Suicide Prevention Saving Lives One Community at a Time

1. Suicide Prevention Saving LivesOne Community at a Time America Foundation for Suicide Prevention Dr. Paula J. Clayton, AFSP Medical Director 120 Wall Street, 29th Floor New York, NY 10005 1-888-333-AFSP www.afsp.org

2. Facing the Facts An Overview of Suicide

3. 3 Facing the Facts In 2008, 36,035 people in the United States died by suicide. About every 14.6 minutes someone in this country intentionally ends his/her life. Although the suicide rate fell from 1992 (12 per 100,000) to 2000 (10.4 per 100,000), it has been fluctuating slightly since 2000 � despite all of our new treatments. From the studies of committed suicide, about 50% of men who died were not in treatment and 75% of the men who died had no medications in their systems at the time of their deaths, so even if they were in treatment, they were not taking the medications. The data on whether treatments will help decrease suicide rates are also controversial. There is only one study (Angst et al, JAD (2002), Angst et al, Arch.Suic.Res. (2005) that indicates, in a naturalistic study (e.g. the patients were sent to their local physicians for treatment after they were discharged from the psychiatric hospital) from Switzerland, if patients with either major depression or bipolar illness were treated with antidepressants, neuroleptics and lithium their suicide rates and deaths from other causes were markedly decreased. There are also three studies that showed that treatment with Lithium, usually in patients with bipolar disease, also helps decrease the suicide and overall death rate significantly. However, many studies have shown, even patients in treatment or patients who have been hospitalized after a suicide attempt, that the treatment is not adequate. The conclusion is that there are many factors that contribute to the suicide rates, and we must work to change all of them to have an impact. In 2008, there were 36,035 suicides, the rate is 11.8 per 100,000.From the studies of committed suicide, about 50% of men who died were not in treatment and 75% of the men who died had no medications in their systems at the time of their deaths, so even if they were in treatment, they were not taking the medications. The data on whether treatments will help decrease suicide rates are also controversial. There is only one study (Angst et al, JAD (2002), Angst et al, Arch.Suic.Res. (2005) that indicates, in a naturalistic study (e.g. the patients were sent to their local physicians for treatment after they were discharged from the psychiatric hospital) from Switzerland, if patients with either major depression or bipolar illness were treated with antidepressants, neuroleptics and lithium their suicide rates and deaths from other causes were markedly decreased. There are also three studies that showed that treatment with Lithium, usually in patients with bipolar disease, also helps decrease the suicide and overall death rate significantly. However, many studies have shown, even patients in treatment or patients who have been hospitalized after a suicide attempt, that the treatment is not adequate. The conclusion is that there are many factors that contribute to the suicide rates, and we must work to change all of them to have an impact. In 2008, there were 36,035 suicides, the rate is 11.8 per 100,000.

4. 4 Facing the Facts Suicide is considered to be the second leading cause of death among college students. Suicide is the second leading cause of death for people aged 25-34. Suicide is the third leading cause of death for people aged 10-24. Suicide is the fourth leading cause of death for adults between the ages of 18 and 65. Suicide is highest in white males over 85. (45.0/100,000, 2008) The first and second leading causes of deaths in young adults (18-24) are accidents and homicides. Since the CDC does not collect data on men and women who are specifically in college, we assume, since homicide is low in this group, it may be the second leading cause of death. Although suicide rates in the US are highest in the very elderly, because there are so many other reasons why men die at this age, it is not a "leading" cause of death. Data on this can best be obtained through the CDC website www.cdc.gov or NIMH website www.nimh.nih.gov.The first and second leading causes of deaths in young adults (18-24) are accidents and homicides. Since the CDC does not collect data on men and women who are specifically in college, we assume, since homicide is low in this group, it may be the second leading cause of death. Although suicide rates in the US are highest in the very elderly, because there are so many other reasons why men die at this age, it is not a "leading" cause of death. Data on this can best be obtained through the CDC website www.cdc.gov or NIMH website www.nimh.nih.gov.

5. 5 Facing the Facts The suicide rate was 11.8/100,000 in 2008. It greatly exceeds the rate of homicide. (5.9/100,000) From 1981-2008, 864,271 people died by suicide, whereas 454,536 died from AIDS and HIV-related diseases.

6. 6 Facing the Facts Death by Suicide and Psychiatric Diagnosis Psychological autopsy studies done in various countries over almost 50 years report the same outcomes: 90% of people who die by suicide are suffering from one or more psychiatric disorders: Major Depressive Disorder Bipolar Disorder, Depressive phase Alcohol or Substance Abuse* Schizophrenia Personality Disorders such as Borderline PD *Primary diagnoses in youth suicides. Psychological autopsies (detailed interviews with the families, physicians, therapists, clergy and anyone close who knew the person who died by suicide usually done on a consecutive group in people who have died by suicide and are chosen from the coroners office) have shown that most of those who suicided were suffering from major mental illnesses as described above. These are a few such studies: Completed Suicides and Psychiatric Diagnoses Psychological Autopsy Studies Robins et al, 1959: 94% psychiatrically ill, 68% depressive or alcoholic Dorpat and Ripley, 1960: 100% psychiatrically ill, 57% depressive or alcoholic Baraclough et al, 1974: 93% mentally ill, 79% depressive or alcoholic Beskow, 1979: 98% mentally ill, 59% depressive Chynoweth et al, 1980: 89% mentally ill, 76% depressive or alcoholic Rich et al, 1988: 92% mentally ill, 96% depressive or alcoholic Arato et al, 1988: 82% mentally ill, 66% depressive or alcoholic Of note, Dr. Mann, AFSP Scientific Council member, has developed an assessment battery for doing such studies that makes it possible to do such studies with the same method throughout the world.Psychological autopsies (detailed interviews with the families, physicians, therapists, clergy and anyone close who knew the person who died by suicide usually done on a consecutive group in people who have died by suicide and are chosen from the coroners office) have shown that most of those who suicided were suffering from major mental illnesses as described above. These are a few such studies: Completed Suicides and Psychiatric Diagnoses Psychological Autopsy Studies Robins et al, 1959: 94% psychiatrically ill, 68% depressive or alcoholic Dorpat and Ripley, 1960: 100% psychiatrically ill, 57% depressive or alcoholic Baraclough et al, 1974: 93% mentally ill, 79% depressive or alcoholic Beskow, 1979: 98% mentally ill, 59% depressive Chynoweth et al, 1980: 89% mentally ill, 76% depressive or alcoholic Rich et al, 1988: 92% mentally ill, 96% depressive or alcoholic Arato et al, 1988: 82% mentally ill, 66% depressive or alcoholic Of note, Dr. Mann, AFSP Scientific Council member, has developed an assessment battery for doing such studies that makes it possible to do such studies with the same method throughout the world.

7. 7 Facing the Facts Suicide Is Not Predictable in Individuals In a study of 4,800 hospitalized vets, it was not possible to identify who would die by suicide � too many false-negatives, false-positives. Individuals of all races, creeds, incomes and educational levels die by suicide. There is no typical suicide victim. A prospective research study attempted to identify persons who would subsequently commit or attempt suicide. The sample consisted of 4,800 patients who were consecutively admitted to the inpatient psychiatric service of a Veterans Administration hospital. They were examined and rated on a wide range of instruments and measures, including most of those previously reported as predictive of suicide. Many items were found to have positive and substantial correlations with subsequent suicides and/or suicide attempts. However, all attempts to identify specific subjects were unsuccessful, including use of individual items, factor scores, and a series of discriminant functions. Each trial missed many cases and identified far too many false positive cases to be workable. Identification of particular persons who will commit suicide is not currently feasible, because of the low sensitivity and specificity of available identification procedures and the low base rate of this behavior. Pokorny AD. Arch Gen Psychiatry. 1983. Data from a 1983 prospective study of suicide in a cohort of 4800 psychiatric inpatients were reanalyzed using logistic regression, which is more appropriate for a binary outcome. The results were the same as in the previous study: too few of the subsequent suicides were identified and there were too many false positives to make this procedure useful. Several additional "artificial" logistic regression analyses were done: one series randomly removed increasing numbers of nonsuicide cases to increase the base rates; another series added an increasingly powerful hypothetical "test." Both of these maneuvers helped, but fell well short of perfection. Pokorny AD. Suicide Life Threat Behav. 1993 Five year follow-up of 4154 patients presenting with deliberate self harm showed that the predictive powers of Beck's Suicidal Intent Scale (SIS) was low (meaning they couldn't predict suicide). Harriss and Hawton, JAD 2005A prospective research study attempted to identify persons who would subsequently commit or attempt suicide. The sample consisted of 4,800 patients who were consecutively admitted to the inpatient psychiatric service of a Veterans Administration hospital. They were examined and rated on a wide range of instruments and measures, including most of those previously reported as predictive of suicide. Many items were found to have positive and substantial correlations with subsequent suicides and/or suicide attempts. However, all attempts to identify specific subjects were unsuccessful, including use of individual items, factor scores, and a series of discriminant functions. Each trial missed many cases and identified far too many false positive cases to be workable. Identification of particular persons who will commit suicide is not currently feasible, because of the low sensitivity and specificity of available identification procedures and the low base rate of this behavior. Pokorny AD. Arch Gen Psychiatry. 1983. Data from a 1983 prospective study of suicide in a cohort of 4800 psychiatric inpatients were reanalyzed using logistic regression, which is more appropriate for a binary outcome. The results were the same as in the previous study: too few of the subsequent suicides were identified and there were too many false positives to make this procedure useful. Several additional "artificial" logistic regression analyses were done: one series randomly removed increasing numbers of nonsuicide cases to increase the base rates; another series added an increasingly powerful hypothetical "test." Both of these maneuvers helped, but fell well short of perfection. Pokorny AD. Suicide Life Threat Behav. 1993 Five year follow-up of 4154 patients presenting with deliberate self harm showed that the predictive powers of Beck's Suicidal Intent Scale (SIS) was low (meaning they couldn't predict suicide). Harriss and Hawton, JAD 2005

8. 8 Facing the Facts Suicide Communications Are Often Not Made to Professionals In one psychological autopsy study, only 18% told professionals of intentions* In a study of suicidal deaths in hospitals: 77% denied intent on last communication 28% had �no suicide� contracts with their caregivers� ** Research does not support the use of no-harm contracts (NHC) as a method of preventing suicide, nor from protecting clinicians from malpractice litigation in the event of a client suicide*** Robins et al, Am J Psychiatry, 1959 Busch et al, J Clin Psychiatry, 2003 Busch et al, Psychiatr Ann, 2004Robins et al, Am J Psychiatry, 1959 Busch et al, J Clin Psychiatry, 2003 Busch et al, Psychiatr Ann, 2004

9. 9 Facing the Facts Suicide Communications ARE Made to Others In adolescents, 50% communicated their intent to family members* In elderly, 58% communicated their intent to the primary care doctor**

10. 10 Facing the Facts Research shows that during our lifetime: 20% of us will have a suicide within our immediate family. 60% of us will personally know someone who dies by suicide. This is from a Canadian study. It involves life time exposure, so the suicide could be a relative who had died before the living person knew him or her. Ramsay, R and Bagley, C. Suic and Life Threat Beh (1985). A more recent study showed that in the last year, 7% of the population knew a person, mainly a friend or acquaintance who killed himself and 1.1% of the population had a family member or relative who killed himself (or herself) Crosby and Sacks, Exposure to Suicide, Suic and Life Threat Beh (2002).This is from a Canadian study. It involves life time exposure, so the suicide could be a relative who had died before the living person knew him or her. Ramsay, R and Bagley, C. Suic and Life Threat Beh (1985). A more recent study showed that in the last year, 7% of the population knew a person, mainly a friend or acquaintance who killed himself and 1.1% of the population had a family member or relative who killed himself (or herself) Crosby and Sacks, Exposure to Suicide, Suic and Life Threat Beh (2002).

11. 11 Annual Deaths, by Cause

12. 12 Spending for Medical Research

13. 13 Facing the Facts Prevention may be a matter of a caring person with the right knowledge being available in the right place at the right time.

14. 14 Myths Versus Facts About Suicide Most of these facts are taken from psychological autopsy reports. Most of these facts are taken from psychological autopsy reports.

15. 15 Myths versus Facts MYTH: People who talk about suicide don't complete suicide. FACT: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously. Robins, E 1981: 50% to spouses, 40% to coworkers Reuneson, B, Suicide Life Threat Beh 1992Robins, E 1981: 50% to spouses, 40% to coworkers Reuneson, B, Suicide Life Threat Beh 1992

16. 16 Myths versus Facts MYTH: Suicide happens without warning. FACT: Most suicidal people give clues and signs regarding their suicidal intentions.

17. 17 Myths versus Facts MYTH: Suicidal people are fully intent on dying. FACT: Most suicidal people are undecided about living or dying, which is called �suicidal ambivalence.� A part of them wants to live; however, death seems like the only way out of their pain and suffering. They may allow themselves to "gamble with death," leaving it up to others to save them.

18. 18 Myths versus Facts MYTH: Men are more likely to be suicidal. FACT: Men are four times more likely to kill themselves than women. Women attempt suicide three times more often than men do. It is estimated that there are 25 attempted suicides for each death by suicide. (Ratio implies 730,000 suicide attempts annually in USA). It is estimated that there are 25 attempted suicides for each death by suicide. (Ratio implies 730,000 suicide attempts annually in USA).

19. 19 Myths versus Facts MYTH: Asking a depressed person about suicide will push him/her to complete suicide. FACT: Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life. In a study investigating the potential risk of screening for mental health problems, high school students were randomly assigned to 2 groups, one who received a survey with suicide questions (experimental group) and one who did not (control group). Distress levels after the survey were no different between the two groups. Two days later both groups were measured again with the same survey that included the suicidal questions. There were no differences in the report of suicidal ideation in the exposed or unexposed groups. "High- risk students" (defined as those with depression symptoms, substance use problems, or any previous suicide attempts) in the experimental group were neither more suicidal or distressed than "high-risk youth" in the control group: on the contrary, depressed students and previous suicide attempters in the experimental group appeared less distressed and suicidal than high-risk youths in the control group. Gould et al, JAMA (2006).In a study investigating the potential risk of screening for mental health problems, high school students were randomly assigned to 2 groups, one who received a survey with suicide questions (experimental group) and one who did not (control group). Distress levels after the survey were no different between the two groups. Two days later both groups were measured again with the same survey that included the suicidal questions. There were no differences in the report of suicidal ideation in the exposed or unexposed groups. "High- risk students" (defined as those with depression symptoms, substance use problems, or any previous suicide attempts) in the experimental group were neither more suicidal or distressed than "high-risk youth" in the control group: on the contrary, depressed students and previous suicide attempters in the experimental group appeared less distressed and suicidal than high-risk youths in the control group. Gould et al, JAMA (2006).

20. 20 Myths versus Facts MYTH: Improvement following a suicide attempt or crisis means that the risk is over. FACT: Most suicides occur within days or weeks of "improvement," when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts. The highest suicide rates are immediately after a hospitalization for a suicide attempt. After psychiatric hospitalization for depression, the days immediately following discharge are the highest risk for suicide and it diminishes gradually over the year. Fawcett et al, Am J Psychiatry, 1990 Hoyer et al, J Affect Disord, 2004 Qin and Nordentoft, Arch Gen Psychiatry, 2005 After psychiatric hospitalization for depression, the days immediately following discharge are the highest risk for suicide and it diminishes gradually over the year. Fawcett et al, Am J Psychiatry, 1990 Hoyer et al, J Affect Disord, 2004 Qin and Nordentoft, Arch Gen Psychiatry, 2005

21. 21 Myths versus Facts MYTH: Once a person attempts suicide, the pain and shame they experience afterward will keep them from trying again. FACT: The most common psychiatric illness that ends in suicide is Major Depression, a recurring illness. Every time a patient gets depressed, the risk of suicide returns. Although it is true that suicide as an outcome is highest in the first years of an illness like Major Depression (Isometsa et al, 1994, Angst, 2004 and 2005), it still can occur every time the patient has a recurring depression. Those who are the most suicidal and complete suicide while depressed are removed from the pool of potential suicides, so the frequency of the event goes down. Still, it happens.Although it is true that suicide as an outcome is highest in the first years of an illness like Major Depression (Isometsa et al, 1994, Angst, 2004 and 2005), it still can occur every time the patient has a recurring depression. Those who are the most suicidal and complete suicide while depressed are removed from the pool of potential suicides, so the frequency of the event goes down. Still, it happens.

22. 22 Myths versus Facts MYTH: Sometimes a bad event can push a person to complete suicide. FACT: Suicide results from having a serious psychiatric disorder. A single event may just be �the last straw.� From studies, although their can be triggering events before a suicide in a person with depression, the most important issue is to identify the depressive disorder and get adequate and aggressive treatment. In patients with a diagnosis of chronic alcoholism who commit suicide (usually later in their illnesses) acute interpersonal losses play a more important role. Murphy G, Suicide in Alcoholism, Oxford Press, 1992. Use of alcohol (or drugs) can play a role in suicide, because of the disinhibition it causes.From studies, although their can be triggering events before a suicide in a person with depression, the most important issue is to identify the depressive disorder and get adequate and aggressive treatment. In patients with a diagnosis of chronic alcoholism who commit suicide (usually later in their illnesses) acute interpersonal losses play a more important role. Murphy G, Suicide in Alcoholism, Oxford Press, 1992. Use of alcohol (or drugs) can play a role in suicide, because of the disinhibition it causes.

23. 23 Myths versus Facts MYTH: Suicide occurs in great numbers around holidays in November and December. FACT: Highest rates of suicide are in May or June, while the lowest rates are in December. 1972-1990 (18 years) Month Average Percent January 75.27 97.4 February 76.66 99.3 March 79.83 103.3 April 80.12 103.7 May 79.45 102.9 June 78.49 101.6 July 78.52 101.6 August 78.30 101.4 September 77.50 100.3 October 76.03 98.4 November 75.00 97.1 December 71.63 92.8 Accurate to the decimal places shown.1972-1990 (18 years) Month Average Percent January 75.27 97.4 February 76.66 99.3 March 79.83 103.3 April 80.12 103.7 May 79.45 102.9 June 78.49 101.6 July 78.52 101.6 August 78.30 101.4 September 77.50 100.3 October 76.03 98.4 November 75.00 97.1 December 71.63 92.8 Accurate to the decimal places shown.

24. 24 Risk Factors For Suicide "Chronic Versus Acute Suicide Risk" "Because patients with depressive disorders present with a wide range of symptoms and severities in a constantly changing environment of stresses and supports, their suicide risk may fluctuate over the course of illness from a chronic high risk state of severity requiring long-term preventive treatment to an acute high risk state requiring some form of immediate clinical intervention. Thus, assessment of acute suicide risk can be viewed as a process that must be repeated depending on the patient's clinical situation. The suicide assessment process should lead to a decision as to whether the patient is at a chronic high risk of suicide, acute high risk of suicide, or no increased risk of suicide at this time." Fawcett J, p.257, Textbook of Suicide Assessment and Management, American Psychiatric Publishing, February, 2006"Chronic Versus Acute Suicide Risk" "Because patients with depressive disorders present with a wide range of symptoms and severities in a constantly changing environment of stresses and supports, their suicide risk may fluctuate over the course of illness from a chronic high risk state of severity requiring long-term preventive treatment to an acute high risk state requiring some form of immediate clinical intervention. Thus, assessment of acute suicide risk can be viewed as a process that must be repeated depending on the patient's clinical situation. The suicide assessment process should lead to a decision as to whether the patient is at a chronic high risk of suicide, acute high risk of suicide, or no increased risk of suicide at this time." Fawcett J, p.257, Textbook of Suicide Assessment and Management, American Psychiatric Publishing, February, 2006

25. 25 Risk Factors Psychiatric disorders Past suicide attempts Symptom risk factors Sociodemographic risk factors Environmental risk factors

26. 26 Risk Factors Psychiatric Disorders Most common psychiatric risk factors resulting in suicide: Depression* Major Depression Bipolar Depression Alcohol abuse and dependence Drug abuse and dependence Schizophrenia *Especially when combined with alcohol and drug abuse Also important, when studies of specific psychiatric disorders are reviewed, there are many that are associated with an outcome of suicide. Suicide in Many Diagnosis SMR = Observed deaths/expected deaths Condition #Studies SMR Eating Disorders 15 23.1 Major Depression 23 20.4 Mixed Drug Abuse 4 19.4 Bipolar Disorder 15 15.0 Opioid Abuse 10 14.0 Dysthmia 10 12.1 OCD 3 11.5 Panic Disorder 9 10.0 Schizophrenia 38 8.5 Personality Disorders 5 7.08 Alcohol Abuse 35 5.86 Pediatric Psychiatirc Disorders 11 4.73 Cannabis Abuse 1 3.85 Neuroses 8 3.72 Mental Retardation 5 0.88 Harris and Barraclough, Br J Psychiarty, 1997Also important, when studies of specific psychiatric disorders are reviewed, there are many that are associated with an outcome of suicide. Suicide in Many Diagnosis SMR = Observed deaths/expected deaths Condition #Studies SMR Eating Disorders 15 23.1 Major Depression 23 20.4 Mixed Drug Abuse 4 19.4 Bipolar Disorder 15 15.0 Opioid Abuse 10 14.0 Dysthmia 10 12.1 OCD 3 11.5 Panic Disorder 9 10.0 Schizophrenia 38 8.5 Personality Disorders 5 7.08 Alcohol Abuse 35 5.86 Pediatric Psychiatirc Disorders 11 4.73 Cannabis Abuse 1 3.85 Neuroses 8 3.72 Mental Retardation 5 0.88 Harris and Barraclough, Br J Psychiarty, 1997

27. 27 Risk Factors Other psychiatric risk factors with potential to result in suicide (account for significantly fewer suicides than Depression): Post Traumatic Stress Disorder (PTSD) Eating disorders Borderline personality disorder Antisocial personality disorder

28. 28 Risk Factors Past suicide attempt (See diagram on right) After a suicide attempt that is seen in the ER about 1% per year take their own life, up to approximately 10% within 10 years. More recent research followed attempters for 22 years and saw 7% die by suicide. All studies agree that one of warning signs for death by suicide is a recent or past suicide attempt and the more serious the attempt, the more serious the risk. Still, in many studies with long follow-ups, between 7-10% of people who attempt suicide and are seen in an ER eventually commit suicide. So this is a risk factor that must be combined with others, like gender (men>women), older age, severity of current episode of depression, symptoms such as hopelessness, severe anxiety or psychic pain, etc. to be useful. It is most useful in the context of assessing the acute risk of suicide.All studies agree that one of warning signs for death by suicide is a recent or past suicide attempt and the more serious the attempt, the more serious the risk. Still, in many studies with long follow-ups, between 7-10% of people who attempt suicide and are seen in an ER eventually commit suicide. So this is a risk factor that must be combined with others, like gender (men>women), older age, severity of current episode of depression, symptoms such as hopelessness, severe anxiety or psychic pain, etc. to be useful. It is most useful in the context of assessing the acute risk of suicide.

29. 29 Risk Factors Symptom Risk Factors During Depressive Episode: Desperation Hopelessness Anxiety/psychic anxiety/panic attacks Aggressive or impulsive personality Has made preparations for a potentially serious suicide attempt* or has rehearsed a plan during a previous episode Recent hospitalization for depression Psychotic symptoms (especially in hospitalized depression) These are the symptoms that indicate, during a current depressive episode, that the patient is at greater risk, in the very near future, for suicide. These are symptoms that should be aggressively treated. These too identify acute high risk. Part of the suicide prevention plan must include psychiatric evaluation in an ER, the availability of a concerned individual, potential hospitalization and means restriction.*Coryell W, Young et al, J Clin Psych, 2005 19% of people who die by suicide are "psychotic" e.g. have delusions, hallucinations, bizarre behavior, formal thought disorders. Sometimes this is missed by the psychiatrist if the patient is an out patient. Robins et al, Biological Psychiatry, 1985These are the symptoms that indicate, during a current depressive episode, that the patient is at greater risk, in the very near future, for suicide. These are symptoms that should be aggressively treated. These too identify acute high risk. Part of the suicide prevention plan must include psychiatric evaluation in an ER, the availability of a concerned individual, potential hospitalization and means restriction.

30. 30 Risk Factors Major physical illness, especially recent Chronic physical pain History of childhood trauma or abuse, or of being bullied Family history of death by suicide Drinking/Drug use Being a smoker All these are acute and long term risk factors for suicide, but usually in the presence of major depression, or other psychiatric disorders. Runs in families: Denmark twin registry 4 concordant pairs in 19 monozygotic twins and no concordant pairs in 58 dizygotic twins Juel-Nielsen & Videbeck, Acta Genet. Med. Gemellol, 1970 ___________________________________________________________________ Higher incidence of suicide in the biologic relatives of adoptees who suffered from depression then in their adopted relatives and higher then the biologic and adopted relatives of adoptee controls who were not depressed. Kety et al, 1979 Same sample, 5,483 adoptees, 57 completed suicide Without regards to depression, these adoptees had more suicides in their biologic families than a comparison group of nonadopted controls. Schulsinger et al, 1979 This goes back to a two-factor solution, depression plus personality of aggression or impulsivity (explains why women have more depression but less suicide). All these are acute and long term risk factors for suicide, but usually in the presence of major depression, or other psychiatric disorders. Runs in families: Denmark twin registry 4 concordant pairs in 19 monozygotic twins and no concordant pairs in 58 dizygotic twins Juel-Nielsen & Videbeck, Acta Genet. Med. Gemellol, 1970 ___________________________________________________________________ Higher incidence of suicide in the biologic relatives of adoptees who suffered from depression then in their adopted relatives and higher then the biologic and adopted relatives of adoptee controls who were not depressed. Kety et al, 1979 Same sample, 5,483 adoptees, 57 completed suicide Without regards to depression, these adoptees had more suicides in their biologic families than a comparison group of nonadopted controls. Schulsinger et al, 1979 This goes back to a two-factor solution, depression plus personality of aggression or impulsivity (explains why women have more depression but less suicide).

31. 31 Risk Factors Sociodemographic Risk Factors Male Over age 65 White Separated, widowed or divorced Living alone Being unemployed or retired Occupation: health-related occupations higher (dentists, doctors, nurses, social workers) especially high in women physicians These factors are all associated, statistically, with an outcome of suicide. Of course, alone, they predict nothing. Like those mentioned in the previous slide, these add to concern when they are present in a depressed person. Occupation is a difficult item to rely on, since as noted in the item before, being unemployed also is associated with suicide. If the person is a physician and is unemployed and is depressed, clearly that is a danger sign. But the majority of people who commit suicide are working, (in school or at a job) despite their illnesses. It may be in certain professions, having the means to commit suicide combined with being depressed, leads to this outcome. Some posit that women in certain professions are more "action oriented" like men. The only definitive associations between occupation and suicide are that clergy have lower rates. Stack S, Social Science Quarterly, 2001, Murphy G, Comprehensive Psychiatry, 1998, Qin P, et al, Am J Psych 2003 These factors are all associated, statistically, with an outcome of suicide. Of course, alone, they predict nothing. Like those mentioned in the previous slide, these add to concern when they are present in a depressed person. Occupation is a difficult item to rely on, since as noted in the item before, being unemployed also is associated with suicide. If the person is a physician and is unemployed and is depressed, clearly that is a danger sign. But the majority of people who commit suicide are working, (in school or at a job) despite their illnesses. It may be in certain professions, having the means to commit suicide combined with being depressed, leads to this outcome. Some posit that women in certain professions are more "action oriented" like men. The only definitive associations between occupation and suicide are that clergy have lower rates. Stack S, Social Science Quarterly, 2001, Murphy G, Comprehensive Psychiatry, 1998, Qin P, et al, Am J Psych 2003

32. 32 Risk Factors Environmental Risk Factors Easy access to lethal means Local clusters of suicide that have a "contagious influence" Study after study has shown that availability of guns, bridges without barriers, pills packed in large numbers (instead of blister packs), toxic domestic gases, vehicle emissions* etc. allow for suicide completion. * Catalytic Converters are required by law on every motor vehicle operated in the United States of America after 1975. These converters reduce emissions of cars, such as carbon monoxide, a poisonous gas which is colorless and odorless. Even with catalytic converters, people are still able to commit suicide by locking themselves in their car with the car exhaust being funneled into the car. Improvements can be made on the catalytic converter which can monitor the carbon monoxide emission and automatically shut-off the engine should the carbon monoxide reach a dangerous level. The car industry has not pursued these improvements because the additional cost for the parts would impact the cost of automobiles. Contagion: Gould MS, Ann N Y Acad Sci., 2001Study after study has shown that availability of guns, bridges without barriers, pills packed in large numbers (instead of blister packs), toxic domestic gases, vehicle emissions* etc. allow for suicide completion. * Catalytic Converters are required by law on every motor vehicle operated in the United States of America after 1975. These converters reduce emissions of cars, such as carbon monoxide, a poisonous gas which is colorless and odorless. Even with catalytic converters, people are still able to commit suicide by locking themselves in their car with the car exhaust being funneled into the car. Improvements can be made on the catalytic converter which can monitor the carbon monoxide emission and automatically shut-off the engine should the carbon monoxide reach a dangerous level. The car industry has not pursued these improvements because the additional cost for the parts would impact the cost of automobiles. Contagion: Gould MS, Ann N Y Acad Sci., 2001

33. 33 Preventing Suicide One Community at a Time

34. 34 Preventing Suicide Prevention within our community Education Screening Treatment Means Restriction Media Guidelines

35. 35 Preventing Suicide Education Individual and Public Awareness Professional Awareness Educational Tools

36. 36 Preventing Suicide Individual and Public Awareness Primary risk factor for suicide is psychiatric illness Depression is treatable Destigmatize the illness Destigmatize treatment Encourage help-seeking behaviors and continuation of treatment

37. 37 Preventing Suicide Professional Awareness Healthcare Professionals Physicians, pediatricians, nurse practitioners, physician assistants Mental Health Professionals Psychologists, Social Workers Primary and Secondary School Staff Principals, Teachers, Counselors, Nurses College and University Resource Staff Counselors, Student Health Services, Student Residence Services, Resident Hall Directors and Advisors Gatekeepers Religious Leaders, Police, Fire Departments, Armed Services Island of Gotland, Sweden instituted an educational program for all general practitioners. After the program GPs identified more patients with major depression and treated them more accurately. Suicide Rates in: Sweden as a whole Gotland_______________ Year n per 100,00 n per 100,000 x2 P 1982 2124 25.5 11 19.7 .73 NS 1983 2087 25.1 14 25.0 0.00 NS 1984 2208 26.5 8 14.3 3.17 NS 1985 2068 24.8 4 7.1 7.06 <0.01 Rutz W. et al Acta Psychiatr Scand 1989:80:151-154 _______________________________________________________________________ Over past 100 years Hungary had the world's highest suicide rate Current rate of 32/100,000 is 3x U. S. rate. Physicians educated to recognize and treat depression in Kiskunhalas � a province in Hungary with a rate almost twice the Hungarian rate. Results: 48 months prior to project VS 48 months after the project Kiskunhalas region � (not the town) 184 suicides 156 suicides 147 men Reduction in men to 126, 14.3% 37 women Reduction in women to 30, 18.9% Total reduction of 15.2% Reduction in comparable control region, 9.4% Reduction in whole country, 11.8% AFSP sponsored studyIsland of Gotland, Sweden instituted an educational program for all general practitioners. After the program GPs identified more patients with major depression and treated them more accurately. Suicide Rates in: Sweden as a whole Gotland_______________ Year n per 100,00 n per 100,000 x2 P 1982 2124 25.5 11 19.7 .73 NS 1983 2087 25.1 14 25.0 0.00 NS 1984 2208 26.5 8 14.3 3.17 NS 1985 2068 24.8 4 7.1 7.06 <0.01 Rutz W. et al Acta Psychiatr Scand 1989:80:151-154 _______________________________________________________________________ Over past 100 years Hungary had the world's highest suicide rate Current rate of 32/100,000 is 3x U. S. rate. Physicians educated to recognize and treat depression in Kiskunhalas � a province in Hungary with a rate almost twice the Hungarian rate. Results: 48 months prior to project VS 48 months after the project Kiskunhalas region � (not the town) 184 suicides 156 suicides 147 men Reduction in men to 126, 14.3% 37 women Reduction in women to 30, 18.9% Total reduction of 15.2% Reduction in comparable control region, 9.4% Reduction in whole country, 11.8% AFSP sponsored study

38. 38 Preventing Suicide Educational Tools Depression and suicide among college students: The Truth About Suicide: Real Stories of Depression in College (2004) Comes with accompanying facilitator�s guide Depression and suicide among physicians and medical students: Struggling in Silence: Physician Depression and Suicide (54 minutes)* Struggling in Silence: Community Resource Version (16 minutes) Out of the Silence: Medical Student Depression and Suicide (15 minutes) Both shorter films are packaged together and include PPT presentations on the DVD�s Depression and suicide among teenagers: More Than Sad: Teen Depression (2009)** Comes with facilitator�s guide and additional resources Suicide Prevention Education for Teachers and Other School Personnel (2010) Includes new film, More Than Sad: Preventing Teen Suicide, More Than Sad: Teen Depression, facilitator�s guide, a curriculum manual and additional resources *received 2008 International Health & Medical Media Award (FREDDIE) in Psychiatry category **received 2010 Eli Lilly Welcome Back Award in Destigmatization category

39. 39 Preventing Suicide Screening Identify At Risk Individuals: Columbia Teen Screen and others AFSP Interactive Screening Program (ISP): The ISP is an anonymous, web-based, interactive screen for individuals (students, faculty, employees) with depression and other mental disorders that put them at risk for suicide. ISP connects at-risk individuals to a counselor who provides personalized online support to get them engaged to come in for an evaluation. Based on evaluation findings, ISP was included in the Suicide Prevention Resource Center�s Best Practice Registry in 2009. It is currently in place in 16 colleges, including four medical schools. These are only a few of the screening instruments. They are usually short, simple questions that unveil depression, alcohol or substance use, and other disorders like anorexia or bulimia. With the first, it is used in high schools, after parental consent and on a day when a counselor is present to refer those in highest distress to appropriate care. With the second, it is done anonymously over a website and can only be used if there is an appropriate counselor available to respond. The others are general depression screening usually done at health centers or designated health care sites around the country on a specific day. October is Depression and Mental Health Month. *Dr. Douglas Jacobs, Associate Clinical Professor of Psychiatry at Harvard Medical School founded and is the Executive Director of Screening for Mental Health, Inc. and founded and directs National Depression Screening Day. Since 1991, the program has provided free nationwide depression screenings each October during Mental Illness Awareness Week. Many mental health web sites, like DBSA or NAMI also have screening instruments for individuals to take to see if they had suffering from specific disorders. The most frequently used screening instrument to recognize depression is the PHQ-9 (online). It will be part of a large New York City campaign in the summer of 2006 to identify and treat people with depression. These are only a few of the screening instruments. They are usually short, simple questions that unveil depression, alcohol or substance use, and other disorders like anorexia or bulimia. With the first, it is used in high schools, after parental consent and on a day when a counselor is present to refer those in highest distress to appropriate care. With the second, it is done anonymously over a website and can only be used if there is an appropriate counselor available to respond. The others are general depression screening usually done at health centers or designated health care sites around the country on a specific day. October is Depression and Mental Health Month. *Dr. Douglas Jacobs, Associate Clinical Professor of Psychiatry at Harvard Medical School founded and is the Executive Director of Screening for Mental Health, Inc. and founded and directs National Depression Screening Day. Since 1991, the program has provided free nationwide depression screenings each October during Mental Illness Awareness Week. Many mental health web sites, like DBSA or NAMI also have screening instruments for individuals to take to see if they had suffering from specific disorders. The most frequently used screening instrument to recognize depression is the PHQ-9 (online). It will be part of a large New York City campaign in the summer of 2006 to identify and treat people with depression.

40. 40 Preventing Suicide Treatment Antidepressants Psychotherapy

41. 41 Preventing Suicide Antidepressants Adequate prescription treatment and monitoring Only 20% of medicated depressed patients are adequately treated with antidepressants � possibly due to: Side effects Lack of improvement High anxiety not treated Fear of drug dependency Concomitant substance use Didn't combine with psychotherapy Dose not high enough Didn't add adjunct therapy such as lithium or other medication(s) Didn't explore all options including: ECT or other somatic treatment Demyttenaere K, et al, J Clin Psychiatry, 2001 Demyttenaere K, et al, J Clin Psychiatry, 2001

42. 42 Preventing Suicide Psychotherapy Research shows that when it comes to treating depression, all therapy is NOT created equal. Study shows applying correct techniques reduce suicide attempts by 50% over 18 month period To be effective, psychotherapy must be: Specifically designed to treat depression Relatively short-term (10-16 weeks) Structured (therapist should be able to give step-by-step treatment instructions that any other therapist can easily follow) Examples: Cognitive Behavior Therapy (CBT), Interpersonal Therapy (IPT), Dialectical Behavior Therapy (DBT) Implement teaching of these techniques *Brown et al, JAMA, 2005*Brown et al, JAMA, 2005

43. 43 Preventing Suicide Means Restrictions Firearm safety Construction of barriers at jumping sites Detoxification of domestic gas Improvements in the use of catalytic converters in motor vehicles Restrictions on pesticides Reduce lethality or toxicity of prescriptions Use of lower toxicity antidepressants Change packaging of medications to blister packs Restrict sales of lethal hypnotics (i.e. Barbiturates) Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., et. al., (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association 294 (16), 2064-2074.Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., et. al., (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association 294 (16), 2064-2074.

44. 44 Preventing Suicide Media Guidelines Considerations

45. 45 Preventing Suicide Media Guidelines Encourage implementation of responsible media guidelines for reporting on suicide, such as those developed by AFSP in partnership with government agencies and private organizations. Reporting on Suicide: recommendations for the media Can be found on AFSP website: www.afsp.org/media

46. 46 Preventing Suicide Media Considerations Consider how suicide is portrayed in the media TV Movies Advertisements The Internet danger Suicide chat rooms Instructions on methods Solicitations for suicide pacts.

47. 47 You Can Help! Adapted with permissionfrom the Washington Youth Suicide Prevention Program

48. 48 You Can Help Know warning signs Intervention

49. 49 You Can Help Most suicidal people don't really want to die � they just want their pain to end About 80% of the time people who kill themselves have given definite signals or talked about suicide

50. 50 Warning Signs Observable signs of serious depression Unrelenting low mood Pessimism Hopelessness Desperation Anxiety, psychic pain, inner tension Withdrawal Sleep problems Increased alcohol and/or other drug use Recent impulsiveness and taking unnecessary risks Threatening suicide or expressing strong wish to die Making a plan Giving away prized possessions Purchasing a firearm Obtaining other means of killing oneself Unexpected rage or anger You Can Help

51. 51 Proposed DSM-V Suicide Assessment Dimension

52. 52 Intervention Three Basic Steps: 1. Show you care 2. Ask about suicide 3. Get help You Can Help

53. 53 Intervention: Step One Show You Care Be Genuine You Can Help

54. 54 Show you care Take ALL talk of suicide seriously If you are concerned that someone may take their life, trust your judgment! Listen Carefully Reflect what you hear Use language appropriate for age of person involved Do not worry about doing or saying exactly the "right" thing. Your genuine interest is what is most important. You Can Help

55. 55 Be Genuine Let the person know you really care. Talk about your feelings and ask about his or hers. "I'm concerned about you� how do you feel?" "Tell me about your pain." "You mean a lot to me and I want to help." "I care about you, about how you're holding up." "I'm on your side�we'll get through this." You Can Help

56. 56 Intervention: Step Two Ask About Suicide Be direct but non-confrontational Talking with people about suicide won't put the idea in their heads. Chances are, if you've observed any of the warning signs, they're already thinking about it. Be direct in a caring, non- confrontational way. Get the conversation started. You Can Help

57. 57 You Can Help You do not need to solve all of the person's problems � just engage them. Questions to ask: Are you thinking about suicide? What thoughts or plans do you have? Are you thinking about harming yourself, ending your life? How long have you been thinking about suicide? Have you thought about how you would do it? Do you have __? (Insert the lethal means they have mentioned) Do you really want to die? Or do you want the pain to go away?

58. 58 Ask about treatment: Do you have a therapist/doctor? Are you seeing him/her? Are you taking your medications? You Can Help

59. 59 Intervention: Step Three Get help, but do NOT leave the person alone Know referral resources Reassure the person Encourage the person to participate in helping process Outline safety plan You Can Help

60. 60 You Can Help Know Referral Resources Resource sheet Hotlines

61. 61 You Can Help Resource Sheet Create referral resource sheet from your local community Psychiatrists Psychologists Other Therapists Family doctor/pediatrician Local medical centers/medical universities Local mental health services Local hospital emergency room Local walk-in clinics Local psychiatric hospitals

62. 62 Hotlines National Suicide Prevention Lifeline 1-800-273-TALK www.suicidepreventionlifeline.org 911 In an acute crisis, call 911 You Can Help

63. 63 Reassure the person that help is available and that you will help them get help: �Together I know we can figure something out to make you feel better.� �I know where we can get some help.� �I can go with you to where we can get help.� �Let's talk to someone who can help . . . Let's call the crisis line now.� Encourage the suicidal person to identify other people in their life who can also help: Parent/Family Members Favorite Teacher School Counselor School Nurse Religious Leader Family doctor You Can Help

64. 64 Outline a safety plan Make arrangements for the helper(s) to come to you OR take the person directly to the source of help - do NOT leave them alone! Once therapy (or hospitalization) is initiated, be sure that the suicidal person is following through with appointments and medications. You Can Help