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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
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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

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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
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Depression and SuicideMajor Public Health Risks

• Analogy
• Passenger Jet

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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

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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

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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

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DepressionFacts for Families

• University of Michigan
• Depression Center
• Family Education Workshop

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It is Common

• About 1 Woman in 5, and 1 Man in 12 Will
  Experience Depression During his or her Lifetime.

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Clinical Depression is...

• 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

Brain Images
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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
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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

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Depression Onset. A complex relationship between
stress and biologic vulnerability.
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Risk of Cycle Acceleration with Aging in
Untreated Illness
Pine et al, AJP, 1998Pine et al, AJP, 1998
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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

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Suicide is

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

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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

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What has delayed suicide prevention?

• Myths
• Stigma
• Belief that no one can stop a person who plans to
  die by suicide
• Suicide Prevention is Everybodys Business!

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An ExampleUS Air Force Suicide Prevention
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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

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Suicide Among Airmen
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Results
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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.

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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.

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QPR

• Question, Persuade, Refer

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QPR

• Ask A Question, Save A Life

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QPR

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

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QPR
Suicide Myths
and Facts

• Myth No one can stop a suicide, it is inevitable.
• Fact If 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.
• Fact Asking 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 everybodys business,
  and anyone can help prevent the tragedy of
  suicide

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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 dont do it.
• Fact People 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...
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QPR Suicide Clues And Warning SignsThe more
clues and signs observed, the greater the risk.
Take all signs seriously!
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QPR

• Direct Verbal Clues
• Ive decided to kill myself.
• I wish I were dead.
• Im going to commit suicide.
• Im going to end it all.
• If (such and such) doesnt happen, Ill kill
  myself.

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QPR

• Indirect Verbal Clues
• Im tired of life, I just cant go on.
• My family would be better off without me.
• Who cares if Im dead anyway.
• I just want out.
• I wont be around much longer.
• Pretty soon you wont have to worry about me.

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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

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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

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QPR Tips for Asking the Suicide Question

• If in doubt, dont 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, counselors name and any other
  information that might help
• Remember How you ask the question is less
  important than that you ask it

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Q QUESTION

• Less Direct Approach
• Have you been unhappy lately? Have you been
  very unhappy lately? Have you been so very
  unhappy lately that youve been thinking about
  ending your life?
• Do you ever wish you could go to sleep and never
  wake up?

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Q QUESTION

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

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How Not to Ask the Suicide Question

• Youre not suicidal, are you?

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P PERSUADE
HOW TO PERSUADE SOMEONE TO STAY ALIVE

• 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

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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
  weve found some help?
• YOUR WILLINGNESS TO LISTEN AND TO HELP CAN
  REKINDLE HOPE, AND MAKE ALL THE DIFFERENCE.

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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.

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• REMEMBER
• Since almost all efforts to persuade someone to
  live instead of attempt suicide will be met with
  agreement and relief, dont hesitate to get
  involved or take the lead.

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For Effective QPR

• Say I want you to live, or Im on your
  side...well get through this.
• Get Others Involved. Ask the person who else
  might help. Family? Friends? Brothers? Sisters?
  Pastors? Priest? Rabbi? Bishop? Physician?

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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.

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

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

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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.

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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!

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What to Do?

• Take all signs seriously never think that
  suicide cant happen to someone you know
• Stay with the person. If you cant, find someone
  who can.
• Involve others friends, trusted adults, mental
  health professionals, family or someone of faith
  if appropriate
• Get the person to additional help as soon as
  possible

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Additional Training Opportunities

• Core Competency Program
• Train the Trainers Curriculum (two days)
• One day Core Competency Curriculum for EAP/Human
  Resources Professionals
• Half-day Pre-Conference Workshop in New Orleans
  (April 2007)
• Is Path Warm? Posters and wallet cards, training
  on DVD
• Plans for Web-cast training with Lanny Berman,
  PhD, Executive Director of AAS
• AASs Workplace-Based Suicide Prevention Program

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To Call for Help

• The National Suicide Prevention Lifeline
• 1 800- 273 TALK (8255)
• If there is imminent threat, call 911

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Contact Information

• Karen M Marshall
• American Association of Suicidology
• 5221 Wisconsin Ave., NW
• Washington DC 20015
• 202-237-2280
• KMarshall_at_suicidology.org
• www.suicidology.org