2Conference Agenda Dr. Gabriel Kaplan Epidemiology Dr. Bennett Silver PsychopathologyRisk Assessment Pharmacological ApproachPsychosocial Approach and Prevention Programs
3PUBLICATIONS/PRESENTATIONS Bennett Silver, MDACADEMIC CREDENTIALSBoard Certified Adult PsychiatristAmerican Board of Psychiatry and Neurology, INCChild PsychiatristMt. Sinai School of Medicine Trained SpecialistDirector of Residency TrainingBergen Regional Medical CenterThree decades of clinical work with suicidal patientsPUBLICATIONS/PRESENTATIONSEditor,Child and Adolescent Psychiatry Alerts national newsletterPsychiatry Drug Alerts national newsletterPresentations to physicians, school personnel, professional associations, parent groups, on the topic of suicide
4PUBLICATIONS/RESEARCH/SYMPOSIA Gabriel Kaplan, MDACADEMIC CREDENTIALSBoard Certified Child Psychiatrist, American Board of Psychiatry and Neurology, INCDistinguished Fellow, American Psychiatric AssociationClinical Associate Professor of Psychiatry, University of Medicine and Dentistry of New JerseyPUBLICATIONS/RESEARCH/SYMPOSIAKaplan G.Co-Investigator. New York Hospital Research Grant Follow-up Suicidal AdolescentsPfeffer C., Newcorn J.H., Kaplan G., et al.Suicidal Behavior in Adolescent Psychiatric Inpatients. J American Academy of Child Adolesc Psychiatry. 1988; 27:Pfeffer, C., Newcorn J.H., Kaplan G., et al.Subtypes of Suicidal and Assaultive Behaviors in Adolescents J Child Psychology and Psychiatry, 1989; 1:Kaplan, G., Oquendo, M., Escobar, J., and Marin, H.Assessment and Management of Depression Symposium 2006 APAAssessment and Management of Suicidal Behavior across the Life Cycle Symposium 2007 APAGreydanus D. and Kaplan G.Strategies to Improve Medication Adherence in Youths: Approaches During the Active to Maintenance Transition. Psychiatric Times pp July, 2012What is New in Adolescent Psychiatry? A Literature Review and Clinical Implications Adolescent Medicine: State of Art Reviews (AM:STARs). Spring 2013 (in Press)
6Definitions Suicidal Ideation Thoughts of harming or killing oneself. Suicidal CommunicationsDirect or indirect expressions of suicidal ideation or of intent to harm or kill self, expressed verbally or through writing, artwork, or other means.Suicidal ThreatsA special case of suicidal communications, used with intent to change the behavior of other people.Suicide AttemptA non-fatal, self-inflicted destructive act with the explicit or inferred intent to die.SuicideFatal self-inflicted destructive act with explicit or inferred intent to die.SuicidalityAll suicide-related behaviors and thoughts including completing or attempting suicide, suicidal ideation or communications.Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002.
7Trends in Suicide Rates Ages 10 Years and Older, by Sex, 1991–2009 Centers for Disease Control:
8Rates have increased since 2004 Influence of internet social networksHigh suicide among young U.S. troopsHigher rates of untreated depression in the wake of recent “black box” warnings on antidepressants—a possible unintended consequence of the medication warnings, required by the FDA in 2004
9Percentage of Suicides Ages 10 Years and Older, by Sex and Mechanism, 2005–2009 Centers for Disease Control:
11Youth Risk Behavior Surveillance System (YRBSS) The YRBSS was developed by the Centers for Disease Control (CDC ) in 1990 to monitor priority health risk behaviors that contribute markedly to the leading causes of death, disability, and social problems among youth and adults in the United StatesThe YRBSS includes national, state, territorial, tribal government, and local school-based surveys of representative samples of 9th through 12th grade students. These surveys are conducted every two years, usually during the spring semester.
12Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
13Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
14Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
15Centers for Disease Control: www.apps.nccd.cdc.gov/youthonline/App
16H S Students Considering, Planning, or Attempting Suicide in Past 12 Months 2009 Centers for Disease Control:
17Suicide Rates Ages 10–24 Years, by Race/Ethnicity and Sex, 2005–2009 Centers for Disease Control:
19Common school suicidal situations A note is foundA student overhears another studentA student confides in a guidance counselorA student threatens during school dayA parent confides in a teacher/counselorA teacher discovers student’s self mutilationA student “does not look well” and is askedStudent is absent, parents confideRoutine suicide school screeningA student who is bullied expresses suicide ideas
20Risk Factors History of depression or other mental illness Psychiatric disorder is present in up to 80-90% of adolescent suicide victims and attemptersMost common psychiatric conditions are mood, anxiety, conduct, and substance abuse disorders.History of previous suicide attemptsFamily history of suicideStressful life event or lossEasy access to lethal methodsExposure to the suicidal behavior of othersIncarcerationBullying (victims and perpetrators)Hopelessness/guilt
21What to do? A plausible suspicion must be assessed immediately A usually happy go lucky 7 year old crying “I want to die” because another student took a toy away does not need an emergent evaluation.Keep in mind risk factors/age discussed hereWhile rare, every suicide is “one too many”Thus, when in doubt, err on the side of caution and refer a.s.a.p.
22EvaluationAdolescent suicidal behavior is a medical emergency that must be assessed by highly qualified professionals:Child Psychiatrist,Psychiatrist,Non-MD with training and experience in the assessment of suicidal behaviorIf an adolescent actively threatens suicide, an assessment must be conducted asap in the Emergency Room setting
23Expert evaluation Comprehensive psychiatric examination Includes medical historyPatient, family, teacher input requiredEvaluation focused on determining potential risk and dispositionMay include rating scales
24Expert will assess Presence of mental illness Large majority of patients who suicide suffer from mental illnessAll psychiatrically ill adolescents are high riskPresence of aggravating circumstancesLoss, bullying, substance abuseSuicide continuum stage
25Suicide Continuum Passive Death Wish Suicidal Ideation without method Suicidal Ideation with methodSelf-Injurious behavior with unclear intentAttemptCompletionAdd threat (verbal or written)Note that self-injury does NOT fall within the continuum.
26Focused assessment of continuum It is vital to assess what the adolescent is thinkingIn order to determine strengths and weaknesses, difficult questions must be asked centered on degree of desire to dieQuestions must be very specific. Trying to assess suicidality without asking about death is like trying to determine appendicitis without asking “does it hurt here?”There is ample evidence that asking about suicide does not “put” ideas in any adolescent’s mind
27Examples of Suicide Continuum Passive death wishI wish God took me awayIdeation without methodI feel bad and have thought about killing myselfIdeation with a methodI am thinking about shooting myself
28Attempt vs. Gesture SUICIDE GESTURE: Self-injury in which there is unclear intent to die but instead an intent to give the appearance of a suicide attempt in order to communicate with others (Nock & Kessler Journal of Abnormal Psychology 2006, Vol. 115, No. 3, 616 – 623)SUICIDE ATTEMPT:Potentially self-injurious behavior with a nonfatal outcome, for which there is evidence (either implicit or explicit) that the person intended at some level to kill self (Goldsmith SK, Pellmar TC, Kleinman AM, et al. Reducing Suicide: A National Imperative. Washington, D.C.: National Academy Press; 2002).There is evidence that these two groups differ but there is also evidence that those who engage in suicide gestures also carry a higher risk of completion.Those who “gesture” must be taken seriously
29High Risk 16 year old male Abuses alcohol Treated for bipolar disorder History of suicidal ideasRecent loss of mother due to medical illnessFather is a hunterBroke up with GF and stated he wants to kill self
30Medium Risk 17 year old female History of self mutilation without intent to dieFamily history of completed suicideDoing poorly in school, ostracized by peersAttends therapy regularlyHas good relationship with parentsDuring an argument with peer in school was overheard voicing wish to die
31Low Risk 9 year old male Parents recently separated Stays with grandmother very oftenDoing well in school and liked by peersNo family history of psychiatric problemsAfter watching a movie showing a suicide, told grandmother nobody likes him and he wishes to die
32Risk And Disposition High Risk Medium Risk Minimal Risk Inpatient treatmentIf condition relapses, next time discharge to structured setting, possibly a therapeutic day schoolMedium RiskIf new condition, Partial Care ProgramIf condition is chronic, structured setting advisable, possibly a therapeutic day schoolMinimal RiskTraditional Outpatient Treatment
34How it HappensAlex was a 17 year old high school senior. He was a warm, sensitive, quiet young man; a high honor roll student and a gifted young writer. He had been accepted to an excellent college, and a promising, successful future seemed assured. Yet one late afternoon in April, upon returning home from work, his horrified mother discovered him on the floor of his bedroom. Alex had killed himself with a gunshot to the head.How is it possible that this young man, who seemed to have everything to live for, would take his own life?
35Why it HappensIn order to understand why tragedies like this occur, we must understand the psychopathology from which it stems.
36Suicide as a SymptomSuicide is to the psychiatrist as cancer is to the internistThe psychiatrist may provide optimal care, yet the patient may die by suicide nonethelessSuicide is best viewed as a symptom of an underlying disease rather than a disease per seThe underlying disease is usually some type of depression, or another psychiatric disorder and therefore is highly treatable
37Causes of DepressionDepression has no single cause. Genetics/Biology definitely play a role (family history)The environment: stressful situations, abuse, family issues, physical illness, loss, romantic breakups, conflict over sexual orientationAnxiety and behavior problems increase chances for depressionPredisposing personality traits: perfectionism, inhibition, isolation, supersensitiveDrug and alcohol dependencyHead injuries (e.g., football, soccer, car accidents), lead to disinhibition, depression and suicideSometimes no clear triggering eventA bio-psycho-social model provides the best understanding of depression
38Biological Theories About Suicide Genetic factors predispose to suicide – clusters of families with both mood disorders & suicides and clusters with mood disorders without suicide, indicates independent inheritance of mood disorders and suicidal behaviorBiological theories about suicide linked to studies of depression-the mental state most often underlying suicideDeficiency of neurotransmitters like norepinephrine/ serotonin at critical sites in brain resulting in depressionMany studies indicate a lower level of serotonin in brains of those who suicided and in cerebrospinal fluid of depressed individuals who have attempted suicide than in depressed patients who are not suicidal
39Low Brain Serotonin, Impulsivity and Suicide More violent suicide attempters/completers(guns, jumping) lower levels of serotonin than those using less violent means (e.g., pills)Studies have found decreased serotonin levels for gamblers/fire- setters/impulsive individuals, compared to control populationsThis non-specificity links lower serotonin levels with poor impulse control which increases suicidal behavior.Alcohol lowers serotonin at same sites in brain as seen in depressed patients. Alcohol is a disinhibiter that increases impulsivity and greatly increases risk of suicide in depressed patients.One third of adolescents who suicide are legally intoxicated at the time of death
40Biopsychosocial Theories Stress plays a role in development of depression, addiction and other psychiatric disordersCorticotrophin releasing factor (CRF), a key brain hormone in the stress response, is implicated in the physiology of both depression & Substance use disorders (SUDs)Elevated CRF concentrations found in the brains of suicide victimsEarly life stress (physical/sexual abuse/neglect) and chronic stress cause sustained elevations of CRF, causing long term damage to brain pathways (neuroadaptation) which increases susceptibility to depression and substance useThis provides the biological underpinnings of the well-established relationship between early life adversity and depression, suicide and SUDs in adolescents and adults
41Suicidal BehaviorMore than 90% of all completed suicides in adolescents (and adults) are individuals with psychiatric disorders:Mood Disorders (most common): Major Depression, Bipolar DisSchizophreniaAlcoholismDrug DependenceConduct DisordersBorderline Personality DisorderPanic DisorderSubstance Abuse Disorders and Anxiety Disorders appear more important as cofactors rather than primary in themselves. Co- existent high anxiety, panic, or substance use, accompanying major depressive disorder or schizophrenia markedly increase suicide risk
42The Suicidal CrisisOften, a crisis situation, what one author called a “state of perturbation,” occurs in a vulnerable adolescent with a psychiatric disorder and that crisis converts a state of potential risk into an actual suicidal actThe most common precipitating events are break-ups, episodes of perceived humiliation, academic or extracurricular failures, school disciplinary/legal problems, or sexual assaults
43Mood Disorders and Completed Suicide 60-70% of suicide victims were suffering from a significant clinical depression at the time of their deathsCompleted SuicideLifetime Suicide AttemptBipolar Disorder10-20%29%Major Depression5-12%16%General Population<.0002% (16/100,000).02%Any Psychiatric Disorder4%
44Some Facts About Bipolar Disorder Prevalence in America of approx 1% to 4%Equally in men and women60% onset before age 2010%-15% of adolescents with recurrent major depression go on to develop Bipolar DisorderResidual symptoms between episodes common, and 60% experience chronic interpersonal and school difficulties between episodesStrong genetic influence-one of most familial psychiatric disorders
45Characterized by Recurrent Mood Episodes Major Depressive EpisodeManic EpisodeMixed EpisodeHypomanic Episode
46Manic EpisodeDistinct period of persistently elevated, expansive, or irritable mood –causes marked impairment in functioningDuring period of mood disturbance at least 3 of the following:Inflated self-esteem or grandiosityDecreased need for sleepMore talkative, pressured speechFlight of ideas or racing thoughtsDistractibilityIncreased in goal-directed activity (social, school work, sexual) or psychomotor agitationExcessive involvement in activities with high potential for negative consequences (e.g., buying sprees, sexual indiscretions)
47Mixed and Hypomanic Episodes During a Mixed Episode manic and depressive symptoms may occur simultaneously or in quick succession.During a Hypomanic Episode, symptoms same as during Manic Episode, but less severe - do not cause marked impairment in functioning.
48Suicide Risk in Bipolar Disorder and Major Depression Mixed StatesHighest Risk(Increased energyand AgitationPredispose to SuicidalBehavior)Major DepressionAcuteMania
49Other Factors That Increase Suicidal Acts in Depressed and Bipolar Patients Severity of depressionAge of onset (younger age)Severity of ideationNumber of prior attemptsStable levels of hopelessnessTransition points: first week of hospitalization, incarceration, bereavement, victimization/abuse
50Comorbid Substance Abuse Prevalence of comorbid substance abuse in bipolar I and bipolar II disorder is as high as 61% and 48% respectivelyThis is greater than the prevalence of substance abuse seen with any other psychiatric conditions, including schizophrenia, panic disorder, dysthymia and unipolar depressionComorbid substance use increases the risk for suicide in mood disorders
51Accurate Diagnosis and Early Intervention Bipolar Disorder is difficult to diagnose in adolescence, due to nature of adolescent moodiness, and similarities with conditions such as ADHD, Schizophrenia, and AddictionBipolar Disorder has a spectrum of severity and milder forms often missed or misdiagnosed.Misdiagnosis leads to delayed or incorrect treatmentEarly intervention/treatment improves long – term outcome, reduces suicidal risk for teens
52Major depression in adults and adolescents At least 5 of these symptoms must be present to the extent that they interfere with daily functioning over at least 2 weeksAdults AdolescentsDepressed mood most of the day Irritable mood; preoccupied with songlyrics that suggest life is meaninglessDecreased interest/ enjoyment in activities Loss of interest in sports, video games, activities with friendsSignificant weight loss /gain Failure to gain normal weight ; anorexia or bulimia; frequent complaint of physical illnessInsomnia or hypersomnia Excessive late night TV or computer; refusal to wake upfor school in morning in morningPsychomotor agitation/ retardation Running away from homeFatigue or loss of energy Persistent boredomLow self-esteem; feelings of guilt Oppositional and/or negative behaviorDecreased ability to concentrate; indecisive Poor performance in school; frequent absencesRecurrent Suicidal ideation or behavior Recurrent suicidal ideation or behavior (writing about death ; giving away favorite objects or possessions
53Signs and Symptoms of Covert Depression Often Seen in Adolescents The quiet, perfectionistic “good boy” who never gets into trouble but who cannot maintain the level of perfection that he or others expect of himBoys with conduct disturbances who become depressed and act out impulsivelyBoys who abruptly develop conduct disturbances as their way of expressing depressionChanges in school performance or friendsBeginning to abuse substances
54Relapse is Common in Major Depression After one episode %After two episodes >70%After three epsodes >90%Relapse is more common when first episode is before the age of 20 years
55Symptoms and Signs of Psychiatric Illness Are Present Prior to Suicide Although the bereaved parents of adolescent suicide victims frequently insist that their child was totally free of any symptoms prior to the suicide, this appears rarely true on closer examination, and may reflect the parents’ denial or their inability to recognize the signs of depression
57Pharmacology is just One of Many Tools within a Comprehensive Approach Individual psychotherapyGroup psychotherapyFamily therapySchool InterventionsMedicationTherapeutic school placement such as New Alliance Academy which can utilize all of above approaches
58Medication Classes Used in Suicide AntidepressantsAntipsychoticsMood StabilizersOnly one medication has been proven to decrease suicide in adult schizophrenia and is FDA approved specifically for suicideClozapine (antipsychotic)There is ample evidence for other medications in adultsLithium (mood stabilizer)
60Side-effects of Antidepressants Most adolescents do not have side-effects. If they do occur they are usually mild and transient.HeadachesUpset stomachDecreased appetiteFlushing and sweatingMild sedationJitterinessAbnormal dreamsRashSexualBLACK BOX WARNING
61Antidepressants Are Compatible With Student Performance in School Low incidence of side-effectsUsually not sedatingOnce daily dosing (morning or nighttime)Usually compatible with other medications
62How Effective Are Antidepressants ? In an important recent study funded by the NIMH (TADS) on adolescents with moderate to severe depression :71% of adolescents who received combination treatment (medication + therapy) improved significantly61% of those receiving medication alone (fluoxetine) improvedCombination treatment was nearly twice as effective in relieving depression as the placebo or psychotherapy aloneMarch J. TADS JAMA Aug 18;292(7):
63Do Antidepressants make people suicidal? 2003 the maker of Paxil disclosed that clinical trial data had found an increased risk of suicidality in youth.FDA concluded that for every 100 treated patients, 1 to 3 patients might be expected to have an increase in suicidality.2004 FDA required all antidepressants carry a black box warningThe data did not indicate any completed suicides, thus, the identified suicidality increase referred to ideas and behaviors but not deaths.2007 FDA expanded the warning to include patients up to age 24.There are only two FDA approved agents indicated for use in adolescent depression: fluoxetine (Prozac) and escitalopram (Lexapro).
64Black Box ControversyData from the CDC show that between 1992 and 2001, the rate of suicide among American youth ages 10 – 19 declined by more than 25%The dramatic decline in youth suicide rates correlates with the increased rates of prescribing antidepressant medication (particularly SSRI’s) to young peopleSince the black-box suicide warnings appeared on the labels of antidepressants, antidepressant use among teens plummeted. At the same time, the suicide rate among U.S. teens rose sharply – bucking a decades long trendThere are no statistical data yet linking the black box to increased suicidality but suspicion is high amongst academicians that this may have been an unintended consequence of the warning
65Data Reanalyses FDA studied only short term data Data were reanalyzed adding longitudinal information, extending the observational period beyond the short term study end point timeframes assessed by the FDA.For adult and geriatric patients medication actually decreased suicidal thoughts and behavior. The protective effect was mediated by decreases in depressive symptoms with treatment.For youths, however, although depression also responded to treatment, no significant effects of treatment on lowering suicidal thoughts and behavior were found, although reassuringly, there was no evidence of increased suicide risk in those receiving active medication.Gibbons RD, Brown CH, Hur K, Davis J, Mann JJ. Suicidal Thoughts and Behavior With Antidepressant Treatment: Reanalysis of the Randomized Placebo- Controlled Studies of Fluoxetine and Venlafaxine. Arch Gen Psychiatry Jun;69(6):580-7.
66Mood Stabilizers USED FOR BIPOLAR DISORDER LITHIUM: Lithium Carbonate (Eskalith,Lithobid)ANTICONVULSANTS:Valproic Acid (Depakote)Carbamazepine (Tegretol)Lamotrigine (Lamictal)
67Lithium Oldest mood stabilizer Improves depression and mania Helps prevent future episodesNarrow dosage range (blood levels required)Very dangerous in overdoseSide – effects: drowsiness, weakness, nausea, fatigue, hand tremor, increased thirst, increased urination, thyroid underactivity, weight gain
68Anticonvulsants Improve depression and mania Lamictal especially good for depressive episodesHelp prevent future episodesNarrow dosage range (blood levels required)Work better than Lithium for rapid cyclers and mixed statesSide – effects: Nausea, headache, double vision, sedation, liver enzyme elevation, weight gain, hormone changes in women (Depakote, e.g., absence of menstruation)
69Antipsychotics TYPICAL ATYPICAL Haloperidol (Haldol) Less sedating, muscle rigidity, Tardive DyskinesiaChlorpromazine (Thorazine) Sedating, low blood pressure, TDATYPICALAripiprazole (Abilify) –weight neutral, less sedatingRisperdone (Risperdal) – Moderate weight gain, increases prolactinQuetiapine (Seroquel) – Moderate weight gain, sedating, may have antidepressant propertiesOlanzapine (Zyprexa) – Very effective, but significant weight gain, metabolic effects (blood sugar, cholesterol)Ziprasidone (Geodon) – Weight neutral, less sedatingClozapine (Clozaril) – Most effective, weight gain, metabolic effects, risk for severe white blood cell suppression requires regular blood tests. Used when other medications fail.
71Psychosocial Approach and Prevention Bennett Silver, M.D.
72Getting the Right Help Can Prevent Suicide > 80% of adolescent suicide attempters/completers communicate suicidal ideation prior to the attemptMajority of youth suicide attempters/completers have seen a doctor/mental health worker in 3 months prior to the suicidal behaviorFew individuals with Major Depressive Disorder receive adequate treatment for depression before and after a suicide attemptOnly 20-40% of suicidal patients continue outpatient treatment after psychiatric hospitalization-treatment dropout another suicide risk factorRecent Study of 102 people who killed themselves revealed more than half had visited mental health specialist during the year prior to deathOnly 5% had contact with addiction services, even though 2/3 suffered from substance abuse as well as depression - need better integration of mental health and addiction services
73Psychotherapy for Suicidal Patients Short-term, group, behavioral, interpersonal, psychoanalytically oriented, and multiple other psychotherapy approaches have all been employed with reported successHowever, Cognitive Behavioral Therapy (CBT) by far the largest evidence base of its effectivenessDialectical Behavioral Therapy (DBT) particularly effective with suicidal Borderline Personality Disorder patients
74Cognitive TherapyCognitive theory emphasizes the psychological significance of people’s beliefs about themselves, their personal world (including the people in their lives), and their future – the “cognitive triad”Maladaptive emotional distress linked to biased beliefs about this cognitive triad of self, world, and futureE.g., clinically depressed people may believe that they are incapable and helpless, view others as judgmental, and the future as bleak and unrewardingCognitive therapy modifies these maladaptive beliefs to help the person gain a more objective view of their problems and their potential solutions
75Thinking Patterns Targeted by Cognitive Therapy Dichotomous (black-white) thinkingCognitive rigidity and constrictionPerfectionistic standards of self/others, high self-criticismOver-general autobiographical memory - past experiences cannot be used as references for effective coping strategiesImpaired problem solvingHopelessness/helplessness-negative expectations about the future“locked-in” to current perceptions, unable to imagine alternativesView death in a favorable lightHave difficulty generating reason for living
76Critical Role of Early Intervention and Parent Education The earlier the intervention in the course of suicidality, the greater the potential for successImportance of parent education of suicidal youth – e.g., 17% of parents keep firearms even after their child’s suicide attempts (more lethal methods with repeat attempts)Parents are 3 times more likely to take protective actions when parent education is provided
77Bullying and SuicideRecent bullying related suicides and school shootings in the US and in other countries have drawn attention to the connection between bullying and suicide/homicideToo many adults see bullying as “just part of being a kid”Bully victims 2 to 9 times more likely to consider suicide30% of students are either bullies or victims of bullying and 160,000 kids stay home daily due to fear of bullyingTypes of bullying- physical, emotional, cyber, sextingBeing a bully also linked to an increased rate of suicide
78New Jersey Anti-Bullying Bill of Rights Act 2011, toughest in country-extension of original anti-bullying law enacted in 2002Defines bullying: any harmful action towards another student or any action that creates a hostile school environment or infringes on a student’s rights at school.Includes cyber bullying and bullying both on and off school groundsAll cases bullying/teasing must be reported to the StateWritten report within 2 days, families, superintendent notified, investigation within 10 days of incidentAll schools a plan to address bullying, teachers/ administrators trained to identify/respond to bullyingAll schools anti-bullying specialist/school safety team
79How to Deal with a Suicidal Adolescent First, a person in crisis needs someone to listen and hear what they are sayingAll suicidal talk should be taken seriouslyDo not be afraid to ask directly if the person has thoughts of suicide – it will do no harm-most individuals relieved and feel given permission to talk about itDo not be misled by the suicidal person’s comment that he is alright and past the crisis – follow-up is crucial to insure good treatment
80How to Deal with a Suicidal Adolescent - 2 Be firm but supportive – give the impression that you know what you are doing and that you intend to do everything possible to prevent him from taking his lifeEvaluate the resources available – inner psychological resources such as intellectualization that can be strengthened & outer resources such as counselors, relatives, clergy and others who can be called in
81How to Deal with a Suicidal Adolescent - 3 Act Specifically – do something tangible, parents must be called in, arrange for him to see someone else, or if necessary, have the person brought to an emergency room for evaluationSchool staff cannot assume that a student’s family will take positive steps to respond to the situation, especially in dysfunctional families and must insure that at risk students receive the necessary servicesDon’t be afraid to ask for assistance and consultation – call upon whomever is needed. Don’t try to handle everything alone
82Postvention in the School Setting Prevention measures implemented after a traumatic event to reduce risk to those who have been affected by the tragedyThe suicide, violent or unexpected death of a student, teacher, even a celebrity can increase risk of suicide for vulnerable young people - “copy-cat suicides”Postvention includes grief counseling for students/staff, identification/support of vulnerable students, and familiesWork with the media-ensure news coverage does not dramatize/romanticize, leading to additional suicidesEstablish school- based suicide prevention programs & crisis response plans including educational activities that encourage students to recognize and find help for emotional issues
83National Suicide Prevention Strategy Sept 10, 2012, U.S. announced $55.6 million in new grants for suicide prevention programsFirst new national strategy plan in over a decadePromotes new Facebook service-users can report suicidal comments they see online from friends-website sends the potential victim an urging a call to hotline/chat online with a counselorNew technologies-mobile apps to connect people with counseling resourcesPlan highlights the 23 million veterans (17,754 veteran suicide attempts last year- 48 per day) and efforts to identify soldiers at risk, reduce stigma and encourage them to seek help
84Elements of the National Strategy Health professionals are not adequately trained for proper assessment, treatment and management of suicidal individuals, or know how to refer them properly for specialized assessment/treatmentProvide targeted education for suicide identification and referral to key gatekeepers such as teachers, guidance counselors, doctors, clergy, social workers, psychologistsImprove marketing of community-level educationalIncorporate screening for depression, substance abuse and suicide risk as a minimum standard of care for assessment in primary care settings, schools, and collegesLimit access to lethal methods of self-harm -firearms, lethal doses of medicines, drugs, alcohol by underage youth, and dangerous settings such as bridges/rooftopsFor example, improvements and changes in car exhaust emissions have resulted in a decrease in deaths by carbon monoxide poisoning
85Other Broad-Based Strategies Develop strategies to reduce stigma for consumers of mental health/substance abuse/suicide prevention servicesIncrease community linkages with mental health and substance abuse servicesImprove portrayals of suicidal behavior, mental illness/ substance abuse in entertainment/news media- avoid dramatization to reduce suicide contagionsPromote/support research on suicide/suicide prevention
86Suicide Prevention Checklist for Schools Does school provide information to staff about the impact/prevalence of adolescent suicide?Does school have policies and procedures in place concerning suicide issues?Does it have support from superintendents/principals/teachers for suicide prevention program?Does school have links to the community to help with a suicidal student and are staff educated about how to contact them?Does your school have a crisis response plan/team that meets on a regular basis?School-Based Youth Suicide Prevention Guide of University of South Florida
87Suicide Prevention Checklist for Schools Does school provide parents with list of community resources if they suspect their child is considering suicide?Does school inform parents about risk factors and restricting access to lethal means (firearms)?Is school staff aware of legislation on liability for suicidal behavior in students?Is school aware that while students are in school, the school must act in loco parentis, or as reasonably as a concerned parent?School-Based Youth Suicide Prevention Guide of University of South Florida
88Traditional Treatment Model for Depressed, Suicidal, Vulnerable Adolescents PsychiatristTherapistorstudentfamilypeerschild study teamteachers
89Integrated School Model New Alliance Academy The most effective treatment for these emotionally fragile adolescents requires a highly integrated (under one roof), multi-pronged treatment team approach in order to prevent poor or tragic treatment outcomespsychiatristpeersfamilyTeachersPrincipaltherapistsstudent