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. QPRT Agenda • Introductions • Scope of the problem • Introduction to risk factors • Mental illness and suicide • Suicide risk rating exercise • Lunch • Avoiding suicide malpractice • Introduction to the QPRT protocol • Role plays and practice • Managing risk over time

3. 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 - Some countries report a 60% increase in the past 5 years Everyone agrees even these conflicting numbers are conservative ….

4. 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; it’s an equal opportunity mode of death.

5. State Rankings Top seven states - suicides per 100,000 Year: 2001 • New Mexico: 19.8 • Montana: 19.3 • Nevada: 18.4 • Wyoming: 16.8 • Colorado: 16.3 • Alaska: 16.1 • Idaho 15.9

6. State Rankings • Bottom seven states - suicides per 100,000 - Rhode Island 8.3 - California 8.2 - Connecticut 8.2 - District of Columbia 7.0 - New Jersey 6.9 - Massachusetts 6.7 - New York 6.6 How do we account for the differences?

7. Numbers that Matter • Think, plan, attempt, die • 10 million adults think about suicide each year • 1.2 million plan a method (gun, MVA, etc) • 750,000 attempt (minimum count) • Less than 30,000 die • Suicide is 11th cause of death overall - 3rd for young people (rate has tripled since 1950s) - first for young people in some states source: CDC and NIMH

8. Intention and Suicide “There are ways of killing yourself without killing yourself.” Tony Manero, Saturday Night Fever, on the “suicide” of his friend. ILTB = Intentional life threatening behavior

9. 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

10. 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.

11. 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 of drugs with a fifth of whisky and a 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.

12. 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)

13. Suicide and Homicide • More homicides or suicides per year in the US? • Is there any overlap between homicide and suicide?

14. Facts you Need to Know “If a man calls, take him seriously.” Men of all ages are in high risk groups • Boys • Teenaged boys • Young men • Old white males are the highest risk group - 71.4% use a firearm (lethal planners) • They know how to do it and plan carefully • They avoid rescue “If a woman calls about a man, take her even more seriously.”

15. Facts you need to know… • Suicide risk rises with age • Responsibility for one or more children is a powerful protective factor against suicide in women (Swedish study) • Contact with a healthcare provider does not confer protection…. and neither does recent psychiatric hospitalization - most suicides occur with weeks to months of last contact AND risk rises after discharge!

16. 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.

17. Intimate Partner Violence • Males who threaten suicide in an intimate partner violence situation are at greater risk for murder-suicide. WSDVFR (Washington State Domestic Violence Final Report) finding: “Abusers were suicidal in 35% of domestic violence fatalities overall (this includes cases where no homicide occurred) and in 31% of the cases in which a homicide was committed.” US AIR FORCE: • Suicide rate down 33%, • Homicide rate down 52% • Serious DV rate down 54% Suicide Prevention IS violence prevention!

18. 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 ---

19. GOOD NEWS! • U.S. suicide rates are at least steady • Things are changing; hope is alive and well • Upside: research, medicine and political will • Downside: stigma, funding and lack of awareness • Leadership has emerged: NIMH, CDC, National Council for Suicide Prevention • U.S. Air Force success story “Suicide can be prevented!”

20. End Module Questions

21. Suicide Risk and Risk Management What you need to know….

22. 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 is relationship sensitive • Summation of risk factors not helpful • Screening tools can get you in trouble (prediction is best done in reverse)

23. Mental Illness & Suicide • Facts: • Over 90% of all people who die by suicide are suffering from a major psychiatric illness. • More teenagers and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia, influenza, and chronic lung disease, COMBINED. • These deaths are due to untreated and under-treated brain disorders.

24. ENVIRONMENTAL RISK FACTORS Attempts Completions Seasonal Variations Unknown Peak Jan, Feb, Mar 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

25. SUICIDE CRISIS EPISODE Risk Imminent Crisis Peaks Crisis Begins RISK LEVEL Crisis Diminishes Hazard Encountered Stable Stable Years Days Hours Years Plus or minus three weeks

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

27. The Many Paths to Suicide Cause of Death Acute (proximal) Risk Factors: triggers/last straw Fundamental (distal) 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.

28. 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

29. 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.

30. NEUROBIOLOGY OF SUICIDE • Familial patterns of suicide suggest biological factors may influence risk. • Low HIAA has been found in severe suicidal depressions. • Research suggests 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

31. 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, electroconvulsive therapy may be the best choice. • Patient education: death is a possible result of discontinuing medications. • Benzodiazepines are often under used in anxious/agitated suicidal depressions.

32. 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

33. SUICIDE AND SCHIZOPHRENIA • 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. • Twenty to 40% make a suicide attempt • Finland National Study (1997) - 7% of all suicides met DSM-IV criteria for schizophrenia (N=92). Of these 92, 64 were also depressed. • Suicide occurs during active phases of the illness. M.T. Tsuang, MD, Harvard Medical School, 1998

34. Suicide and Schizophrenia • 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, history of 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.

35. 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, co-morbid 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

36. 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)

37. 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 Co-morbid Physical Illness Alcohol Myopia WALL OF RESISTANCE SUICIDAL BEHAVIORS

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

39. Psychiatric DX and Suicide: Tthe Global Picture • Prevention and treatment of mental disorders saves lives? • Which disorders should we target? • 31 psych. autopsy studies from 1959-2001 • Over 90% of suicides had psychiatric disorder • 19,716 cases studied (inpatient and gen. pop.) Bertolote, Fleischmann, DeLeo and Wasserman, Crisis. 2004

40. Findings • Only 2% of completed suicides had no psychiatric diagnosis • 30.2% had mood disorders (lower than expected) • 17.6% had substance abuse disorders • 14.1% had schizophrenia • 13.0% had personality disorders

41. 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)

42. Needed? • Numbers of lives saved is not “particularly impressive.” • Best case outcome for Rx of all disorders: 15.1 to 12.0/100K • To save lives we must focus more broadly - find the folks (gatekeeper training) - reduce stigma - 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

43. What can we do? • Do we know how to sober people up? • Do we know how to treat anxiety? • Do we know how reduce psychic pain? • Are there effective treatments for agitation? • Do we know what to do about serotonin deficits? • CBT for depressive hopelessness? • DBT for Axis II consumers

44. See New APA Guidelines on the Assessment, Management and Treatment of Persons with Suicidal BehaviorsDiscussion

45. Risk Rating Exercise Compare yourself with other judges Rate each of the following on a scale of 1 to 7 (1= no risk; 7 = high risk) Stecklemeyer

46. CASE #1 A 21 year old male, foreign graduate student was brought to the Crisis Intervention Center by friends and a pastor. After informing his friends that he planned to jump off a bridge, he actually went there and had to be physically restrained from jumping. He had written several suicide notes, one willing his computer to a friend, another to a different friend stating that the patient would be dead by the time his note was opened.

47. CASE # 1 Continued The patient described himself as being quite depressed, with low energy, poor sleep and appetite, and persistent suicidal ideation. The precipitant seems to have been his girlfriend’s breaking off their engagement four days ago. He has a psychiatric history of several years, but refuses to reveal any details. He exhibits some grandiosity, paranoid mentation, anger, agitation and irritability. He appears somewhat manic but not depressed. He denies any acute plan to commit suicide and is threatening to sue the CID for having been detained.

48. Risk Rating • Rating: High Risk • Mean 6.21 • SD. 0.86

49. Case # 2 A 16-year-old Native America female presented as a self-referral following an overdose of 12 aspirin tables. Patient reports that she could not tolerate the rumors at school that she and another girl are sharing the same boyfriend. The patient denies being suicidal at this time (“I won’t do it again; I learned my lesson.”) She reports that she has always had difficulty expressing her feelings. In the interview she is quiet, guarded and initially reluctant to talk. Diagnostic impression: adjustment disorder

50. Risk Rating • Rating: Low Risk • Mean: 2.25 • SD: 1.29