H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment

1. North Dakota Conference on Injury Prevention & Control “Co-occurring Substance Abuse and Mental Disorders & Suicide” October 29, 2008 Mandan, ND H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services

2. President George W. Bush “…above all, our efforts rest on an unwavering commitment to stop drug use. Acceptance of drug use is simply not an option...” May 2001 2

3. Substance Abuse and Mental Health Services Administration/CSAT • SAMHSA’s Mission: • To build resilience and facilitate recovery for people with or at risk for substance abuse and mental illness. • Center for Substance Abuse Treatment (CSAT) Mission: • To improve the health of the nation by bringing effective alcohol and drug treatment to every community.

4. SAMHSA Matrix of Priorities • Suicide prevention and Co-occurring Disorders are two of SAMHSA’s priorities.

5. The Issue… • Every 18 minutes another life is lost to suicide – totaling more than 32,000 Americans each year. • That equals 89 suicides each day or 1 suicide every 16 minutes. • In 2006, 162,359 people were hospitalized due to self-inflicted injury. • Suicide is now the 11th leading cause of death in Americans. • Many who attempt suicide never seek professional care. Source: National Strategy for Suicide Prevention web site & CDC

6. U.S. Suicide Rate is Up • According to a new study, the U.S. suicide rate rose to 11 per 100,000 people in 2005 – an increase of almost 5% since 1999. • The greatest impact was attributable to a nearly 16% jump in suicides among people aged 40 to 64. Within that age group, from 1999 to 2005: • Suicides for whites rose 17%. • The rate for middle-aged white men rose 16%. • For middle-aged white women, the rate rose 19%. • The suicide rate for middle-aged African Americans rose 7% Source: Baker, S.A. et al (in press) Mid-life suicide: An increasing problem in U.S. whites. 1999-2005, American Journal of Preventive Medicine

7. Possible Influencers in Rate Increase • Although the reason for the increase is not clear, one possibility is a tie to a concurrent increase in abuse of prescription pain pills – such as OxyContin. • Another explanation might be the drop in hormone replacement therapy due to health risks, since women who gave up the drugs might be more susceptible to depression. Source: Baker, S.A. et al (in press) Mid-life suicide: An increasing problem in U.S. whites. 1999-2005, American Journal of Preventive Medicine

8. Trends in U.S. Suicide Mortality by Method Source: Baker, S.A. et al (in press) Mid-life suicide: An increasing problem in U.S. whites. 1999-2005, American Journal of Preventive Medicine

9. Trends in U.S. Suicide Mortality by Method • Suicide by firearm, hanging/suffocation, and poisoning together comprise 92% of all suicides. • In 2005, suicide by firearm comprised 52% of all suicides. • Hanging/suffocation accounting for 22% of all suicides in 2005, and • Poisoning accounted for 18%. Source: Baker, S.A. et al (in press) Mid-life suicide: An increasing problem in U.S. whites. 1999-2005, American Journal of Preventive Medicine

10. Trends in U.S. Suicide Mortality by Race Source: Baker, S.A. et al (in press) Mid-life suicide: An increasing problem in U.S. whites. 1999-2005, American Journal of Preventive Medicine

11. North Dakota Suicide Rates by Race Source: North Dakota Department of Health

12. Suicide Rates among Native Americans/Alaska Natives • Among Native Americans/Alaska Natives ages 15-34 years, suicide is the 2nd leading cause of death • at 21.7 per 100,000 it is 2.2 times higher than the national average. • Young Native American women have suicide rates that are 2 to 3 times higher than for females in the general population. CDC 2005

13. National Suicide Mortality Rates by Gender: 1950-2004 • Suicide is the 8th leading cause of death for men of all ages and the 17th leading cause of death for women (CDC 2005) Source: National Center for Health Statistics, 2007

14. North Dakota Suicide Mortality Rates by Gender: 1999 - 2007 Source: North Dakota Department of Health

15. Gender Disparities in Suicide Rates • Males represent 79.4% of all U.S. suicides. • However, during their lifetime, women attempt suicide about 2 to 3 times as often as men. • Among males, adults ages 75 and older have the highest rate of suicide (37.97 per 100,000). • Among females, those in their 40s and 50s have the highest suicide rate (7.53 per 100,000). • Firearms are the most commonly used method of suicide among men, while poisoning is the most common among women. Source: CDC 2005

16. Co-occurring Disorders & Suicidality • Research shows that most people who commit suicide have a diagnosable mental or substance use disorder or both, and that the majority of them have depressive illness. • Studies also indicate that the most promising way to prevent suicide and suicidal behavior is through the early recognition and treatment of substance abuse and mental illnesses. This is especially true of clients who have serious depression (U.S. Public Health Service 1999). Source: Treatment Improvement Protocol 42

17. Call to Action • Surgeon General issued “Call to Action to Prevent Suicide” (1999) • First step toward adoption of a National Strategy on Suicide Prevention and the acknowledgement of suicide as a public health issue. • Called for the implementation of strategies to reduce the stigma associated with suicidal behavior, mental illnesses and substance abuse disorders. • Recommended that health care providers be trained to better recognize and either refer or treat depression, substance abuse, and major mental illnesses associated with suicide risk.

18. Definition:Co-Occurring Disorders • Clients said to have co-occurring disorders have one or more mental disorders as well as one or more disorders relating to the use of alcohol and/or other drugs. • A diagnosis of a co-occurring disorder (COD) occurs when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder.

19. Consequences of Co-occurring Disorders • Increased vulnerability to relapse and re-hospitalization • More psychotic symptoms • Inability to manage finances • Housing instability and homelessness • Noncompliance with medications and treatment • Increased vulnerability to HIV infection and hepatitis

20. Consequences of Co-occurring Disorders (continued) • Lower satisfaction with familial relationships • Increased family burden • Violence • Incarceration • Higher service utilization and costs • Increased depression and “suicidality” (the composite of suicidal behaviors)

21. Serious Psychological Distress (SPD) & Drug Use Source: NSDUH 2007

22. Substance Abuse & Suicide • As many as 27% of all deaths of people who abuse alcohol are caused by suicide, with the lifetime risk for suicide among people who abuse alcohol estimated to be 15%. • According to SAMHSA’s Drug Abuse Warning Network (DAWN), in 2005 over 132,500 visits to emergency rooms were for alcohol or drug-related suicide attempts. • The most frequently identified substance was alcohol – found in 1/3 of those tested. • Illicit drugs were involved in approximately 19% of the ED visits for drug-related suicide attempts. Source: Treatment Improvement Protocol 42

23. Substance Abuse & Suicide • Alcohol and drug abuse are second only to depression and other mood disorders as the most frequent risk factors for suicide. • The association between alcohol use and suicide also may relate to the capacity of alcohol to remove inhibitions, leading to poor judgment, mood instability, and impulsiveness. • Substance intoxication is associated with increased violence, both toward others and self. Source: Treatment Improvement Protocol 42

24. Substance Dependence or Abuse among Adults Aged 18 or Older, by Major Depressive Episode (MDE) in the Past Year: 2007 Source: SAMHSA NSDUH 2007

25. Treatment Data: General Population2007 National Survey on Drug Use and Health Of the 5.4 million adults with both serious psychological distress (SPD) and a substance use disorder: Source: NSDUH 2007

26. Suicide & Major Depressive Episodes (MDE) • Among adults (18 and older) who experienced a past year MDE – during their worst or most recent episode -- 56.3% thought it would be better if they were dead. • 40.3% thought about committing suicide, • 14.5% made a suicide plan, and • 10.4% made a suicide attempt. • There were no significant differences between males & females who thought it would be better if they were dead. • However, males were more likely than females to actually consider committing suicide (45.5% vs. 37.6%) Source: SAMHSA Office of Applied Studies, 2006

27. Suicidal Thoughts & Past Year MDE Adults aged 18 or older with a Past Year MDE Source: NSDUH 2004 & 2005

28. Suicidal Thoughts/Attempts, MDE & Past Month Binge Alcohol Use Adults aged 18 or older with a Past Year MDE Past Year Suicidal Thoughts Past Year Suicide Attempt Source: NSDUH 2004 & 2005

29. Suicidal Thoughts/Attempts, MDE & Past Month Illicit Drug Use Adults aged 18 or older with a Past Year MDE Past Year Suicidal Thoughts Past Year Suicide Attempt Source: NSDUH 2004 & 2005

30. Mental Health and Co-Occurring Illness Among Veterans From 2004 to 2006, 395,000 veterans had co-occurring serious psychological distress (SPD) and substance use disorder (SUD) Veterans aged 18 to 25 have the highest rate of SPD and SUD at 8.4%, with veterans 55 or older having the lowest rate at 0.7%. The NSDUH Report, November 1, 2007

31. Prevalence of Serious Psychological Distress (SPD), Substance Use Disorder (SUD), and Co-Occurring SPD and SUD in the Past Year among Veterans: 2004 to 2006 Source: The NSDUH Report, November 1, 2007

32. Mental Health and Co-Occurring Illness Among Veterans A NSDUH study found no significant difference in co-occurring disorders among male and female veterans (1.5% vs. 2.0% respectively.) Veterans with family incomes of less than $20,000 per year were more likely to have had co-occurring SPD & SUD in the past year than veterans with higher family incomes.1 According to the Department of Veterans Affairs, 18% of the veterans recently back from tours of duty are unemployed. Of those employed since leaving the military, 25 percent earn less than $21,840 a year. 1 The NSDUH Report, November 1, 2007

33. Prevalence of Serious Psychological Distress (SPD), Substance Use Disorder (SUD), and Co-Occurring SPD and SUD in the Past Year among Veterans, by Family Income: 2004 to 2006 Source: The NSDUH Report, November 1, 2007

34. Prevalence of Reporting a Mental Health Problem Among Returning Veterans • The prevalence of reporting a mental health problem was 19.1% among veterans returning from Iraq, compared with 11.3% after returning from Afghanistan, and 8.5% after returning from other locations. • 35% of Iraq war veterans accessed mental health services in the year after returning home; 12% per year were diagnosed with a mental health problem. • More than 50% of those referred for a mental health reason were documented to receive follow-up care. 34 Hoge, C. W., et al., JAMA, 3/1/06

35. Veterans and Suicide • Between 2002 and 2005, 144 out of 490,346 separated OEF/OIF service members committed suicide, for an overall rate of 21.9 per 100,000. • Among veterans receiving care from the Department of Veterans Affairs (VA) who died from suicide, almost 60% of those under age 65 had a mental health or substance abuse diagnosis on their medical records. • Those veterans who are wounded in combat are at higher risk of suicide. Source: VA Testimony of The Honorable James B. Peake, M.D. before Congress on May 6, 2008 - Congressional and Legislative Affairs

36. Unique Characteristics of Returning Veterans Returning veterans may be different from others in public substance abuse and mental health treatment: They are generally younger, with a shorter history of substance abuse. They have been used to a very structured, controlled environment National Guard and Reservists, in particular, might feel split between who they were before seeing combat, and who they are now, i.e., citizen-soldier. The military culture is shared across ethnic and racial populations, but also has ethnic/racial tensions. 36

37. Key Questions for Community Providers to Consider Counselors should routinely assess clients for histories of traumatic events and for the diagnosis of PTSD Counselors should ask both male and female clients about military experiences Counselors should ask if their clients or family members are part of the military and/or combat veterans family network. 37

38. SAMHSA Priority Population SAMHSA recently established returning veterans and their families as one of SAMHSA’s priority populations. This means that, beginning in FY 2008, this population is included in all relevant announcements of grant availability, and Applicants for SAMHSA grants will be strongly encouraged to address veterans’ issues. The returning veterans and families population is now one of the SAMHSA Matrix program areas, assuring continuing attention throughout SAMHSA’s major, ongoing programs. 38

39. A Public Health Approach to Suicide Prevention & Treatment • A public health approach is population-based that focuses on the full range of the health-illness continuum: • Promotion of health through the prevention of illness and disability • Treatment and rehabilitation of those affected • Prevention and treatment are both important. • While focusing treatment and care on the needs of the individual, a public health model also supports development of preventive interventions for the entire population. Source: Substance Abuse and Suicide Prevention: Evidence & Implications, White Paper (in press), DHHS, SAMHSA, 2008

40. Working Upstream and Downstream • A public health approach focuses on prevention as well as illness. • Providers keep “rescuing drowning individuals” downstream, • But, they also need to move “upstream” to keep people from falling into the river in the first place. • The emphasis is on connections rather than a stovepipe approach to services. Source: Substance Abuse and Suicide Prevention: Evidence & Implications, White Paper (in press), DHHS, SAMHSA, 2008

41. A Public Health Approach to Suicide Prevention & Treatment • A public health approach follows an ordered, continuous set of steps to promote health and prevent illness: • Identify the problem • Identify risk and protective factors • Risk factors include extreme economic deprivation, academic failure, peer rejection, family conflict • Protective factors include strong family bonds and social skills, opportunities for success, and community involvement • Develop, implement and test interventions • Ensure widespread adoption of evidence-based practices Source: Substance Abuse and Suicide Prevention: Evidence & Implications, White Paper (in press), DHHS, SAMHSA, 2008

42. Public Health Approach Values A public health approach values: • Preventive care that can identify and act on risks for suicide early, including attention to both substance abuse and mental disorders. • Primary care practitioners and behavioral health care providers who look beyond their individual disciplines. • Connections between the scientific community and the broader public – and between the behavioral health service community and consumers. Source: Substance Abuse and Suicide Prevention: Evidence & Implications, White Paper (in press), DHHS, SAMHSA, 2008

43. Role of Primary Care Providers • According to the Institute of Medicine, a majority of people who die by suicide visited a health care provider within a year of their deaths. • 40% had seen a clinician within a month. • A study of suicides of elderly patients indicated that 18% saw their primary care provider on the same day as their suicide. (Loebel 2005) • Primary care providers need to be vigilant in screening for suicide risk. Source: Substance Abuse and Suicide Prevention: Evidence & Implications, White Paper (in press), DHHS, SAMHSA, 2008

44. SAMHSA’s National Suicide Prevention Initiative (NSPI) Center for Mental Health Services Kathryn A. Power, Director

45. National Suicide Prevention Initiative (NSPI) SAMHSA suicide prevention programs currently are underway under NSPI: • National Suicide Prevention Lifeline • Suicide Prevention Resource Center (SPRC) • National Strategy for Suicide Prevention (NSSP)

46. National Suicide Prevention Lifeline • The SAMHSA-funded National Suicide Prevention Lifeline has become the nation’s leading source of immediate help for those dealing with suicide-related issues. • It offers a 24/7 toll-free suicide prevention service at 1-800-273-TALK (8255) • The Lifeline receives an average of 43,000 calls a month from people seeking help for themselves or someone else. • Callers are routed to the closest in a network of 135 local emergency, mental health, and social services resources. • Web site: http://www.suicidepreventionlifeline.org/

47. National Suicide Prevention Lifelinefor Veterans In July 2007, SAMHSA, in collaboration with the U.S. Department of Veterans Affairs, modified its toll-free National Suicide Prevention Lifeline. A new prompt offers the option of pressing #1 and connecting directly to a special VA suicide crisis line, located in Canandaigua, NY, and staffed by mental health professionals, who can refer callers to more than 150 Suicide Prevention Coordinators at local VA Medical Centers across the country. Over 22,000 calls have come into the Lifeline during its first year from veterans and those seeking help for veterans who are family members or friends. 47

48. Lifeline Efforts to Reach Young People • Recently the National Suicide Prevention Lifeline arranged to establish sites within the MySpace, Facebook and YouTube social networks. • Also, users who mention “suicide” in their postings to Help.com receive an automatic response from Lifeline – urging them to call 1-800-273-TALK.

49. Lifeline Gallery • The online Lifeline Gallery: Stories of Hope and Recovery is an interactive web site designed to raise awareness about the effects of suicide. • Animated avatars allow survivors of people who have died through suicide, suicide attempt survivors, and those in the suicide prevention field to share messages of hope and recovery. • Web site: www.lifeline-gallery.org

50. National Suicide Prevention Lifeline – North Dakota • North Dakota National Suicide Prevention Lifeline centers received 756 calls during the past 12 full months. • Calls were handled by North Dakota’s two Lifeline centers: • FirstLINK HotLINE – Fargo, ND • Mental Health America of North Dakota – Bismark, ND