Saving Lives: Understanding Depression And Preventing Suicide

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Saving LivesUnderstanding Depression And
Preventing Suicide Prevention Training For
Physicians and Medical Personnel

• The Ohio Suicide Prevention Foundation
• Developed by Ellen J. Anderson, Ph.D., SPCC,
  2003-2008

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• Still the effort seems unhurried. Every 17
  minutes in America, someone commits suicide.
  Where is the public concern and outrage?
• Kay Redfield Jamison
• Author of Night Falls Fast Understanding Suicide

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Training Goals

• Learn about local suicide prevention efforts, how
  these efforts connect with your practice and
  patients
• Understand the pivotal role of medical personnel
  in the treatment of depressed patients and in
  reducing suicide risk
• Increase awareness of suicide risk
  characteristics in patients who may not present
  as depressed/suicidal
• Learn a brief suicide risk assessment model
• Learn to ask the S question

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Why Do We Need To Improve Suicide Prevention
Efforts?

• Suicide is the last taboo
• We can talk about sex, alcoholism, cancer, but
  not suicide
• People need to understand the impact of
  depression and other mental illnesses, and how
  they lead to suicide
• Suicide is a preventable death
• Integrating medical staff into the efforts of
  suicide prevention coalitions to reduce deaths,
  increase awareness, and reduce stigma seems
  critical to local, state, and national efforts to
  change our approach to this age-old problem

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Changing Our Approach Depression Is An Illness

• Suicide has been viewed for countless generations
  as
• A moral failing, a spiritual weakness
• An inability to cope with life
• The cowards way out
• A character flaw
• This cultural view of suicide is not validated by
  our current understanding of brain chemistry and
  its interaction with stress, trauma and genetics
  on mood and behavior

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The Feel of Depression

• I am 6 feet tall. The way I have felt these past
  few months, it is as though I am in a very small
  room, and the room is filled with water, up to
  about 5 10, and my feet are glued to the floor,
  and its all I can do to breathe.

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Gatekeeper Training- Dr. Ellen Anderson
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• The research evidence is overwhelming- what we
  think of as depression is far more than a sad
  mood. It includes
• Weight gain/loss
• Sleep problems
• Sense of tiredness, exhaustion
• Sad mood
• Loss of interest in pleasurable things, lack of
  motivation
• Irritability
• Confusion, loss of concentration, poor memory
• Negative thinking
• Withdrawal from friends and family
• Often, suicidal thoughts
• (DSMIVR, 2002)

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• 20 years of brain research teaches that what we
  are seeing is the behavioral result of
• Changes in the physical structure of the brain
• Destruction or shutting down of brain cells in
  the hippocampus and amygdala (5HTP axis)
• Decrease in neurotransmitters
• increased agitation in the limbic system
• Depressed people suffer from a physical illness
  within the brain what we might consider faulty
  wiring
• (Braun, 2000 Surgeon Generals
  Call To Action, 1999, Stoff Mann, 1997, The
  Neurobiology of Suicide)

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Faulty Wiring?

• Literally, damage to certain nerve cells in our
  brains
• The result of too many stress hormones
  cortisol, adrenaline and testosterone
• Hormones activated by our Autonomic Nervous
  System to protect us in times of danger
• Chronic stress causes changes in the functioning
  of the ANS, so that a high level of activation
  occurs with little stimulus
• Causes changes in muscle tension, imbalances in
  blood flow patterns leading to illnesses such as
  asthma, IBS, back pain and depression
• (Goleman, 1997, Braun, 1999)

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Faulty Wiring?

• Without a way to return to rest, hormones
  accumulate, doing damage to brain cells
• Stress alone is not the problem, but how we
  interpret the event, thought or feeling
• People with genetic predispositions, placed in a
  highly stressful environment will experience
  damage to brain cells from stress hormones
• This leads to the cluster of thinking and
  emotional changes we call depression
  (Goleman, 1997 Braun, 1999)

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Where It Hits Us
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One of Many Neurons

• Neurons make up the brain and cause us to think,
  feel, and act
• Neurons must connect to one another (through
  dendrites and axons)
• Stress hormones damage dendrites and axons,
  causing them to shrink away from other
  connectors
• As fewer connections are made, more and more
  symptoms of depression appear

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• As damage occurs, thinking changes in the
  predictable ways identified in our 10 criteria
• Thought constriction can lead to the idea that
  suicide is the only option
• How do antidepressants affect this brain
  damage?
• May counter the effects of stress hormones
• We know now that antidepressants stimulate genes
  within the neurons (turn on growth genes) which
  encourage the growth of new dendrites
• (Braun, 1999)

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• Renewed dendrites increase the number of neuronal
  connections
• The more connections, the more information flow,
  the more flexibility and resilience the brain
  will have
• Why does increasing the amount of serotonin, as
  many anti-depressants do, take so long to reduce
  the symptoms of depression?
• It takes 4-6 weeks to re-grow dendrites axons
• (Braun, 1999)

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Why Dont We Seek Treatment?

• We dont know we are experiencing a brain
  disorder we dont recognize the symptoms
• When we talk to doctors, we are vague about
  symptoms
• We believe the things we are thinking and feeling
  are our fault, our failure, our weakness, not an
  illness
• We fear being stigmatized at work, at church, at
  school

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No Happy Pills For Me

• The stigma around depression leads to refusal of
  treatment
• Taking medication is viewed as a failure by the
  same people who cheerfully take their blood
  pressure or cholesterol meds
• Medication is seen as altering personality,
  taking something away, rather than as repairing
  damage done to the brain by stress hormones

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Therapy? Are You Kidding? I Dont Need All That
Woo-Woo Stuff!

• How can patients seek treatment for something
  they believe is a personal failure?
• Acknowledging the need for help is not popular in
  our culture (Strong Silent type, Cowboy)
• People who seek therapy may be viewed as weak
• Therapists are viewed as crazy
• Theyll just blame it on my mother or some other
  stupid thing

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How Does Psychotherapy Help?

• Medications may improve brain function, but do
  not change how we interpret stress
• Psychotherapy, especially cognitive or
  interpersonal therapy, helps people change the
  (negative) patterns of thinking that lead to
  depressed and suicidal thoughts
• Research shows that cognitive psychotherapy is as
  effective as medication in reducing depression
  and suicidal thinking
• Changing our beliefs and thought patterns alters
  our response to stress we are not as reactive
  or as affected by stress at the physical level
  (Lester, 2004)

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What Therapy?

• The standard of care is medication and
  psychotherapy combined
• At this point, only cognitive behavioral and
  interpersonal psychotherapies are considered to
  be effective with clinical depression
  (evidence-based)
• Consider EMDR for patients with trauma
  experiences
• Look for therapists with specific training Ask!

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• Yet most people do not understand the physical
  aspects of mental illness, as you have no doubt
  found in talking with your patients
• Suicide is strongly linked with certain mental
  illnesses, and most people do not understand this
  connection
• Your county Suicide Prevention Coalition is
  attempting to Reduce the stigma attached to
  mental illness, increase help-seeking behavior,
  and increase awareness of the consequences of
  untreated depression

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Suicide Prevention Efforts

• First national effort established at NIMH in 1969
• Surgeon General issued a call to action to
  prevent suicide in 1999
• In 2001, a National Strategy for Suicide
  Prevention Committee developed future goals and
  objectives
• An Ohio Suicide Prevention Plan was developed in
  May, 2002, and grants for local coalitions were
  given out in November of 2002

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Development Of Prevention Efforts

• Over the past 20 years, we have acquired valuable
  information on risk and protective factors,
  methods for preventing suicidal behavior, and
  improved research methods
• An increase in suicide prevention programs in
  schools
• The rapid development of suicidology as a
  multidisciplinary sub-specialty
• Establishment of centers for the study and
  prevention of suicide

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Framework For Prevention

• Public health approach to prevention in contrast
  to clinical approaches used in the past
• The prevailing model is the Universal, Selective,
  and Indicated model (WHO, 2002)
• Focuses attention on defined populations, from
  everyone, to specific at-risk groups, to specific
  high-risk individuals

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Is Suicide Really a Problem?

• 89 people complete suicide every day
• 32,637 people in 2005 in the US
• Over 1,000,000 suicides worldwide (reported)
• This data refers to completed suicides that are
  documented by medical examiners it is estimated
  that 2-3 times as many actually complete suicide
• (Surgeon Generals Report on Suicide, 1999)

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The Unnoticed Death

• For every 2 homicides, 3 people complete suicide
  yearly data that has been constant for 100 years
• During the Viet Nam War from 1964-1972, we lost
  58,000 troops, and 220,000 people to suicide

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Who Is At Risk?

• Most people assume young people
• are more likely to complete suicide,
• It is the 3rd largest killer of youth ages 15-24
• In 2005, 267 children aged 10-14 completed
• Adult males from 35-55 actually complete suicide
  at a far greater rate than youth
• The elderly are at significant risk among those
  over 75, 1 out of 4 attempts end in death because
  the elderly tend to use more lethal means
• (Surgeon Generals call to Action, 1999)

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• Comparative Rates Of U.S. Suicides-2004
• Rates per 100,000 population
• National average - 11.1 per
  100,000
• White males - 18
• Hispanic males - 10.3
• African-American males - 9.1
• Asians - 5.2
• Caucasian females - 4.8
• African American females - 1.5
• Males over 85 - 67.6
• Annual Attempts 811,000 (estimated)
• 150-1 completion for the young - 4-1 for the
  elderly
• (AAS website),(Significant increases have
  occurred among African Americans in the past 10
  years - Toussaint, 2002)

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Suicide Rate By Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hovert, 1999)
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Suicide Rates Among The Elderly

• The elderly have the highest suicide rate of any
  group
• Depression in late life affects six million
  people, one out of six patients in a general
  medical practice
• However, only one of those six patients is
  diagnosed and treated appropriately
• The majority of these people have seen their
  primary care physician within the last month of
  life
• There is evidence that the majority of elderly
  suicide victims die in the midst of their first
  episode of major depression
• Depression is not a normal consequence of aging
  and can significantly alter the course of other
  medical conditions
• (Empfield, 2003)

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PCPs And Diagnosis Of Depression

• Seniors have often visited a health-care provider
  before completing suicide
• 20 of elderly (over 65 years) who complete
  suicide visited a physician within 24 hours
• 41 within a week
• 75 within one month
• Patients may not use the words depression or
  sadness
• Because of the stigma that is still attached to
  this diagnosis, somatic symptoms may become the
  focus of complaint
• There may be much denial and minimizing of
  affective symptoms
• (Empfield, 2003)

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Poor Quality Of Mental Health Care For Elders

• Increased risk for inappropriate medication
  treatment (Bartels, et al., 1997, 2002)
• gt 1 in 5 older persons given an inappropriate
  prescription (Zhan, 2001)
• The elderly are less likely to be treated with
  psychotherapy (Bartels, et al., 1997)
• Lower quality of general health care is
  associated with increased mortality
• (Druss, 2001)

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Depression Associated With Worse Health Outcomes

• Depression is common among older patients with
  certain medical disorders
• Associated with worse health outcomes
• Greater use and costs of medications
• Greater use of health services
• Medical illness greatly increases the risk for
  depression particularly in
• Ischemic heart disease (e.g. MI, CABG)
• Stroke Cancer Chronic lung disease
  Alzheimers disease Parkinsons
  disease
• Rheumatoid Arthritis
  (Empfield, 2003)

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• In Cancer, depression leads to
• Increased Hospitalization
• Poorer physical function
• Poorer quality of life
• Poorer pain control
• Increased mortality rates for
• Hip fractures
• Long Term Care Residents
• Myocardial Infarction
• In heart attack patients, depression is a
  significant predictor of death at 6 months
• ( Frasure-Smith 1993, 1995 Mossey 1990 Penninx
  et al. 2001 Katz 1989,
• Rovner 1991, Parmelee 1992Ashby1991 Shah 1993,
  Samuels 1997)

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Rates Of Depression Among Elders With Illness

• Cognitively intact nursing home patients shown to
  have symptoms consistent with depressive
  disorders 60
• Chronically ill outpatients in a primary care
  practice - 25
• Hospitalized patients - 20
• In nursing homes, regardless of physical health,
  major depression increases the likelihood of
  mortality by 59 in one year
• (Empfield, 2003)

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Benefits Of Treatment For Depression In The
Elderly

• Depression is one of the few medical conditions
  in which treatment can make a rapid and dramatic
  difference in an elderly persons level of
  function and quality of life
• Treatment may help patients accept medical
  treatment that they otherwise might refuse
  because of feelings of hopelessness or futility
• Treatment also helps enhance or recover coping
  skills needed to deal with the inevitable losses
  associated with chronic medical illness
• (Empfield, 2003)

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What Factors Put Someone At Risk?

• Many things increase ones risk for suicide-
  biological, psychological, social factors all
  apply
• The single greatest risk factor for suicide
  completion - Having a Depressive Disorder
• 90 of reported US suicides are experiencing
  depression
• The 2nd biggest factor - having an alcohol or
  drug problem - However, many people with alcohol
  and drug problems are significantly depressed,
  and are self-medicating
• (Lester, 1998)

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• Other risk factors include
• Previous suicide attempts
• A family history of suicide - increases our risk
  by 6 times
• A significant loss by death, divorce, separation,
  moving, or breaking up with a loved one. Shock or
  pain, even long term lower level stress, can
  affect the structure of the brain, especially the
  limbic system
• 30 years of research confirms the relationship
  between hopelessness and suicide, across
  diagnoses
• Impulsivity, particularly among youth, is
  increasingly linked to suicidal behavior
• Access to firearms 60 of completed suicides
  used firearms
• (Surgeon Generals call to Action, 1999)

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• Biological factors
• Biological changes are associated with
• both completed and attempted suicide
• Changes include abnormal functioning of
• the Hypothalamic-Pituitary-Adrenal axis,
• a major component of the way we adapt to
  stress
• Psychological factors
• Changes in thinking (constricted thought) leading
  to the belief that suicide is the only answer
  negative automatic thoughts that lead to sadness,
  hopelessness, loss of pleasure, inability to see
  a future, low self-esteem
• Suicidality, although clearly overlapping the
  symptoms of associated MH disorders, does not
  appear to respond to treatment in exactly the
  same way
• In some cases, depressive symptoms can be reduced
  by medication without a reduction in suicidal
  thinking

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Protective Factors

• Stigma reduction programs, especially
• among youth, increase help-seeking behavior
• Resiliency and coping skills to reduce risk can
  be taught (Dialectical Behavioral Training)
• Spirituality improves defenses against suicidal
  thinking
• Social support those with close relationships
  cope better with various stresses, including
  bereavement, job loss, and illness
• Social disapproval of suicide reduces rates
• (Berman Jobes, 1996 Beck, 1985 Rush et al,
  1992, Surgeon Generals Call To Action, 1999)

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Treatment

• Treatment of suicidality has improved
  dramatically in the last 20 years
• Evidence is clear that lithium treatment of
  bi-polar disorder significantly reduces suicide
  rates
• A correlation has been noted between an increase
  in prescription rates for SSRIs and a decline in
  suicide rates
• (Baldessarini, et.al, 1999, NIMH, 2002)

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• However, medication alone is insufficient to
  reduce suicidal ideation
• Psychotherapy can reduce suicidality by helping
  people learn to interpret the stresses in their
  lives more effectively, reducing the level of
  stress hormones in the body
• Psychotherapy provides a necessary therapeutic
  relationship that reduces risk through increased
  hope and support
• Cognitive-behavioral approaches that include
  problem-solving training reduce suicidal ideation
  and attempts more effectively than other
  approaches
• Medication combined with psychotherapy is the
  current standard of care for clinical depression
• (Beck, 1996, Quinnett, 2000, Macintosh, 1996)

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SSRIs And SuicideMore Mythology?

• Media has sensationalized the idea that Prozac
  causes suicide in teens
• There is a very low risk that SSRIs can induce
  suicidal agitation in a very few individuals
• Many teens on SSRIs are, in fact already
  suicidal, and meds may not work well enough, or
  in time
• The FDA has recently banned the use of Paxil for
  depression in adolescents, but Prozac has been
  approved for use in teens

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• The American College of Neuropsychopharmacology's
  Task Force report from January 21, 2004, which
  reviewed all clinical trials, epidemiological
  studies and toxicology studies in autopsies did
  not find evidence for a link between SSRI's and
  increased risk of suicide in children and
  adolescents
• In a recent preliminary study of 49 adolescent
  suicides, researchers found that 24 had been
  prescribed antidepressants, but none had any
  trace of SSRI's in their system at the time of
  their death
• There is an increased risk of suicide in
  depressed individuals who do not take their
  medication which is a factor common to
  adolescents
• A 2003 World Health Organization study in over
  fifteen countries found a significant reduction,
  averaging about 33, in the youth suicide rate
  that coincided with the introduction of SSRI's
• (Altesman, 2005)

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• A review of all the research on this topic was
  conducted recently
• CONCLUSION No increased susceptibility to
  aggression or suicidality can be connected with
  fluoxetine or any other SSRI. In fact SSRI
  treatment may reduce aggression toward self or
  others
• In the absence of any convincing evidence to
  link SSRIs causally to violence and suicide, the
  recent media reports are potentially dangerous,
  unnecessarily increasing the concerns of
  depressed patients who are prescribed
  antidepressants (Goldberg, 2003)
• In November, Newsweek reported that prescriptions
  for SSRIs for teens have dropped by 50 in 03
  and 04 suicide rates have climbed 18 in 03

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High Risk Behaviors and Suicide

• Miller and Taylor (2000) analyzed high risk
  behaviors in 9th-12th graders and found a
  correlation with suicide ideation and attempts
• High risk health behaviors included
• High Risk Sex (multiple partners, before age 14)
• Binge Drinking (5 or more in several hours)
• Drug Use
• Disturbed eating patterns (boys do not get asked
  about this)
• Smoking
• Violence (girls do not get asked about this)

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• The 17 of youth with more than three problem
  behaviors were the youth who acted
• They accounted for 60 of medically treated
  suicidal acts
• Compared to adolescents with zero problem
  behaviors, the odds of a medically treated
  suicide attempt were
• 2.3 times greater among respondents with one
• 8.8 with two
• 18.3 with three
• 30.8 with four
• 50.0 with five
• 227.3 with six
• A count of problem behaviors may offer a reliable
  way to identify suicide risk
• (Miller Taylor, 2000)

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Barriers To Treatment

• Fragmentation of services and cost of care are
  the most frequently cited barriers to treatment
• About 67 of people with significant mental
  disorders do not receive treatment
• Psychological autopsy studies reveal that less
  than 14 of completers were receiving adequate
  treatment, and fewer than 17 were being treated
  with psychiatric medications
• However, 50-70 had contact with health services
  in the weeks before their death
• Surgeon Generals Call To Action, 1999 Empfield,
  2003

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• Currently, no psychological test, clinical
  technique or biological marker is sensitive
  enough to accurately and consistently predict
  suicide
• Primary care has become a critical setting for
  detection of the two most common factors
  depression and alcoholism
• Depression is the second most common chronic
  disorder seen by PCPs
• According to the AMA, a diagnostic interview for
  depression is comparable in sensitivity to
  laboratory tests commonly used in diagnosis, but
  currently, less than 50 of adults with
  diagnosable depression are accurately diagnosed
  by PCPs
• Physicians are often reticent to talk with
  patients about suicide intent or ideation, and
  patients seldom spontaneously report it
• (Surgeon Generals Call to Action, 1999
  Quinnett, 2000 )

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What Is Your County Doing?

• Suicide prevention coalitions have been developed
  over the past 3 years across the state with
  grants from Ohio Dept. of Mental Health
• In many counties, the Mental Health Board is
  spearheading this process, with help
• from all areas of the community,
• including health care providers, mental
• health professionals, suicide survivors,
• clergy, school personnel, human resource
• personnel, police/sheriff dept, health
• department, and many others

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How Do We Know Suicide Prevention Coalitions Work?

• In 1996 the U.S. Air Force decided to mount an
  assault on its high suicide rate
• They targeted help-seeking behavior, stigma, and
  awareness
• After 5 years of a major collaborative effort
  within the service, suicide rates dropped 78
• Comparable rates in the other 4 armed services
  remained the same

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How Can You Help?

• Medical personnel are the front line of defense
  against this insidious killer - assess your
  patients for suicidal ideation when depressive
  symptoms arise
• Specifically ask your patients if they are
  experiencing suicidal ideation They may not
  volunteer the information
• Train staff in depression awareness, and in
  asking the S question
• We must gain confidence in asking people if they
  are thinking about dying
• (Surgeon Generals Call To Action, 1999)

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Comfort And Competence Lead To Hopefulness

• A study by Dr. Paul Quinett, a long-time
  researcher and clinician in suicide, indicates
  that patients who felt their clinician was
  comfortable asking questions about their suicidal
  thoughts and feelings reported much higher levels
  of hope about the future
• The best outcome of asking the S question is
  immediate relief for the patient
• (Quinnett, 2001)

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• Hopelessness is the most immediate risk factor
  for suicide, so instilling hope is essential
• If your patient is on anti-depressant or
  anti-anxiety medication, refer them to a
  psychologist or counselor who can work with them
  on the maintaining causes of depression
• Consider using a risk assessment format to ensure
  you ask the right questions

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What To Ask?

• Except for psychiatrists, routine
• questioning about suicidal ideation
• is not the current standard of care
• If you have a patient with depressive symptoms or
  other mental health disorders (especially
  anxiety)
• Learn to Ask the S question
• Not you arent thinking of suicide are you?
• But - Some people who experience the amount of
  pain youre in think about killing themselves.
  Have you ever thought about it?
• (Lester, 1998)

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Use Of A Structured Interview

• Many patients will not overtly acknowledge common
  symptoms of depression, focusing more on vague
  pain
• You may wish to develop or purchase a guided
  clinical interview for use with suicidal clients
• A structured form assesses current risk, sets up
  a management plan, and ensures that all the right
  questions are asked
• Most take just a few minutes to complete, and
  people are surprisingly honest

56
Screening Recommendations

• The U.S. Preventive Services Task Force reviewed
  new evidence that patients fare best when medical
  professionals recognize the symptoms of
  depression and make sure they receive appropriate
  treatment
• The USPSTF issued new depression screening
  recommendations in May, 2002, asking PCPs to
  routinely screen adult patients for depression
• Medical professionals should have systems in
  place to assure accurate diagnosis, effective
  treatment, and follow-up if patients are to
  benefit from screening
• The journal of AAFP offers the article Screening
  for Depression across the Lifespan A review of
  Measures of Use in Primary Care settings to help
  medical professionals make appropriate choices of
  screening tool
  (Sharp and Lipsky, 2002)

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Possible Depression Scales

• Beck Depression Inventory
• Childrens Depression Inventory
• CES-DC (Center for Epidemiological Studies
  Depression Scale)
• Edinburgh Post-Natal Depression Scale
• Geriatric Depression Scale
• QPRT - Question, Persuade, Refer or Treat -QPR
  Institute - www.qprinstitute.com
• Zung Depression Inventory

58
Learning QPR Or, How To Ask The S Question

• It is essential, if we are to reduce the number
  of suicide deaths in our country, that community
  members/gatekeepers learn QPR
• First identified by Dr. Paul Quinnett as an
  analogue to CPR, QPR consists of
• Question asking the S question
• Persuade Getting the person to talk, and to seek
  help
• Refer Getting the person to professional help
• Medical staff can learn this method in a very
  short time
• (Quinnett, 2000)

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Intervention

• Once a patient has told someone they are thinking
  of suicide, you need a thorough suicide
  assessment
• In your area, what mental health facilities with
  emergency services are available?
• Sending a suicidal patient alone to the emergency
  room could be a mistake
• Most mental health agencies have crisis workers
  who can come to your office to interview your
  patient suicidal people should never be left
  alone!

60
Psychiatric Hospitalization

• The actual prediction of suicide is, essentially,
  impossible
• The base rates are too low, and risk level
  changes from day to day
• Statistically, you could almost always bet that
  no given individual will complete suicide
• Other risks are managed by understanding what
  risk factors exist, and limiting as many of them
  as possible, like wearing sunscreen
• It is imperative that medical professionals know
  risk factors for suicide
• (MacIntosh, 1993)

61
The Top Ten Risk Factors When Thinking Of
Hospitalization

• Previous Suicide attempt(s)
• Mental disorders (especially depression, bipolar)
• Co-occurring mental and AL/SA disorders
• Family history of suicide
• Hopelessness (should this be first?)
• Impulsive/aggressive tendencies
• Barriers to accessing mental health treatment
• Relational, social, work or financial loss
• physical illness (esp. with chronic pain)
• Easy access to lethal methods, especially guns
• (Surgeon Generals Call to Action to Prevent
  Suicide, 1999)

62
Voluntary Hospitalization

• Best choice less hard on the patients sense of
  self-worth a way to buy time (to think it over,
  get sleep, etc.)
• Safety is the main message a good nights
  sleep, a start on medications, talk with doctors,
  put things on hold for awhile
• Allows them to save face I didnt want to, but
  they insisted

63
Sharing Knowledge Of Hospitals

• Ease the transition by addressing their fears
• Facts hospital stays tend to be short
• Staff are well-trained and know about suicidal
  suffering
• ECT cannot be given without patient permission
• Patients rights are guaranteed
• Modern hospitals are not snake pits

64
Know Your Local Resources And Agencies

• Where to hospitalize
• Who do you call
• Have your risk assessment information ready
• Help to overcome barriers to hospitalization such
  as child care, pets, transportation, calls to
  work, etc.

65
Local Professional Resources

• Your Local Mental Health Agencies
• Your Local Mental Health Board
• School Guidance Counselors
• Your Hospital Emergency Room

• Local Crisis Hotlines
• National Crisis Hotlines
• School nurses
• 911
• Local Police/Sheriff
• Local Clergy

66

• Suicide is a
• permanent solution
• to a
• temporary problem
• Edwin Schneidman, MD.
• Founder of Suicidology

67

• The Ohio Suicide Prevention Foundation
• The Ohio State University, Center on Education
  and Training for Employment
• 1900 Kenny Road, Room 2072
• Columbus, OH 43210
• 614-292-8585

68
A Brief Bibliography

• Anderson, E. The Personal and Professional
  Impact of Client Suicide on Mental Health
  Professionals. Unpublished Doctoral dissertation,
  U. of Toledo, 1999
• Berman, A. L. Jobes, D. A. (1996) Adolescent
  Suicide Assessment and Intervention.
• Blumenthal, S.J. Kupfer, D.J. (Eds) (1990).
  Suicide Over the Life Cycle Risk Factors,
  Assessment, and Treatment of Suicidal Patients.
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