Suicide Prevention: It’s Everybody’s Business

1. Suicide Prevention:It’s Everybody’s Business October 2005 Mark Garry, M.D. Director of Behavioral Health Rapid City IHS Hospital Assistant Clinical Professor University of Colorado Health Sciences Center

2. Demographics

4. Adjusted for Race Misreporting Unadjusted 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

5. S.D. AND U.S. SUICIDE: YOUTH AND YOUNG ADULTS 1999–2001

6. S.D. & U.S. SUICIDE RATES, RANKINGS, FATALITIES Year U.S. Rate S.D. Rate S.D. vs. all states S.D. Deaths U.S. Deaths 1990 12.4 13.1 21st 91 30,906 1991 12.2 13.5 15th 95 30,810 1992 12.0 11.2 39th 79 30,484 1993 12.1 16.3 8th 117 31,102 1994 12.0 13.5 17th 97 31,142 1995 11.9 11.8 33rd 86 31,284 1996 11.6 16.9 7th 124 30,903 1997 11.4 17.2 7th 127 30,535 1998 11.3 15.6 11th 115 30,575 1999 10.7 14.0 12th 103 29,199 2000 10.7 12.9 18th 95 29,350 2001 10.8 13.8 15th 105 30,622 2002 11.0 12.4 22nd 94 31,655

7. U.S. AND S.D. MEN — 1989–1998 SUICIDE RATES OF WHITES AND NATIVE AMERICANS

8. Suicide Facts

9. 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 *

10. 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

11. Prevention

12. 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 *

13. QPR • QPR is NOT intended to be a form of counseling or treatment • QPR IS intended to offer hope through positive action *

14. QPR DIRECT VERBAL CLUES: • “I’ve decided to kill myself.” • “I wish I were dead.” • “I’m going to commit suicide.” • “I’m going to end it all.” • “If (such and such) doesn’t happen, I’ll kill myself.” *

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

16. 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 *

17. 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 *

18. 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 * Long Term Suicide Risk Factors

19. 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 * Imminent Suicide Risk Factors

20. Self Mutilation vs. Suicide

21. Myths

22. Myths About Suicide • People who talk about suicide don’t 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.

23. 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.

24. 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.

25. 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? *

26. 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 people’s heads • Bay Area psychologist studied 515 of those restrained (didn’t 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 *

27. The Bridge Story • First thoughts after they jumped…. • “I want to live…I want to live!” • “I wish I wouldn’t 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 *

28. 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

29. 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 person’s disease nor a poor person’s curse. Suicide is very democratic and is represented proportionately among all levels of society

30. 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.

31. 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.

32. 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.

33. Intervention

34. 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

35. 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 “You’re not thinking of suicide, are you?” *

36. Suicide Intervention • Buy Some Time • Use Assessment Oriented Questioning rather than open-ended questions *

37. 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

38. 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?” *

39. 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?” *

40. 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?” *

41. 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?” *

42. 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?” *

43. 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 • Don’t condemn the idea of suicide • Accept as interesting option but possibly too much solution to whatever problem is at hand *

44. 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 don’t play well with suicidal folks • Don’t be afraid to say you don’t understand *

45. 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 person’s status a secret *

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

47. Suicide Intervention • Get an Agreement to Safety • NOT “Contract for Safety” or “No Suicide Contract” • Commitment to Life *

48. “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

49. “No Suicide Contracts” • “No-suicide” contracts are sometimes wrongly used by professionals in an effort to avoid complaints of malpractice. In a word, the practitioner’s duty is to assess and manage suicide risk, not secure a “contract.”

50. “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.