1. Suicide Prevention Saving Lives One Community at a Time
America Foundation for Suicide Prevention
Dr. Paula J. Clayton, AFSP Medical Director
120 Wall Street, 22nd Floor
New York, NY
AFSP

2. Facing the Facts
An Overview of Suicide

3. Facing the Facts
In 2007, 34,598 people in the United States died by suicide. About every 15.2 minutes someone in this country intentionally ends his/her life.
Although the suicide rate fell from 1992 (12 per 100,000) to 2000 (10.4 per 100,000), it has been fluctuating slightly since 2000 – despite all of our new treatments.
From the studies of committed suicide, about 50% of men who died were not in treatment and 75% of the men who died had no medications in their systems at the time of their deaths, so even if they were in treatment, they were not taking the medications.
The data on whether treatments will help decrease suicide rates are also controversial. There is only one study (Angst et al, JAD (2002), Angst et al, Arch.Suic.Res. (2005) that indicates, in a naturalistic study (e.g. the patients were sent to their local physicians for treatment after they were discharged from the psychiatric hospital) from Switzerland, if patients with either major depression or bipolar illness were treated with antidepressants, neuroleptics and lithium their suicide rates and deaths from other causes were markedly decreased. There are also three studies that showed that treatment with Lithium, usually in patients with bipolar disease, also helps decrease the suicide and overall death rate significantly. However, many studies have shown, even patients in treatment or patients who have been hospitalized after a suicide attempt, that the treatment is not adequate.
The conclusion is that there are many factors that contribute to the suicide rates, and we must work to change all of them to have an impact.
In 2006, there were 33,300 suicides, the rate is 11.2 per 100,000.

4. Facing the Facts
Suicide is considered to be the second leading cause of death among college students.
Suicide is the second leading cause of death for people aged
Suicide is the third leading cause of death for people aged
Suicide is the fourth leading cause of death for adults between the ages of 18 and 65.
Suicide is highest in white males over 85.
(45.4/100,000, 2007)
The first and second leading causes of deaths in young adults (18-24) are accidents and homicides.
Since the CDC does not collect data on men and women who are specifically in college, we assume, since homicide is low in this group, it may be the second leading cause of death.
Although suicide rates in the US are highest in the very elderly, because there are so many other reasons why men die at this age, it is not a "leading" cause of death.
Data on this can best be obtained through the CDC website or NIMH website

5. Facing the Facts The suicide rate was 11.5/100,000 in 2007.
It greatly exceeds the rate of homicide. (6.1/100,000)
From , 881,443 people died by suicide, whereas 550,304 died from AIDS and HIV-related diseases.

6. Facing the Facts Suicide Communications ARE Made to Others
In adolescents, 50% communicated their intent to family members*
In elderly, 58% communicated their intent to the primary care doctor**

7. 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.
This is from a Canadian study. It involves life time exposure, so the suicide could be a relative who had died before the living person knew him or her. Ramsay, R and Bagley, C. Suic and Life Threat Beh (1985).
A more recent study showed that in the last year, 7% of the population knew a person, mainly a friend or acquaintance who killed himself and 1.1% of the population had a family member or relative who killed himself (or herself) Crosby and Sacks, Exposure to Suicide, Suic and Life Threat Beh (2002).

8. Prevention may be a matter of a caring person with the right knowledge being available in the right place at the right time.

9. Risk Factors Psychiatric disorders Past suicide attempts
Symptom risk factors
Sociodemographic risk factors
Environmental risk factors

10. Risk Factors Psychiatric Disorders
Most common psychiatric risk factors resulting in suicide:
Depression*
Major Depression
Bipolar Depression
Alcohol abuse and dependence
Drug abuse and dependence
Schizophrenia
*Especially when combined with alcohol and drug abuse
Also important, when studies of specific psychiatric disorders are reviewed, there are many that are associated with an outcome of suicide.
Suicide in Many Diagnosis
SMR = Observed deaths/expected deaths
Condition #Studies SMR
Eating Disorders
Major Depression
Mixed Drug Abuse
Bipolar Disorder
Opioid Abuse
Dysthmia
OCD
Panic Disorder
Schizophrenia
Personality Disorders
Alcohol Abuse
Pediatric Psychiatirc Disorders
Cannabis Abuse
Neuroses
Mental Retardation
Harris and Barraclough, Br J Psychiarty, 1997

11. Risk Factors
Other psychiatric risk factors with potential to result in suicide (account for significantly fewer suicides than depression):
Post Traumatic Stress Disorder (PTSD)
Eating disorders
Borderline personality disorder
Antisocial personality disorder

12. Risk Factors Major physical illness, especially recent
Chronic physical pain
History of childhood trauma or abuse, or of being bullied
Family history of death by suicide
Drinking/Drug use
Being a smoker
All these are acute and long term risk factors for suicide, but usually in the presence of major depression, or other psychiatric disorders.
Runs in families:
Denmark twin registry
4 concordant pairs in 19 monozygotic twins and no concordant pairs in 58 dizygotic twins Juel-Nielsen & Videbeck, Acta Genet. Med. Gemellol, 1970
___________________________________________________________________
Higher incidence of suicide in the biologic relatives of adoptees who suffered from depression then in their adopted relatives and higher then the biologic and adopted relatives of adoptee controls who were not depressed. Kety et al, 1979
Same sample, 5,483 adoptees, 57 completed suicide
Without regards to depression, these adoptees had more suicides in their biologic families than a comparison group of nonadopted controls. Schulsinger et al, 1979
This goes back to a two-factor solution, depression plus personality of aggression or impulsivity (explains why women have more depression but less suicide).

13. Risk Factors Sociodemographic Risk Factors Male Over age 65 White
Separated, widowed or divorced
Living alone
Being unemployed or retired
Occupation: health-related occupations higher (dentists, doctors, nurses, social workers)
especially high in women physicians
These factors are all associated, statistically, with an outcome of suicide. Of course, alone, they predict nothing. Like those mentioned in the previous slide, these add to concern when they are present in a depressed person.
Occupation is a difficult item to rely on, since as noted in the item before, being unemployed also is associated with suicide. If the person is a physician and is unemployed and is depressed, clearly that is a danger sign. But the majority of people who commit suicide are working, (in school or at a job) despite their illnesses. It may be in certain professions, having the means to commit suicide combined with being depressed, leads to this outcome. Some posit that women in certain professions are more "action oriented" like men. The only definitive associations between occupation and suicide are that clergy have lower rates.
Stack S, Social Science Quarterly, 2001, Murphy G, Comprehensive Psychiatry, 1998, Qin P, et al, Am J Psych 2003

14. Risk Factors Environmental Risk Factors Easy access to lethal means
Local clusters of suicide that have a "contagious influence"
Study after study has shown that availability of guns, bridges without barriers, pills packed in large numbers (instead of blister packs), toxic domestic gases, vehicle emissions* etc. allow for suicide completion.
* Catalytic Converters are required by law on every motor vehicle operated in the United States of America after These converters reduce emissions of cars, such as carbon monoxide, a poisonous gas which is colorless and odorless. Even with catalytic converters, people are still able to commit suicide by locking themselves in their car with the car exhaust being funneled into the car. Improvements can be made on the catalytic converter which can monitor the carbon monoxide emission and automatically shut-off the engine should the carbon monoxide reach a dangerous level. The car industry has not pursued these improvements because the additional cost for the parts would impact the cost of automobiles.
Contagion: Gould MS, Ann N Y Acad Sci., 2001

15. You Can Help!
Adapted with permission from the Washington Youth Suicide Prevention Program

16. How you can help prevent suicide
Know warning signs
Intervention

17. You Can Help
Most suicidal people don't really want to die – they just want their pain to end
About 80% of the time people who kill themselves have given definite signals or talked about suicide

18. You Can Help 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

19. You Can Help Intervention Three Basic Steps: 1. Show you care
2. Ask about suicide
3. Get help

20. You Can Help
Intervention: Step One
Show You Care
Be Genuine

21. You Can Help 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.

22. You Can Help
Be Genuine
Let the person know you really care. Talk about your feelings and ask about his or hers.
"I'm concerned about you… how do you feel?"
"Tell me about your pain."
"You mean a lot to me and I want to help."
"I care about you, about how you're holding up."
"I'm on your side…we'll get through this."

23. You Can Help Intervention: Step Two Ask About Suicide
Be direct but non-confrontational
Talking with people about suicide won't put the idea in their
heads. Chances are, if you've observed any of the warning signs,
they're already thinking about it. Be direct in a caring, non-
confrontational way. Get the conversation started.

24. You Can Help
You do not need to solve all of the person's problems – just engage them. Questions to ask:
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?

25. You Can Help Ask about treatment: Do you have a therapist/doctor?
Are you seeing him/her?
Are you taking your medications?

26. You Can Help Know referral resources Reassure the person
Intervention: Step Three
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

27. You Can Help
Know Referral Resources
Resource sheet
Hotlines

28. You Can Help Resource Sheet
Create referral resource sheet from your local community
Psychiatrists
Psychologists
Other Therapists
Family doctor/pediatrician
Local medical centers/medical universities
Local mental health services
Local hospital emergency room
Local walk-in clinics
Local psychiatric hospitals

29. You Can Help Georgia Crisis and Access Line
Hotlines
Georgia Crisis and Access Line or
Run by Behavioral Health Link
National Suicide Prevention Lifeline
TALK
911
In an acute crisis, call 911

30. You Can Help
Reassure the person that help is available and that you will help them get help:
“Together I know we can figure something out to make you feel better.”
“I know where we can get some help.”
“I can go with you to where we can get help.”
“Let's talk to someone who can help Let's call the crisis line now.”
Encourage the suicidal person to identify other people in their life who can also help:
Parent/Family Members
Favorite Teacher
School Counselor
School Nurse
Religious Leader
Family doctor

31. You Can Help Outline a safety plan
Make arrangements for the helper(s) to come to you OR take the person directly to the source of help - do NOT leave them alone!
Once therapy (or hospitalization) is initiated, be sure that the suicidal person is following through with appointments and medications.

32. Preventing Suicide
One Community at a Time

33. Preventing Suicide Prevention within our community Education Screening
Treatment
Means Restriction
Media Guidelines

34. Preventing Suicide Education Individual and Public Awareness
Professional Awareness
Educational Tools

35. Preventing Suicide Individual and Public Awareness
Primary risk factor for suicide is psychiatric illness
Depression is treatable
Destigmatize the illness
Destigmatize treatment
Encourage help-seeking behaviors and continuation of treatment

36. Preventing Suicide Educational Tools
Depression and suicide among college students:
The Truth About Suicide: Real Stories of Depression in College (2004)
Comes with accompanying facilitator’s guide
Depression and suicide among physicians and medical students:
Struggling in Silence: Physician Depression and Suicide (54 minutes)*
Struggling in Silence: Community Resource Version (16 minutes)
Out of the Silence: Medical Student Depression and Suicide (15 minutes)
Both shorter films are packaged together and include PPT presentations on the DVD’s
Depression and suicide among teenagers:
More Than Sad: Teen Depression (2009)**
Comes with facilitator’s guide and additional resources
Suicide Prevention Education for Teachers and Other School Personnel (2010)
Includes new film, More Than Sad: Preventing Teen Suicide, More Than Sad: Teen Depression, facilitator’s guide, a curriculum manual and additional resources
*received 2008 International Health & Medical Media Award (FREDDIE) in Psychiatry category
**received 2010 Eli Lilly Welcome Back Award in Destigmatization category

37. Preventing Suicide Screening Identify At Risk Individuals:
Columbia Teen Screen and others
AFSP Interactive Screening Program (ISP):
The ISP is an anonymous, web-based, interactive screen for individuals (students, faculty, employees) with depression and other mental disorders that put them at risk for suicide. ISP connects at-risk individuals to a counselor who provides personalized online support to get them engaged to come in for an evaluation. Based on evaluation findings, ISP was included in the Suicide Prevention Resource Center’s Best Practice Registry in It is currently in place in 16 colleges, including four medical schools.
Georgia currently has the ISP in 4 colleges (Agnes Scott, Emory, GCSU & Kennesaw State). More than any other state.
These are only a few of the screening instruments. They are usually short, simple questions that unveil depression, alcohol or substance use, and other disorders like anorexia or bulimia.
With the first, it is used in high schools, after parental consent and on a day when a counselor is present to refer those in highest distress to appropriate care.
With the second, it is done anonymously over a website and can only be used if there is an appropriate counselor available to respond.
The others are general depression screening usually done at health centers or designated health care sites around the country on a specific day.
October is Depression and Mental Health Month.
*Dr. Douglas Jacobs, Associate Clinical Professor of Psychiatry at Harvard Medical School founded and is the Executive Director of Screening for Mental Health, Inc. and founded and directs National Depression Screening Day. Since 1991, the program has provided free nationwide depression screenings each October during Mental Illness Awareness Week.
Many mental health web sites, like DBSA or NAMI also have screening instruments for individuals to take to see if they had suffering from specific disorders. The most frequently used screening instrument to recognize depression is the PHQ-9 (online). It will be part of a large New York City campaign in the summer of 2006 to identify and treat people with depression.

38. Preventing Suicide
Treatment
Antidepressants
Psychotherapy

39. Preventing Suicide Antidepressants
Adequate prescription treatment and monitoring
Only 20% of medicated depressed patients are adequately treated with antidepressants – possibly due to:
Side effects
Lack of improvement
High anxiety not treated
Fear of drug dependency
Concomitant substance use
Didn't combine with psychotherapy
Dose not high enough
Didn't add adjunct therapy such as lithium or other medication(s)
Didn't explore all options including: ECT or other somatic treatment
Demyttenaere K, et al, J Clin Psychiatry, 2001

40. Preventing Suicide Psychotherapy
Research shows that when it comes to treating depression, all therapy is NOT created equal.
Study shows applying correct techniques reduce suicide attempts by 50% over 18 month period
To be effective, psychotherapy must be:
Specifically designed to treat depression
Relatively short-term (10-16 weeks)
Structured (therapist should be able to give step-by-step treatment instructions that any other therapist can easily follow)
Examples: Cognitive Behavior Therapy (CBT), Interpersonal Therapy (IPT), Dialectical Behavior Therapy (DBT)
Implement teaching of these techniques
*Brown et al, JAMA, 2005

41. Preventing Suicide Means Restrictions Firearm safety
Construction of barriers at jumping sites
Detoxification of domestic gas
Improvements in the use of catalytic converters in motor vehicles
Restrictions on pesticides
Reduce lethality or toxicity of prescriptions
Use of lower toxicity antidepressants
Change packaging of medications to blister packs
Restrict sales of lethal hypnotics (i.e. Barbiturates)
Mann, J. J., Apter, A., Bertolote, J., Beautrais, A., Currier, D., et. al., (2005). Suicide prevention strategies: A systematic review. Journal of the American Medical Association 294 (16),

42. Preventing Suicide Media Guidelines
Suicide is a public health issue. Media and online coverage of suicide should be informed by using best practices. The way media covers suicide can influence behavior negatively by contributing to contagion or positively by encouraging help-seeking. Suicide Contagion or “Copycat Suicide” occurs when one or more suicides are reported in a way that contributes to another suicide.
Recommendations for Reporting on Suicide can be found on the AFSP website ( or

43. Our mission statement
The American Foundation for Suicide Prevention (AFSP) is the leading national not-for-profit organization exclusively dedicated to understanding and preventing suicide through research, education and advocacy, and to reaching out to people with mental disorders and those impacted by suicide.

44. AFSP-Metro Atlanta
Contact Information:
Chris Owens, RN, BSN
Metro Atlanta Area Director
American Foundation for Suicide Prevention