery plan, not a treatment plan”. 7

26. Review • Identify suicidal statements. • I wish I could go to sleep and never wake up. • Be direct. • It sounds like things may be difficult for you, are you having thoughts of wanting to harm yourself. • Be empathetic, let them know you are concerned. • Get specifics. • How would you harm yourself? • Make a safety plan to help reduce risk (details, details details). • Who can they call for support. Who is there to support. Who will remove the means. What will the person do if the thoughts are persistent? • Follow up.

27. Tools • http://www.veteranscrisisline.net/SignsOfCrisis/Identifying.aspx • http://training.sprc.org/mod/scorm/player.php?scoid=6&cm=92&currentorg=Counseling_on_Access_to_Lethal_Means_ORG&display=popup • http://www.suicidology.org/c/document_library/get_file?folderId=229&name=DLFE-73.pdf

29. References • http://store.samhsa.gov/shin/content/SMA10-4589/SMA10-4589.pdf • http://www.cdc.gov/ViolencePrevention/pdf/Suicide-FactSheet-a.pdf • http://www.sprc.org/sites/sprc.org/files/library/ai.an.facts.pdf • http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtm • http://www.nimh.nih.gov/health/publications/suicide-in-the-us-statistics-and-prevention/index.shtml • Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS): www.cdc.gov/ncipc/wisqars • http://store.samhsa.gov/shin/content/SMA10-4589/SMA10-4589.pdf • http://download.ncadi.samhsa.gov/ken/pdf/SMA01-3517.pd • http://www.hsph.harvard.edu/means-matter/means-matter/impulsivity/ • http://www.afsp.org/preventing-suicide/treatment • http://www.mayoclinic.com/health/suicide/MH00058 • http://www.cdc.gov/nchs/fastats/lcod.htm • http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf