3Facing the FactsIn 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.
4Facing the FactsSuicide is considered to be the second leading cause of death among college students.Suicide is the second leading cause of death for people agedSuicide is the third leading cause of death for people agedSuicide 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
5Facing 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.
6Facing 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**
7Facing 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).
8Prevention may be a matter of a caring person with the right knowledge being available in the right place at the right time.
10Risk Factors Psychiatric Disorders Most common psychiatric risk factors resulting in suicide:Depression*Major DepressionBipolar DepressionAlcohol abuse and dependenceDrug abuse and dependenceSchizophrenia*Especially when combined with alcohol and drug abuseAlso important, when studies of specific psychiatric disorders are reviewed, there are many that are associated with an outcome of suicide.Suicide in Many DiagnosisSMR = Observed deaths/expected deathsCondition #Studies SMREating DisordersMajor DepressionMixed Drug AbuseBipolar DisorderOpioid AbuseDysthmiaOCDPanic DisorderSchizophreniaPersonality DisordersAlcohol AbusePediatric Psychiatirc DisordersCannabis AbuseNeurosesMental RetardationHarris and Barraclough, Br J Psychiarty, 1997
11Risk FactorsOther psychiatric risk factors with potential to result in suicide (account for significantly fewer suicides than depression):Post Traumatic Stress Disorder (PTSD)Eating disordersBorderline personality disorderAntisocial personality disorder
12Risk Factors Major physical illness, especially recent Chronic physical painHistory of childhood trauma or abuse, or of being bulliedFamily history of death by suicideDrinking/Drug useBeing a smokerAll 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 registry4 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, 1979Same sample, 5,483 adoptees, 57 completed suicideWithout regards to depression, these adoptees had more suicides in their biologic families than a comparison group of nonadopted controls. Schulsinger et al, 1979This goes back to a two-factor solution, depression plus personality of aggression or impulsivity (explains why women have more depression but less suicide).
13Risk Factors Sociodemographic Risk Factors Male Over age 65 White Separated, widowed or divorcedLiving aloneBeing unemployed or retiredOccupation: health-related occupations higher (dentists, doctors, nurses, social workers)especially high in women physiciansThese 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
14Risk 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
15You Can Help!Adapted with permission from the Washington Youth Suicide Prevention Program
16How you can help prevent suicide Know warning signsIntervention
17You Can HelpMost suicidal people don't really want to die – they just want their pain to endAbout 80% of the time people who kill themselves have given definite signals or talked about suicide
18You Can Help Warning Signs Observable signs of serious depression Unrelenting low moodPessimismHopelessnessDesperationAnxiety, psychic pain, inner tensionWithdrawalSleep problemsIncreased alcohol and/or other drug useRecent impulsiveness and taking unnecessary risksThreatening suicide or expressing strong wish to dieMaking a planGiving away prized possessionsPurchasing a firearmObtaining other means of killing oneselfUnexpected rage or anger
19You Can Help Intervention Three Basic Steps: 1. Show you care 2. Ask about suicide3. Get help
20You Can HelpIntervention: Step OneShow You CareBe Genuine
21You 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 CarefullyReflect what you hearUse language appropriate for age of person involvedDo not worry about doing or saying exactly the "right" thing. Your genuine interest is what is most important.
22You Can HelpBe GenuineLet 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."
23You Can Help Intervention: Step Two Ask About Suicide Be direct but non-confrontationalTalking with people about suicide won't put the idea in theirheads. 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.
24You Can HelpYou 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?
25You Can Help Ask about treatment: Do you have a therapist/doctor? Are you seeing him/her?Are you taking your medications?
26You Can Help Know referral resources Reassure the person Intervention: Step ThreeGet help, but do NOT leave the person aloneKnow referral resourcesReassure the personEncourage the person to participate in helping processOutline safety plan
27You Can HelpKnow Referral ResourcesResource sheetHotlines
28You Can Help Resource Sheet Create referral resource sheet from your local communityPsychiatristsPsychologistsOther TherapistsFamily doctor/pediatricianLocal medical centers/medical universitiesLocal mental health servicesLocal hospital emergency roomLocal walk-in clinicsLocal psychiatric hospitals
29You Can Help Georgia Crisis and Access Line HotlinesGeorgia Crisis and Access LineorRun by Behavioral Health LinkNational Suicide Prevention LifelineTALK911In an acute crisis, call 911
30You Can HelpReassure 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 MembersFavorite TeacherSchool CounselorSchool NurseReligious LeaderFamily doctor
31You 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.
33Preventing Suicide Prevention within our community Education Screening TreatmentMeans RestrictionMedia Guidelines
34Preventing Suicide Education Individual and Public Awareness Professional AwarenessEducational Tools
35Preventing Suicide Individual and Public Awareness Primary risk factor for suicide is psychiatric illnessDepression is treatableDestigmatize the illnessDestigmatize treatmentEncourage help-seeking behaviors and continuation of treatment
36Preventing 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 guideDepression 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’sDepression and suicide among teenagers:More Than Sad: Teen Depression (2009)**Comes with facilitator’s guide and additional resourcesSuicide 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
37Preventing Suicide Screening Identify At Risk Individuals: Columbia Teen Screen and othersAFSP 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.
39Preventing Suicide Antidepressants Adequate prescription treatment and monitoringOnly 20% of medicated depressed patients are adequately treated with antidepressants – possibly due to:Side effectsLack of improvementHigh anxiety not treatedFear of drug dependencyConcomitant substance useDidn't combine with psychotherapyDose not high enoughDidn't add adjunct therapy such as lithium or other medication(s)Didn't explore all options including: ECT or other somatic treatmentDemyttenaere K, et al, J Clin Psychiatry, 2001
40Preventing 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 periodTo be effective, psychotherapy must be:Specifically designed to treat depressionRelatively 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
41Preventing Suicide Means Restrictions Firearm safety Construction of barriers at jumping sitesDetoxification of domestic gasImprovements in the use of catalytic converters in motor vehiclesRestrictions on pesticidesReduce lethality or toxicity of prescriptionsUse of lower toxicity antidepressantsChange packaging of medications to blister packsRestrict 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),
42Preventing 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 (www.afsp.org/media) or
43Our mission statementThe 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.
44AFSP-Metro AtlantaContact Information:Chris Owens, RN, BSNMetro Atlanta Area DirectorAmerican Foundation for Suicide Prevention