Preventing Suicide The Gap Between What We Know and What We Do

1. Preventing Suicide The Gap Between What We Know and What We Do For: the EAPA Conference Nashville, TN Presented By: Karen M Marshall American Association of Suicidology Washington, DC Sunday, October 8, 2006

2. An Overview • A Framework • What We Know • What We Do • Question, Persuade, Refer (CPR for Suicide Prevention) • Best Practices: Warning Signs of Acute Suicide Risk and How to Respond

3. Depression and SuicideMajor Public Health Risks* Relevant Facts: • More than 30,000 suicide deaths annually • Suicide deaths occur twice as frequently deaths from HIV/AIDS • And nearly twice as often as homicides • Estimated 750,000 non-fatal attempts, many requiring medical intervention; many resulting in lifelong health problems or permanent disability *Former US Surgeon General Dr. David Satcher

4. Depression and SuicideMajor Public Health Risks* • Analogy: • Passenger Jet

5. Relevant Facts: • Third leading cause of death among 15-24 year olds • Second leading cause of death for college-age young people The Good News is …

6. Relevant Facts • White males over age 65 have the highest rate of suicide • Two-thirds of suicide deaths are among the workforce, those ages 25 – 59 • Depression costs American business in excess of $78 billion a year • Suicide adds another $12 billion annually

7. Relevant Facts • Men end their lives four times more often than women • Women attempt suicide four times more often than men • Firearms account for more than two-thirds of all suicide deaths • 90 percent of all suicide deaths are linked to a diagnosable, treatable brain illness

8. Depression…Facts for Families University of Michigan Depression Center Family Education Workshop

9. It is Common……… About 1 Woman in 5, and 1 Man in 12 Will Experience Depression During his or her Lifetime….

10. 1990 Begins the Decade of the Brain Clinical Depression is... Brain Images • Treatable! • Usually under-treated because of no diagnosis, misdiagnosis or stigma • A disorder that can now be “visualized” with new brain imaging techniques • Terrific progress since “Decade of the Brain” launched in 1990

11. Clinical Depression is not... Something that you can just “snap out of” without effective treatment A character flaw or a sign of weakness Just normal sadness or disappointment Just “in your head” A normal part of aging

12. Symptoms of Depression • Loss of pleasure • Persistent sadness • Change in appetite • Sleep disturbance • Feelings of worthlessness • Helplessness/hopelessness • Aches and pains • Irritability/impulsivity • Self-medicating • Suicidal thoughts

13. Depression Onset…. A complex relationship between stress and biologic vulnerability.

14. Risk of Cycle Acceleration with Aging in Untreated Illness Pine et al, AJP, 1998Pine et al, AJP, 1998

15. Untreated symptoms then linked to: • Poor school performance and more stress • Alcohol and drug abuse and occasional disciplinary or legal problems • Feelings of worthlessness and hopelessness • Problems with relationships • Overt depressive disorder • Suicide

16. Suicide is… The result of a complex mix of biological, emotional, physical and circumstantial conditions. And, it is preventable

17. What Is Suicide Prevention? A Public Health Approach • Ranges from general education and awareness • To research • To treatment of individuals All must be funded, increased and improved

18. What has delayed suicide prevention? • Myths • Stigma • Belief that no one can stop a person who plans to die by suicide Suicide Prevention is Everybody’s Business!

19. An Example:US Air Force Suicide Prevention

20. USAF Program Elements • General suicide awareness and prevention training - annual • Special training for • Key gatekeepers • Service providers • Policies to improve access to key services • Communications (social marketing) campaign • De-stigmatize EARLY help-seeking • Promote social support – “caring community” • Screening for mental health problems • Improved coordination of social services • Focus on strengthening life/coping skills

21. Suicide Among Airmen

22. Results

23. Evaluators Noted: “The key lessons derived from this community based intervention may be particularly adaptable in selected workplace contexts that are more tightly organized and provide or coordinate human services for their employees or in settings with naturally occurring social networks.”

24. National Strategy for Suicide Prevention • Goal 1: Promote awareness that suicide is a public health problem that is preventable. • Objective 4.4: By 2005, increase the proportion of employers that ensure the availability of evidence-based prevention strategies for suicide.

25. QPR Question, Persuade, Refer

26. QPR Ask A Question, Save A Life

27. QPR • QPR is not intended to be a form of counseling or treatment. • QPR is intended to offer hope through positive action.

28. QPRSuicide Myths and Facts • Myth No one can stop a suicide, it is inevitable. • FactIf people in a crisis get the help they need, they will probably never be suicidal again. • Myth Confronting a person about suicide will only make them angry and increase the risk of suicide. • FactAsking someone directly about suicidal intent lowers anxiety, opens up communication and lowers the risk of an impulsive act. • Myth Only experts can prevent suicide. • Fact Suicide prevention is everybody’s business, and anyone can help prevent the tragedy of suicide

29. QPR Myths And Facts About Suicide • Myth Suicidal people keep their plans to themselves. • Fact Most suicidal people communicate their intent sometime during the week preceding their attempt. • Myth Those who talk about suicide don’t do it. • FactPeople who talk about suicide may try, or even complete, an act of self-destruction. • Myth Once a person decides to die by suicide, there is nothing anyone can do to stop them. • Fact Suicide is the most preventable kind of death, and almost any positive action may save a life. How can I help? Ask the Question...

30. QPRSuicide Clues And Warning SignsThe more clues and signs observed, the greater the risk. Take all signs seriously!

31. QPR Direct Verbal Clues: • “I’ve decided to kill myself.” • “I wish I were dead.” • “I’m going to commit suicide.” • “I’m going to end it all.” • “If (such and such) doesn’t happen, I’ll kill myself.”

32. QPR Indirect Verbal Clues: • “I’m tired of life, I just can’t go on.” • “My family would be better off without me.” • “Who cares if I’m dead anyway.” • “I just want out.” • “I won’t be around much longer.” • “Pretty soon you won’t have to worry about me.”

33. QPR Behavioral Clues: • Any previous suicide attempt • Acquiring a gun or stockpiling pills • Co-occurring depression, moodiness, hopelessness • Putting personal affairs in order • Giving away prized possessions • Sudden interest or disinterest in religion • Drug or alcohol abuse, or relapse after a period of recovery • Unexplained anger, aggression and irritability

34. QPR Situational Clues: • Being fired or being expelled from school • A recent unwanted move • Loss of any major relationship • Death of a spouse, child, or best friend, especially if by suicide • Diagnosis of a serious or terminal illness • Sudden unexpected loss of freedom/fear of punishment • Anticipated loss of financial security • Loss of a cherished therapist, counselor or teacher • Fear of becoming a burden to others

35. QPR Tips for Asking the Suicide Question • If in doubt, don’t wait, ask the question • If the person is reluctant, be persistent • Talk to the person alone in a private setting • Allow the person to talk freely • Give yourself plenty of time • Have your resources handy; QPR Card, phone numbers, counselor’s name and any other information that might help Remember: How you ask the question is less important than that you ask it

36. Q QUESTION Less Direct Approach: • “Have you been unhappy lately? Have you been very unhappy lately? Have you been so very unhappy lately that you’ve been thinking about ending your life?” • “Do you ever wish you could go to sleep and never wake up?”

37. Q QUESTION Direct Approach: • “You know, when people are as upset as you seem to be, they sometimes wish they were dead. I’m wondering if you’re feeling that way, too?” • “You look pretty miserable, I wonder if you’re thinking about suicide?” • “Are you thinking about killing yourself?” NOTE: If you cannot ask the question, find someone who can.

38. How Not to Ask the Suicide Question “You’re not suicidal, are you?”

39. P PERSUADE • Listen to the problem and give them your full attention • Remember, suicide is not the problem, only the solution to a perceived insoluble problem • Do not rush to judgment • Offer hope in any form HOW TO PERSUADE SOMEONE TO STAY ALIVE

40. P PERSUADE Then Ask: • Will you go with me to get help?” • “Will you let me help you get help?” • “Will you promise me not to kill yourself until we’ve found some help?” YOUR WILLINGNESS TO LISTEN AND TO HELP CAN REKINDLE HOPE, AND MAKE ALL THE DIFFERENCE.

41. R REFER • Suicidal people often believe they cannot be helped, so you may have to do more. • The best referral involves taking the person directly to someone who can help. • The next best referral is getting a commitment from them to accept help, then making the arrangements to get that help. • The third best referral is to give referral information and try to get a good faith commitment not to complete or attempt suicide. Any willingness to accept help at some time, even if in the future, is a good outcome.

42. REMEMBER Since almost all efforts to persuade someone to live instead of attempt suicide will be met with agreement and relief, don’t hesitate to get involved or take the lead.

43. For Effective QPR • Say: “I want you to live,” or “I’m on your side...we’ll get through this.” • Get Others Involved. Ask the person who else might help. Family? Friends? Brothers? Sisters? Pastors? Priest? Rabbi? Bishop? Physician?

44. For Effective QPR • Join a Team. Offer to work with clergy, therapists, psychiatrists or whomever is going to provide the counseling or treatment. • Follow up with a visit, a phone call or a card, and in whatever way feels comfortable to you, let the person know you care about what happens to them. Caring may save a life.

45. REMEMBER WHEN YOU APPLY QPR, YOU PLANT THE SEEDS OF HOPE. HOPE HELPS PREVENT SUICIDE.

47. Warning Signs of Acute Suicide Risk* *Developed by AAS with an international task force

48. Is Path Warm? I Ideation: Threats or talk of wish to hurt or kill self; seeking access to means; talk or writing about death dying or suicide S Substance Abuse: Increased alcohol or drug use

49. Is Path Warm? P Purposeless: Expressing no reasons for living, feeling like a burden A Anxiety: Agitation, restlessness, unable to sleep T Trapped: Feeling that there is no way out; black or white thinking; Life sucks … death seems like the only option HHopelessness: Communications describing sense of self as lacking value, others as not caring and the future as unchanging; use of absolute negative words: “Things will never be any different,” “I always screw up,” “Nobody cares.”

50. Is Path Warm? W Withdrawal: From friends, family, society; sleeping all the time. A Anger: Uncontrolled and excessive expressions of anger, rage or homicidal ideation, statements about seeking revenge R Recklessness: Acting reckless; engaging in risky activities seeming without thinking M Mood Changes: Dramatic shifts from typical mood state ?You must ask!