Suicide Prevention: Its Everybodys Business

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Suicide PreventionIts Everybodys Business
October 2005

• Mark Garry, M.D.
• Director of Behavioral Health
• Rapid City IHS Hospital
• Assistant Clinical Professor
• University of Colorado Health Sciences Center

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Demographics
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Age-Adjusted Suicide Death Rates CY 1996-1998
U.S. All Races (1997) 10.6
IHS Adjusted Total - All Areas 20.2
Regional Differences in Indian Health
2000-2001 Chart 4.19
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S.D. AND U.S. SUICIDE YOUTH AND YOUNG ADULTS
19992001
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U.S. AND S.D. MEN 19891998 SUICIDE RATES OF
WHITES AND NATIVE AMERICANS
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Suicide Facts
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Suicide Facts

• More Americans die by suicide than by homicide
• 93 of all suicides are completed by persons with
  Axis I diagnosis
• Suicide is the leading cause of death for persons
  with Bipolar Disorder
• 15 of persons with Major Depressive Disorder
  will take their own lives, at a cost of 8
  billion dollars to the US economy/year
• 15 of persons with schizophrenia die by suicide
• 5 to 7 of persons with Borderline Personality
  Disorder die by suicide

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Basic Concepts About Suicide

• Suicide is multi-factorial
• Most suicidal people do not want to die
• Suicide often results from a long-term, wearing
  process
• The final decision is with the individual
• Ambivalence exists until the moment of death

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Prevention
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QPRQuestion, Persuade, Refer

• Ask a question, Save a life
• A group training experience that raises awareness
  about suicide as a problem in our community
• Identifies the most common causes of suicidal
  thinking, feeling, and actions
• Teaches the trainee three simple skills he or she
  may use to help prevent the unnecessary tragedy
  of suicide

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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

• 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 OR CODED 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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How QPR Differs From Other Suicide Prevention
Programs

• QPR recognizes that even socially isolated
  individuals usually have some sort of contact
  within their community (family MD, teachers,
  employers, banker, counselors)
• QPR teaches diverse groups within each community
  how to recognize the real crisis of suicide and
  the symptoms that accompany it
• QPR addresses high-risk people within their own
  environments (vs. requiring them to initiate
  request for support or treatment on their own)
• QPR, like CPR, does not require formal counseling
  or medical training to be effective

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How QPR Differs From Other Suicide Prevention
Programs

• QPR training specifically targets those groups
  most at risk for suicide and the least likely to
  self-refer (males, young people, older adults)
• QPR offers the increased possibility of
  intervention early in the depressive and/or
  suicidal crisis
• QPR encourages the Gatekeeper to take the
  individual directly to a treatment provider or
  community resource
• QPR stresses active follow-up on each
  intervention that occurs

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Long Term Suicide Risk Factors

• Hopelessness
• Male gender
• Living alone
• Prior suicide attempts
• Family history of suicide attempts
• Psychosis

• Family history of substance abuse
• General medical illness
• Substance abuse
• Mood disorder

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Imminent Suicide Risk Factors

• First week of hospitalization
• Losses within the last month
• Lack of parenting responsibility
• Recent alcohol or drug abuse
• Writing suicide notes
• Expressing shame or remorse
• Final arrangements
• Sense of relief/release talking about suicide
• Wish to reunite with a loved one
• Death viewed as positive experience

• Anxious ruminations
• Delusions of poverty or doom
• Hopelessness
• Rapid cycling mood
• Recipient of bad news
• Bizarre withdrawn behavior
• Giving away prized possessions

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Self Mutilation vs. Suicide
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Myths
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Myths About Suicide

• People who talk about suicide dont commit
  suicide.
• Of any ten persons who kill themselves, eight
  have given definite warning of their suicidal
  tendencies. Most communicate their intent
  sometime during the week preceding their attempt.

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Myths About Suicide

• Suicide happens without warning.
• Studies reveal that the suicidal person gives
  many clues and warnings regarding his/her
  suicidal intentions. If people in a crisis get
  the help they need, they will probably never be
  suicidal again.

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Myths About Suicide

• Suicidal persons are fully intent on dying
• Most suicidal people are undecided about living
  or dying and they gamble with death leaving it
  to others to save them. Few commit suicide
  without letting others know how they are feeling.
  Suicide is the most preventable kind of death,
  and almost any positive action may save a life.

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The Bridge Story

• 60 year old bridge
• Considered to be an architectural marvel
• There have been over 1,000 documented suicides
  off of this bridge (to be documented it means
  that there were at least 2 witnesses)
• Staff stop an average of 2 or 3 people PER WEEK
• What bridge is this?

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The Bridge Story

• Dilemmas on whether to have anti-jumping nets or
  not (Some assume that they will just try to kill
  themselves some other way or that the nets will
  plant an idea in peoples heads
• Bay Area psychologist studied 515 of those
  restrained (didnt succeed)
• At the end of five years, it was found that 95
  had NOT gone on to suicide
• 16 people jumped but did not die
• 240 foot drop -- time to think

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The Bridge Story

• First thoughts after they jumped.
• I want to liveI want to live!
• I wish I wouldnt have done this
• Swim through the air to avoid an abutment
  (probably saved his life)
• No one who survived swam to shore and tried
  again!!
• BAD NEWS Over 1,000 died after jumping
• REALLY BAD NEWS No reason to believe that those
  who jumped and died did not feel the same
  immediately after jumping as those who did not
  die
• GOOD NEWS 95 will NOT go on to commit suicide
  if an intervention occurs

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Myths About Suicide

• Once a person is suicidal, he/she is suicidal
  forever
• Individuals who wish to kill themselves are
  suicidal only for limited period of time. The
  suicidal crisis lasts only a few hours. Only 1
  of all survivors of suicide attempts kill
  themselves within one year only 10 within 10
  years

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Myths About Suicide

• There is a certain type of person who commits
  suicide usually from poor families or mentally
  ill
• Suicide is neither a rich persons disease nor a
  poor persons curse. Suicide is very democratic
  and is represented proportionately among all
  levels of society

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Myths About Suicide

• When a depressed person cheers up, the danger of
  suicide has passed
• Depression often dulls the ability to act. While
  in the depths of depression, the person may wish
  to die and may actually plan to end his life, but
  lacks the willpower or energy to do it. As the
  depression lifts, the ability to act returns and
  suicide plans made earlier can now be carried
  out.

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Myths About Suicide

• Suicide is inherited or runs in the family
• Suicide does not run in families per se. It is
  an individual pattern. Differences in
  serotonergic brain systems could account for some
  heritability. Also, behavior can be modeled by a
  relative or close friend, so it is important that
  you help the person learn that there is a better
  way of coping.

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Myths About Suicide

• Assessing suicidal risk is something best left to
  mental health professionals.
• Preliminary assessments can be effectively done
  even at the runaway shelters. Waiting for an
  appointment for a mental health professional may
  be wasting crucial time.

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Intervention
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Suicide Intervention

• Ask the S Question
• Buy Some Time
• Create a Safe Working Environment
• Get and Keep a Suicidal Person Talking
• Build a Safety Net
• Make a Survival Plan
• Get an Agreement to Safety

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Suicide Intervention

• Ask the S Question
• Make it a habit
• Be prepared to respond to the answer
• Frame the question in a direct manner NOT Youre
  not thinking of suicide, are you?

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Suicide Intervention

• Buy Some Time
• Use Assessment Oriented Questioning rather than
  open-ended questions

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Assessment Oriented Questioning(Six Techniques
to Sharpen Assessment of Suicidal Risk)

• Behavioral Incident Questions
• NOT How close were you to killing yourself last
  night?
• Did you pick up the gun?
• How long did you hold it?
• Was the safety on or off?

Shawn Shea, MD -- Dartmouth
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Assessment Oriented Questioning(Six Techniques
to Sharpen Assessment of Suicidal Risk)

• Shame Attenuation
• NOT Do you have trouble keeping a job?
• Do you find your bosses tend to make life
  difficult for you at work?
• Is your workplace really hard for you and your
  colleagues to go to everyday?

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Assessment Oriented Questioning(Six Techniques
to Sharpen Assessment of Suicidal Risk)

• Gentle Assumption
• NOT Have you thought of other ways of killing
  yourself?
• What other ways have you thought of killing
  yourself?
• What did you do on the day you decided to end
  your life?

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Assessment Oriented Questioning(Six Techniques
to Sharpen Assessment of Suicidal Risk)

• Symptom Amplification (Ask at excessive levels)
• NOT Have you ever tried to kill yourself
• How many times have you thought of killing
  yourself? Thirty? Forty?

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Assessment Oriented Questioning(Six Techniques
to Sharpen Assessment of Suicidal Risk)

• Denial of the Specific
• NOT Have you thought of other ways of killing
  yourself?
• Have you ever thought of shooting yourself?
• Have you ever thought of overdosing?
• Have you ever thought of hanging?

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Assessment Oriented Questioning(Six Techniques
to Sharpen Assessment of Suicidal Risk)

• Normalization
• Most people in similar circumstances would
  respond as you did
• Many people who have lost their jobs feel they
  would be better off dead. Do you feel that way?
  

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Suicide Intervention

• Create a Safe Working Environment
• Remove any means of harming self nearby (may
  require hospitalization)
• Learn about the problems that suicide may solve
• Dont condemn the idea of suicide
• Accept as interesting option but possibly too
  much solution to whatever problem is at hand

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Suicide Intervention

• Get and Keep a Suicidal Person Talking
• Good rapport -- pay perfect attention
• Remain calm and talk about suicide openly
• State plainly that you will be there to help the
  person
• Platitudes dont play well with suicidal folks
• Dont be afraid to say you dont understand

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Suicide Intervention

• Build a Safety Net
• Get more information
• Get others involved to gather risk information
  (family, colleagues, friends, consultants)
• Never promise to keep a suicidal persons status
  a secret

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Suicide Intervention

• Make a Survival Plan
• Safety first
• Phone access
• Crisis instructions
• involve caretakers
• get follow-up plan in place

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Suicide Intervention

• Get an Agreement to Safety
• NOT Contract for Safety or No Suicide
  Contract
• Commitment to Life

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No Suicide Contracts

• Despite clinical lore and according to research
  literature and expert clinical suicidologists,
  there is no scientific evidence that so-called
  no suicide contracts actually save lives or
  prevent suicide attempts
• Specific training in the use of no-suicide
  contracts is largely unavailable, including those
  working in the helping professions

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No Suicide Contracts

• No-suicide contracts are sometimes wrongly used
  by professionals in an effort to avoid complaints
  of malpractice. In a word, the practitioners
  duty is to assess and manage suicide risk, not
  secure a contract.

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Commitment to Life

• The person in crisis may feel supported by the
  gatekeeper and come to believe that at least one
  person wants him or her to live
• The gatekeeper provides a hot link to help and
  thus may reduce the impulse to attempt suicide.
• The person in crisis may experience some comfort
  and relief at making a public commitment to life
• Agreeing to stay alive is an affirmation that
  life is still worth living
• Summary allows suicidal person to recommit to
  life and to promise that they will postpone any
  suicide attempt and wait until help can be
  obtained or the crisis passes.

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Treatment
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Look at Treatment

• Refer, refer, refer to Mental Health Professional
• Psychotherapy (Supportive and CBT)
• Medication management -- many studies prove
  efficacy especially with depression, bipolar d/o
  and schizophrenia
• Screen and treat substance abuse/dependence
• Alternative remedies -- omega 3 fatty acids
• Diet, exercise
• Spirituality and religion

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Pediatric Suicide Risk and SSRIs
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SSRI Suicides (Behind the Scenes)

• Compliance issues -- The patients who completed
  suicide were not taking the SSRI at the time of
  the completion (confirmed by blood levels in 2
  cases at autopsy)
• Confounding Factors -- There were confounding
  variables such as substance abuse, severe
  psychosocial stress, and recent loss in the
  completed suicides
• Improper diagnosis -- Likely bipolar diagnosis
  given activation on the medication

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Medication Management

• SSRIs Recent controversy based on expected
  improvement when depression initially treated
• SSRIs Still the gold standard in psychiatry
  for the treatment of anxiety and depressive
  conditions that lead to suicidality
• Some studies with SSRIs show serotonergic
  changes in the CSF that are similar to
  non-suicidal controls
• Medications with the strongest studies supporting
  this research Sertraline (Zoloft) and
  Fluoxetine (Prozac)

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Medication Management

• Caution advised with the use of SSRI in bipolar
  patients
• Long term studies have shown significant overall
  improvement in bipolar suicidality when used
  concomitantly with mood stabilizers/atypical
  antipsychotics however

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National Suicide Prevention Network (NSPN)
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NSPN

• Group of approximately 50 IHS and tribal mental
  health employees that serve proactively to
  address suicide prevention, intervention and
  community change after a community loss
• Started work in June 2005 and have conducted
  youth and community training in Billings and Ft.
  Yates thus far
• Community healing techniques are culturally
  geared towards Native people

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Gathering of Native Americans (GONA)
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Four Days of GONA

• Day 1 Belonging A place for all ages, a place
  for all kinds of people. The first day
  represents infancy and childhood, a time when we
  need to know how we belong.
• Day 2 Mastery Empowerment, for individual and
  for community. The second day honors adolescence
  as a time of vision and mastery

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Four Days of GONA

• Day 3 Interdependence Action, community
  leadership. The third day is symbolized by
  adults, integral and interdependent within their
  families and communities.
• Day 4 Generosity Teacher/Elder, and resources
  in the community. The final day honors our
  elders, who give their knowledge and teachings to
  our generations of the future.

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GONA Assumptions

• Community healing IS prevention.
• Capacity building is essential.
• Healthy traditions ARE prevention.
• Holistic approach is critical to wellness,
  interconnections, and interdependence.
• A correct history of the important role AIAN play
  in American history, culture, and government is
  an important foundation.

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GONA Assumptions

• Effective prevention must include the grassroots
  community.
• Individuals must understand the importance of
  their role in the holistic universe.
• It is critical to honor, respect, and incorporate
  ceremonies, rituals, and spiritual teachings.
• Effective prevention provides the means for
  feelings and healings to translate into actions
  and different behaviors.
• Healing requires a safe place.

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Suicide has stolen lives around the world and
across centuries. Meanings attributed to suicide
and notions of what to do about it have varied
with time and place, but suicide has continued to
exact a relentless toll. Only recently have the
knowledge and tools become available to approach
suicide as a preventable problem with realistic
opportunities to save many lives.
--National Strategy For Suicide
Prevention
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Suicide is ultimately a private act. It is
difficult to put into words the suffering and
agonized state of mind of those who kill
themselves ... A minority of those who kill
themselves actually write suicide notes, and
these only infrequently try to communicate the
complex reasons for the act. Still, some
consistent psychological themes emerge. Clearest
of these is the presence of an unendurable
heartache, captured in the simple phrase, I
cant stand the pain any longer. Reducin
g Suicide A National Imperative
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Suicide is a serious public health challenge
that has not received the attention and degree of
national priority it deserves. Many Americans are
unaware of suicides toll and its global impact.
It is the leading cause of violent deaths
worldwide, outnumbering homicide or war-related
deaths ... The Commission urges swiftly
implementing and enhancing the National Strategy
for Suicide Prevention to serve as a blueprint
for communities and all levels of
government. Presidents New Freedom
Commission on Mental Health
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S.D. Strategy for Suicide Prevention Goals and
Objectives for Action GOAL 1 Maintain a South
Dakota Community Toolkit for Suicide Prevention
that guides the development and implementation of
suicide prevention programs and training. GOAL
2 Promote strategies to educate the public as
well as community and industry leaders that
suicide is a public health problem that is
preventable. GOAL 3 Develop and promote
effective clinical and professional
practices. GOAL 4 Improve access to and
community linkages among primary care, mental
health, and substance abuse services. GOAL 5
Improve reporting and portrayals of suicidal
behavior, mental illness, and substance abuse in
the media. GOAL 6 Reduce the danger of lethal
means and methods of self-harm. GOAL 7 Improve
and expand surveillance systems. GOAL 8 Improve
services to people who have been affected by the
death of a loved one by suicide.
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Community Plans and Interventions

• Yellow ribbon awareness campaigns
• Breaking down stigma and stereotypes
• Address community taboos
• Establishing crisis room via pressure on local
  hospital
• Active involvement with law enforcement
• Getting media on their side
• Adult mentoring
• High school/peer leaders
• Establish gatekeepers
• Inservice of school personnel

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Postvention
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LOSS Teams

• Developed by Frank Campbell, PhD of Baton Rouge,
  LA.
• Started in Rapid City in June 2005.
• Very successful in helping the family to cope
  with the initial loss issues

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Postvention Strategies

• Should begin as soon as possible after the
  suicide, at least within the first three days
• Survivors are often eager to talk and will show
  little resistance to help
• Negative emotions can be explored, but generally
  after the initial shock has been dealt with
• Acknowledge early on that grief work takes time,
  from several months to a lifetime

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Postvention Strategies

• A common guilt reaction of suicide survivors is
  to take 100 of the responsibility for the
  deceased. Sharing the sense of guilt with others
  close to the person relieves the burden
• The grief inflicted by suicide may the hardest to
  bear -- it is complicated by shock, denial,
  anger, guilt, and shame
• Survivors of suicide feel more anger than other
  mournersthey have anger at the person for
  rejecting them, anger at God, anger at the
  providers that were SUPPOSED to be helping

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Postvention Strategies

• Social and cultural background and context should
  be carefully considered in determining
  intervention and treatment
• Family therapy is a valuable modality to
  facilitate conjoint mourning of close relatives
• Individual therapy is often helpful, especially
  for intimate survivors
• Consider a comprehensive postvention effort if
  the suicide occurred in hospital, treatment
  facility, school or other organization

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Postvention Strategies

• Suicide is an occupational risk for front line
  providers (law enforcement, EMS, firefighters)
  debriefing and support must be offered to these
  individuals as well
• If you are a service provider, outreach to
  suicide survivors is both ethically necessary and
  clinically indicated

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Thank You!!

• mark.garry_at_ihs.hhs.gov