Epidemiology of Suicide in Latinos A Practical Approach

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Epidemiology of Suicide in LatinosA Practical
Approach

• Miguel A. Cruz-Feliciano, MS
• Institute on Research, Education and Services in
  Addiction
• Universidad Central del Caribe, School of Medicine

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Objectives

• Understand suicide epidemiology
• Identify protective and risk factors
• Highlight interventions and approaches
• Draw attention to future steps

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Epidemiology of Suicide

• Definition
• Trends
• Latinos Situation

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Definitions

• Suicide behavior
• Suicide
• Completed
• Attempt
• Gesture
• Threat
• Ideation
• Self-injure

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COMPLETION ATTEMPT GESTURE THREAT IDEATION
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World Health Organization-Suicide

• Approximately one million people die per year.
• Rates have increased by 60 worldwide.
• Thirteenth leading cause of death worldwide.
• Attempts are 20 times more frequent.
• Represent 1.8 of the total global burden of
  disease.
• Rate higher in elderly.
• Young people have highest risk.
• Mental disorders (particularly depression and
  substance abuse) are associated with more than
  90 of all cases of suicide.

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WHO Suicide Stats 2007 Americas Top 10
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Suicide in United States

• Rate 2005 - 11.0 X 100,000
• Eleventh position
• Among the top five causes of death for all people
  in the US aged 1054 years
• Second 15-24 age 1054 years
• Third in Hispanics 15-24 age

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Suicide in United States

• Every 17 minutes another life is lost to suicide.
  
• Every day 86 Americans take their own life and
  over 1500 attempt suicide.
• There are an estimated 8 to 25 attempted suicides
  for every one death by suicide.
• Suicide rates are consistently higher in the
  western states than in the rest of the U.S.
• Among young adults ages 15 to 24 years old, there
  is 1 suicide for every 100-200 attempts.
• Among adults ages 65 years and older, there is 1
  suicide for every 4 suicide attempts.
• For every suicide death there are 5
  hospitalizations and 22 Emergency Department
  visits for suicidal behaviors over 670,000 visits
  in a year.

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Suicide in United States

• The most frequently reported mental health
  diagnoses in 2004 were
• depression (85.2),
• bipolar disorder (7.4),
• schizophrenia (3.3).
• Roughly half of victims were described by family
  or friends as being depressed before the time of
  death.
• Problems with a current or former intimate
  partner contributed to 27.9 of suicides.
• Physical health problems, most commonly in older
  adults, contributed to approximately 24.9 of the
  suicides.
• Nearly 19.0 of suicide victims had made previous
  attempts, and 16.5 had alcohol dependence
  problems.
• There are now twice as many deaths due to suicide
  than due to HIV/AIDS.

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Hispanic Demographics in US

• Hispanics/Latinos (H/L) now comprise the largest
  minority group in the United States (14.2)
• By 2020, Hispanics are expected to represent 17
  of the U.S. population
• As a group
• They are young
• 40 are under the age of 21
• Have a disproportionately low-income level
• 23 live below the poverty line
• Have a low level of educational attainment
• More than half of H/L under the age of 25 have
  not graduated from high school
• 32.7 have no health coverage at all

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Hispanic Demographics in US

• Hispanics/Latinos accounted for about 50 of the
  national population growth of 2.9 million between
  July 1, 2003, and July 1, 2004.
• Hispanic growth rate of 3.6 over a year was more
  than 3 times that of total population (1).
• In 2006 the Hispanic/Latino population passed the
  42.7 million mark in the US.

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Hispanic Suicide in US

• During 1997-2001, a total of 8,744 Hispanics died
  from suicide
• The age-adjusted rate for males was 5.9 times the
  rate for females
• Approximately 50 of all suicides occurred among
  persons 10-34 years
• Highest overall rate was among persons aged gt85
  years

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Hispanic Suicide in US

• By Ethnic Group
• Mexican origin 4,934 (56)
• Unknown Hispanic origin 1,219 (14)
• Central and South Americans 950 (11)
• Puerto Ricans 932 (11)
• Cubans 709 (8).
• Methods
• Firearms (48)
• Suffocation (35)
• Poisoning (7).

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Hispanic Suicide in US

• YRBS
• Suicide Plan (2007)
• (12.8 Hispanics) vs. (9.5 Black, 10.8 White)
• Attempted suicide (2007)
• (10.2 Hispanics) vs. (7.7 Black, 5.6 White)
• Attempted suicide (2005)
• (11.3 Hispanics) vs. (7.6 Black, 7.3 White)
• Seriously Considered Attempting Suicide (2005,
  Females)
• (24.4 Hispanics) vs. (17.1 Black, 21.5 White)
• Felt Sad or Hopeless (2005, Females)
• (46.7 Hispanics) vs. (36.9 Black, 33.4 White)

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Hispanic Suicide in US

• Hispanic female high school students in grades
  9-12 reported a higher percentage of suicide
  attempts
• (14.9 Hispanics) vs. (9.8 Black, 9.3 White).
  (Eaton et al. 2006).

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Hispanic Suicide in US

• The NHSDA Report Risk of Suicide Among Hispanics
  Females (12-17)
• Hispanic female youths born in the United States
  were at higher risk than Hispanic female youths
  born outside the United States.
• Hispanic female youths in small metropolitan
  areas were more likely to be at risk than their
  counterparts in large metropolitan or
  nonmetropolitan Areas
• Only 32 of Hispanic females at risk for suicide
  during the past year received mental health
  treatment during this same time period.
• Among youths at risk for suicide who received
  mental health treatment, Hispanic females were
  less likely than non-Hispanic females to report
  suicidal thoughts or attempts as the reason for
  the last time they received these services

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Alcohol-induced mortality

• Among the major race-sex groups, the rate
  significantly changed for black males, and among
  the major race ethnic-sex groups,
• The rate decreased significantly
• Black males (7.3)
• Non-Hispanic black males (7.2)
• The rate increased significantly
• Hispanic males (7.3)

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Drug-induced mortality

• Between 2004 and 2005, the age-adjusted death
  rate for drug-induced causes among the major
  ethnic-race-sex groups increased

• 12.4 Hispanic males
• 10.5 Black males
• 8.6 White males.

• 9.1 Black females
• 7.4 White females
• 2.9 Hispanic females.

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Polydrug use - Suicide

• Alcohol and drug use predict subsequent suicide
  attempts.
• Previous use is not a significant predictor among
  current nonusers.
• Abuse and dependence are significant predictors
  among users for three of the 10 substances
  considered (alcohol, inhalants, and heroin).
• The number of substances used is more important
  than the types of substances used in predicting
  suicidal behavior.

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Risky Family in Risky Environment

• This longitudinal study aims to understand the
  relationship between suicidal attempts, polydrug
  use and depression in a sample of adolescents 12
  to 15 years old in Puerto Rico.
• The study sample is comprised of 691 adolescents
  and their parents.
• Adolescents were interviewed in their homes
  utilizing a computer-assisted personal
  interviewing (CAPI) system and a
  self-administered form.

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Risky Family in Risky Environment

• Multiple logistic regression analysis revealed
  that subjects with these characteristics were
  more likely to report suicide attempts
• Who met the criteria for depression (OR6.8,
  plt0.001).
• Alcohol (OR7.5, plt0.001).
• Polydrug users (OR8.7, p0.032) who use alcohol
  and illegal substances.
• Adolescents with mothers who met the criteria for
  depression (OR2.4, p0.069).

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Race-Ethnic DifferencesUS National Sample

• The pattern of race-ethnic differences in risk
  for psychiatric disorders suggests the presence
  of protective factors that originate in childhood
  and have generalized effects on internalizing
  disorders.

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Race-Ethnic Differences

• Rates of major depression ranged from 9.3 (Puerto
  Ricans) to 3.2 (Cuban Americans).
• Puerto Ricans and whites had the highest rates of
  depression.
• Suicide attempt rates ranged from 9.1 for Puerto
  Ricans to 1.9 for Cuban Americans.
• Puerto Ricans had higher suicide attempt rates
  compared with other groups.
• Conclusion This study underscores that there are
  differences between Hispanic ethnic groups. The
  impact of the migration process, socioeconomic
  status, and acculturation may underlie
  differences in major depression and suicide
  attempt rates across ethnic groups.

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Risk factors

• There are several risk factors for suicide
• Past suicide attempts
• Psychiatric disorders
• Symptom risk factors
• Sociodemographic risk factors
• Environmental risk factors

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Risk factors

• Psychiatric Disorders
• Most common psychiatric risk factor resulting in
  suicide
• Depression
• Major Depression
• Bipolar Depression
• Alcohol abuse and dependence
• Adults with a past year major depressive
  episode who reported past month binge alcohol or
  illicit drug use were more likely to report
  suicidal thoughts and suicide attempts than their
  counterparts with past year depression who did
  not binge drink or use an illicit drug in the
  past month.
• Drug abuse and dependence
• Schizophrenia
• Other psychiatric risk factors with potential to
  result in suicide (account for significantly
  fewer suicides than Depression)
• Post Traumatic Stress Disorder (PTSD)
• Eating disorders

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Risk factors

• Symptom Risk Factors During Depressive Episode
• Desperation
• Hopelessness
• Anxiety/psychic anxiety/panic attacks
• Sudden change in mood
• 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)

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Risk factors

• Major physical illness-especially recent
• Chronic physical pain
• History of trauma, abuse, or being bullied
• Family history of death by suicide
• Drinking/Drug use
• Being a smoker

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Risk factors

• Sociodemographic
• Male
• Being over 65
• White
• Separated, widowed or divorced
• Living alone
• Being unemployed or retired
• Occupation health related occupation higher
  (dentists, doctors, nurses, social workers)
  especially high in women physicians
• Sociocultural
• Lack of social support and sense of isolation
• Stigma associated with help-seeking behavior
• Barriers to accessing health care, especially
  mental health and substance abuse treatment
• Certain cultural and religious beliefs (for
  instance, the belief that suicide is a noble
  resolution of a personal dilemma)
• Exposure to, including through the media, and
  influence of others who have died by suicide

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Risk factors

• Environmental Risk Factors
• Easy access to lethal means
• Local clusters of suicide that have a contagious
  influence

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Symptoms and Danger SignsWarning Signs of Suicide

• Danger
• Talking about suicide.
• Statements about hopelessness, helplessness, or
  worthlessness.
• Preoccupation with death.
• Suddenly happier, calmer.
• Loss of interest in things one cares about.
• Visiting or calling people one cares about.
• Making arrangements setting one's affairs in
  order.
• Giving things away, such as prized possessions.

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Symptoms and Danger SignsWarning Signs of Suicide

• 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

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Warning Signs

• IS PATH WARM? (From American Association of
  Suicidology)
• I Ideation
• S Substance Abuse
• P Purposelessness
• A Anxiety
• T Trapped
• H Hopelessness
• W Withdrawal
• A Anger
• R Recklessness
• M Mood Change

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Important to Assess Hispanics and Suicide

• Mental illness (e.g., depression, depressive
  symptoms)
• Substance abuse (e.g., alcohol, illegal drugs)
• Social and interpersonal conflict (e.g.,
  relationship break-up, arguments, fight with
  parents)
• Migration Patterns
• Acculturative stress
• Felt guilty about leaving family/friends in
  country of origin
• Same respect in US as in country of origin
• Limited contact with family and friends
• Interaction hard due to difficulty with English
  language
• Treated badly due to poor/accented English
• Difficult to find work due to Latino descent
  
• Questioned about legal status
• Think might be deported if go to
  social/government agency
• Avoid health service due to Immigrant officials

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Important to Assess Hispanics and Suicide

• Family dysfunction
• Lower socioeconomic status
• Age of onset alcohol and drugs
• Homelessness
• Lower levels of acculturation
• Acculturative discrepancies
• Hispanic ancestry
• Generational status
• Social coping (e.g., skills in problem solving,
  conflict resolution, and nonviolent handling of
  disputes

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Important to Assess Hispanics and Suicide

• Negative parenting
• History of sexual or physical abuse
• Same sex attraction
• Family support
• Access to health care
• School Performance
• Friend suicide attempt or completion
• Weapon-carrying at school
• Religious Beliefs

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Assessment of Suicide

• H-History
• E-Environmental Influences
• L-Lethality
• P-Psychological Organization
• E-Evaluation of Risk Potential
• R-Recommendations

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Screening Instruments

• Beck Hopelessness Scale
• Beck Scale for Suicidal Ideation
• Beck Suicide Intent Scale
• Beck Depression Inventory
• Los Angeles Suicide Prevention Center Scale
• Hamilton Rating Scale for Depression
• The SAD PERSON Score Patterson
• Columbia Teen Screen
• AFSP College screening instrument

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Quick Assessment

• Have you ever wanted to go sleep and not to wake
  up?
• Have you ever thought about hurting yourself?
• If you were to hurt yourself, how would you do
  it?
• I above is yes, have you carried any of that plan
  out?
• Chemical Dependency Counseling

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Suicidal Thoughts What to Do

• Hotlines
• National Suicide Prevention Lifeline
• 1-800-273-TALK
• www.suicidepreventionlifeline.org
• 911
• In an acute crisis call 911
• 1-800-SUICIDE http//www.hopeline.com/

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Resources

• American Foundation for Suicide Prevention
• American Association of Suicidology
• Centers for Disease Control and Prevention
• National Center for Injury Prevention and
  Control
• Suicide Prevention Action Network
• American Association of Suicidology (AAS)
• Suicide Awareness Voices of Education (SAVE)
• Suicide Prevention Advocacy Network (SPAN USA)
• Yellow Ribbon Suicide Prevention Program
• National Strategy For Suicide Prevention
• Suicide Prevention Resource Center
• American Psychiatric Association
• National Suicide Prevention Lifeline

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Intervention

• If You See the Warning Signs of Suicide...
• Begin a dialogue by asking questions. Suicidal
  thoughts are common with depressive illnesses and
  your willingness to talk about it in a
  non-judgmental, non-confrontational way can be
  the help a person needs to seeking professional
  help. Questions okay to ask
• "Do you ever feel so badly that you think about
  suicide?"
• "Do you have a plan to commit suicide or take
  your life?"
• "Have you thought about when you would do it
  (today, tomorrow, next week)?"
• "Have you thought about what method you would
  use?"

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Intervention

• Three Basic Steps
• Show you care
• Ask about suicide
• Get help

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Show You Care and Be Genuine

• 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.
• Be Genuine
• Let the person know you really care. Talk about
  your feelings and ask about his or hers.
• Im concerned about youabout how you feel.
• Tell me about your pain.
• You mean a lot to me and I want to help.
• I care about you, about how youre holding up.
• I dont want you to kill yourself.
• Im on your sidewell get through this.

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Ask About Suicide

• Be direct but non-confrontational
• Dont hesitate to raise the subject.
• Talking with people about suicide wont put the
  idea in their heads. Chances are, if youve
  observed any of the warning signs, theyre
  already thinking about it. Be direct in a caring,
  non-confrontational way. Get the conversation
  started.

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Ask About Suicide

• You do not need to solve all of the persons
  problems Just engage them
• 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?

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Ask About Suicide

• Treatment
• Do you have a therapist/doctor?
• Are you seeing him/her?
• Are you taking your medications?

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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

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List of NREPP-Reviewed Suicide Interventions

• The following interventions addressing suicide
  currently are listed on the NREPP registry
• Prevention Programs
• American Indian Life Skills Development/Zuni Life
  Skills Development
• CARE (Care, Assess, Respond, Empower)
• CAST (Coping and Support Training)
• Teen Screen
• Emergency Room Intervention for Adolescent
  Females
• PROSPECT (Prevention of Suicide in Primary Care
  Elderly Collaborative Trial)
• SOS Signs of Suicide
• United States Air Force Suicide Prevention
  Program
• Treatment Programs
• Cognitive Behavioral Therapy for Adolescent
  Depression
• Dialectical Behavior Therapy

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Challenges of Suicide Research

• Suicide is not a single illness but a fatal
  complication of different disorders
• Depression
• Bipolar illness
• Schizoaffective disorder
• Anxiety disorders, including PTSD
• Alcoholism and other substance abuse
• Adjustment disorder (children adolescents)
• Personality disorders (e.g. borderline)
• Personality traits (e.g., impulsivity, aggression)

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Challenges

• Suicide is a behavior, influenced and shaped by
  different forces
• Biological the body, especially the brain
• Psychological feelings, attitudes, personality,
  shaped by human development and life experiences,
  including stress
• Social roles and norms assigned by gender,
  race, ethnicity, social class, etc. social
  relationships, especially family (e.g., abuse)
• Cultural values, beliefs and attitudes of
  groups and sub-groups
• Laws

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Challenges

• The many disciplines involved in suicide research
  use different approaches and methods.
• Lack of consistent terminology
• Procedures for determining suicide death vary
  across the country (e.g., requirement of suicide
  note)
• Deliberate self-harm vs. suicide attempt
• Suicide attempts by lethality
• Suicidal ideation, preoccupation frequency?
  intensity? duration?
• Suicidality ??

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Challenges

• With 11 suicides for every 100,000 people, an
  enormous sample is needed to have enough suicides
  to reach valid conclusions.
• Suicide attempt is often used as a proxy for
  suicide death. But, while suicide attempt is a
  risk factor for suicide death, it is a weak
  predictor 1 of 10 suicide attempters dies by
  suicide.

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Challenges

• Suicidal persons are commonly prevented from
  participating in research studies by
  Institutional Review Boards.
• Most studies of suicide death are retrospective
  or after the fact (e.g., psychological
  autopsies).
• Omits observations or self-reports from the
  person prior to suicide.

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Exercise

• Divide Group
• Network
• Topic Discussion - Challenges
• Wrap-up

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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.

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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

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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.

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Myths versus facts

• MYTH
• People who talk about suicide dont 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.

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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.

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Myths versus facts

• MYTH
• Males are more likely to be suicidal.
• FACT
• Men COMPLETE suicide more often than women.
  However, women attempt suicide three times more
  often than men.

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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.

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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.

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Myths versus facts

• MYTH
• Once a person attempts suicide the pain and
  shame 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.

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Myths versus facts

• MYTH
• Sometimes a bad event can push a person to
  complete suicide.
• FACT
• Suicide results from serious psychiatric
  disorders not just a single event.