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QPRT T4T Summer 2007

QPRT T4T Summer 2007. Paul Quinnett, Ph.D. QPR Institute, Spokane, Washington. Goals. - Describe developing public policy and implications for practice Update research on mental illness, substance abuse and suicide New theory of suicide

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QPRT T4T Summer 2007

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  1. QPRT T4TSummer 2007 Paul Quinnett, Ph.D. QPR Institute, Spokane, Washington

  2. Goals - Describe developing public policy and implications for practice • Update research on mental illness, substance abuse and suicide • New theory of suicide • Introduce Reliability Theory and its applications for consumer safety • Describe the limitations of the clinical interview

  3. Goals • Share developing research program for predicting suicide attempt behavior • New ways to think about evaluating suicide risk • What to teach and how to teach it • Practice, practice, practice

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

  5. The President’s New Freedom Commission on Mental Health (2003) Goal 1. Americans understand that Mental Health is Essential to Overall Health • Rec. 1.1: Advance and implement a national campaign to reduce the stigma of seeking care and a national strategy for suicide prevention • Rec. 1.2: Address mental health with the same urgency as physical health

  6. Performance expectations are rising • Clinical providers and their employers are charged with doing a better job (Goal 6). • Families are being taught suicide is preventable, so “Why did my brother die after I brought to your hospital, mental health center or substance abuse treatment program?” • Lawsuits against us are on the rise.

  7. Global Public Health Problem • 1 million people die by suicide • 10-20 million attempt • Leading cause of death in 1/3 of all countries • ½ of all violence-related deaths More die by suicide each year than from all armed conflicts around the world

  8. The cost of doing nothing? • 30,000 deaths by suicide in US • 1.8 million suicide attempts/year US • 1.3 million years of life lost/year • $3.8 billion in hospitalization costs for suicide attempts/year • $2.3 billion in lost earnings/year • Unmeasured grief, suffering, and negative psychological impacts to survivors

  9. US data… • Range: ideations, attempts, deaths • 31,483 completed suicides in US (2003) • Suicide rates are trending down, not rising • Rates vary widely by race, gender, geography, ethnicity, but all deaths have commonalities Am. Journal of Public Health, McKeown, 2006)

  10. What do they die from? • 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.

  11. National Violent Death Reporting System • Preliminary data: AK, CO, MD, NJ, OR, SC, VA • 17 states participating • 2003, N = 7,710 deaths - Suicide: 46.7% - Homicide: 26% - Undetermined: 25.6% - Legal intervention: 0.8% - Unintentional firearm: 0.7% NDVRS 2005

  12. Veterans General population: 11.3/100,000 VA (Medical patients) - under 65: 45/100,00 vs. over 65: 85/100,000 Psychiatric population: - VA psychiatric inpatients: 279/100,000 Previous attempters - est. 1,000/100,000 Ann Haas AFSP

  13. Journey to suicide, from idea to act

  14. Idea to act….. ”Once the principal of movement has been supplied, one thing follows on after another without interruption” Aristotle. If suicide is a journey from an idea to an act, …. interrupting it early is easy, interrupting late is hard…

  15. From idea to act • Impossible problem – no solutions • Suicide as solution • Ideation (passive to active) • Plan (method? lethal? available? ego-syntonic? when? where? witnesses?) • Preparation (writing will, “tidying up”, suicide note?) • Securing means • Rehearsal/practice with means • Habituation to painful stimuli (e.g., hesitation cuts) • Non-fatal attempt (except with firearm) • Attempt

  16. Trends in suicidal behavior..National Co morbidity Study 1990-92 vs. 2001-2003 • Ideations = 2.8% - 3.3% (up) • Plan = .7% - 1.0% (up) • Gesture = .3% - .2% (down) • Attempt = .4% - .6% (up) • Cumulative probabilities for transition: - ideation to plan = 34% - plan to attempt = 72% - ideation to unplanned attempt = 26%

  17. Factoids • Those who talk about suicide are at higher risk of attempting (on autopsy, 40-90% of completed suicide sent warning signs including talking about suicide) • History of severe ideation/planning and rehearsal are strong predictors of death by suicide. (Beck, et al) • Those who attempt are at highest risk for eventual death by suicide (best single predictor) • 5-year follow up study of attempters found 1 in 6 had died of suicide or risky-behavior accidents (Soc. Psych. Epidemiology, 2001)

  18. Youth especially at risk? Highest suicide rate in US? Native American males Greatest increasing rate? African American males (up 200%) Highest rate of suicide attempts? Hispanic youth (males & females) Highest rate of suicide attempts of any group? Hispanic females

  19. Youth numbers…(CDC) • Think, plan, attempt, die (last 12 months) • 19% of all high school students (1 in 5) thought seriously about suicide • 14% made suicide plan • 8.3% made an attempt • 2,000 +- die each year • First choice: firearm (both sexes)

  20. Do the math in your school Of 1,000 students this year – - 200 will think seriously about suicide - 140 will plan how to kill themselves - 80 will make a suicide attempt Let’s work to make sure none die!

  21. “Suicide prevention is not so much the stopping of a self-inflicted death as it is the restoration of hope in the hopeless before the fatal planning begins.”

  22. 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)

  23. Why now? • The problem isn’t going away: with every cure for a disease, preventing suicide moves up the healthcare to-do list • Since 9/11, 150,000 have died • 900,000 new survivors since 9/11 • WHO’s death and disability ranking (depression) • Emergent federal, state and grassroots local leadership

  24. What happened? • Suicide is no longer a sin or crime (religious leadership emerged) • The Happy Rockefeller effect took hold and the survivor movement began • 1998 and the birth of a national strategy • Society is changing – AFSP 40 marches • The buzz is on….

  25. Why now? • The cause is right/the mission clear • The tools are available • Doing nothing is measured in lives lost • Evidence is in: Kendra's Law: OMH New York – 55% reduction in suicidal behaviors over 5 years (assisted outpatient program) and the US Air Force study (more later) “It is always the right time to do the right thing.” Martin Luther King, Jr.

  26. What else is different? -We know mentally healthy people don’t kill themselves • Dramatic new knowledge to prevent suicide and suicide attempts • If recovery is possible, suicide is preventable • 78% of Americans believe many suicides are preventable (SPAN USA) • 86% of Americans believe we should invest in suicide prevention (SPAN USA)

  27. Our problem? Fatalism, Wrong Beliefs and the Status Quo • “You can’t help the mentally ill and suicide is inevitable” • “If they really want to kill themselves you can’t stop them.” • Not! 515 would-be jumpers from the Golden Gate followed for 25 years – 94% died of natural causes or were still alive • What kills people? The 3 S’s: Silence, Stigma, Shame

  28. Question If there is an acceptable rate of suicide where live and work and go to school, what is it?

  29. The Golden Gate Bridge • Icon – 220 feet, 75 mph – 26 survivors of more than 1,300 deaths • 1 fatality every 15 days • Sara Brinbaum 88 & Roy Raymond 93 (VS) • Safety net controversy/Eiffel Tower & Empire State Bldg • Jumpers who did not die • Is there a change in the wind?

  30. A Plan: The National Strategy • Aims: • Prevent premature deaths due to suicide across the life span • Reduce the rates of other suicidal behaviors • Reduce the harmful after-effects associated with suicidal behaviors and their impacts on others • Promote opportunities and settings to enhance resiliency, resourcefulness, respect and interconnectedness for individuals, families and communities.

  31. 11 Major goals 1. Promote awareness that suicide is a preventable public health problem 2. Develop broad support for suicide prevention 3. Develop and implement SP strategies for consumers of health services 4. Develop and implement SP programs 5. Promote means restriction

  32. Major goals 6. Implement training for recognition of at-risk behavior and delivery of effective treatment 7. Develop and promote effective clinical care 8. Improve access to services 9. Improve reporting in the media 10. Promote and support research 11. Improve and expand surveillance systems

  33. IOM Preventing Suicide Recommendations Strategies • Research centers, violent death surveillance systems • Improved use of screening tools to identify depression, substance abuse, child abuse, impulsivity and relationship stresses • Referral by PCPs of suicidal patients or those with multiple risk factors to mental health professionals

  34. IOM Recommendations Strategies • Professional in-service training of health care providers in suicide risk, detection and intervention • Modifying the curriculum of medical and nursing schools to include the study of suicidal behavior

  35. Why us? • Clinical providers and their employers are charged with doing a better job (Goal 6). • Families are being taught suicide is preventable, so “Why did my brother die after I brought to your hospital, mental health center or substance abuse treatment program?” • Lawsuits against us are on the rise.

  36. Goal 6: “Implement training for recognition of at-risk behavior and delivery of effective treatment” 1. Who is qualified to conduct a suicide risk assessment? 2. What are these qualifications? 3. When is the risk assessment done? How often? 4. Where are staff trained in recognition of at-risk behavior? 5. How is this risk assessment documented?

  37. JCAHO and Suicide 2007 National Patient Safety Goals # 15 The organization identifies patients at risk for suicide. (M) C 1: The risk assessment includes identification of specific factors and features that may increase or decrease risk for suicide. (M) C 2. The patient’s immediate safety needs and most appropriate setting for treatment are addressed. (M) C 3. The organization provides information such as a crisis hotline to individuals and their family members for crisis situations.

  38. Why the new safety requirement? Case Study • A 30 yr old male patient jumped from the 7th floor in the Atrium of the National Institutes of Health Clinical Center in Bethesda, Maryland. • The patient was an active inpatient on a National Institute of Mental Health Unit. • Protocols on that unit usually call for medication washout.

  39. A chicken and a pig go to breakfast.. Case Study • The patient jumped over an 8 ft wall during a busy Christmas party for patients and staff. • Event witnessed by about 300 patients and visitors. • Event attracted attention of everyone present

  40. JCAHO and Suicide JCAHO Reports 501 Inpatient Suicides From 1995 To 2004 And 56 In 2005 Ballard et al. Psychosomatics 2006

  41. JCAHO and Suicide JCAHO Reported 501 Inpatient Suicides From 1995 To 2004 And 56 In 2005

  42. The Relationship of Mental Illness and Substance Abuse to Suicide… “Suicide is a national public health problem.” David Satcher, M.D. Former Surgeon General of the United States

  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. 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…

  45. 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

  46. 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)

  47. 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. 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

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

  50. A note on antidepressants • TCAs deadly in overdose • SSRI’s not deadly in overdose • Lot’s of TCAs prescriptions = more suicides • Lot’s of SSRIs prescriptions = fewer suicides (EU, Australia, Scandinavia, USA) Sources: Grunebaum, et al, J. Clin. Psychiatry, 2004 Gibbons, et al, Arch Gen Psychiatry, 2005 Gibbons, et al, Am J. Psychiatry, 2006

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