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Advances in Suicidology: What We Know and Don’t Know Michael F Myers, MD Professor Clinical Psychiatry SUNY Downstate Medical Center Brooklyn, NY.

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Presentation on theme: "Advances in Suicidology: What We Know and Don’t Know Michael F Myers, MD Professor Clinical Psychiatry SUNY Downstate Medical Center Brooklyn, NY."— Presentation transcript:

1 Advances in Suicidology: What We Know and Don’t Know Michael F Myers, MD Professor Clinical Psychiatry SUNY Downstate Medical Center Brooklyn, NY

2 Summary of Presentation Facts and stats Recent research initiatives and findings Special populations – youth, LGBT, military, elderly, physicians, attempt survivors, survivors of suicide loss Challenges and “good news” Resources Creative Q & A 2

3 Facts and stats (AAS) 40,600 Americans died by suicide (2012) 110.9 deaths daily 1 person dies by suicide every 13.0 minutes 1 person attempts suicide every 31 seconds Suicide = 10 th ranking cause of death (2 nd for age 15-24 and age 25-34) 3.6 male deaths by suicide for every female vs 3 female attempts for each male attempt 3

4 Facts and stats (AAS) Elderly = 16 percent of suicides Youth = 12.2 percent of suicides Middle aged = 38.9 percent Highest rates in whites 4

5 Wisconsin (AAS) # 36 = 723 deaths by suicide in 2012 (#30 in 2011) Rate = 12.6 #1 = Wyoming at 29.7 #51 = District of Columbia at 5.8 5

6 Suicide Methods (AAS) Firearms = 50.6% of total Suffocation, hanging = 25.1% Poisoning = 16.6% Cut/pierce = 1.7% Drowning = 0.9% Other = remaining 6

7 Fact It is generally believed that approximately 85- 90 percent of people who kill themselves have been living with some form of mental illness And these mental illnesses are often unrecognized and undiagnosed Even if diagnosed, they may be untreated or commonly undertreated 7

8 Health Factors (AFSP) Mental health conditions. Depression. Bipolar (manic-depressive) disorder. Schizophrenia. Borderline or antisocial personality disorder. Conduct disorder. Psychotic disorders, or psychotic symptoms in the context of any disorder Anxiety disorders. Substance abuse disorders Serious or chronic health condition and/or pain. 8

9 Important research….. “The increasing domination of biological approaches in suicide research and prevention, at the expense of social and cultural understanding, is severely harming our ability to stop people dying…” From “Suicide and Culture: Understanding the Context” Editors Erminia Colucci and David Lester. Hogrefe. Cambridge, MA. 2013 9

10 Survivor statistics (AAS) Survivors are family members and friends of a loved one who has died by suicide It is estimated that each suicide intimately affects at least 6 other people It follows that with someone dying by suicide every 13 minutes, six new people become survivors every 13 minutes too 10

11 Suicidology “101” There is no one factor that causes someone to kill herself/himself Most often there is a complicated – and confusing mix – of current stressors and losses + old psychological wounds (which may be hidden or unrecognized) + genetic or biological factors + a psychiatric illness + alcohol or other drugs + a readily available way of dying 11

12 Suicide is an outcome that requires several things to go wrong all at once. -- There is no one cause of suicide and no single type of suicidal person. Suicide is an outcome that requires several things to go wrong all at once. -- There is no one cause of suicide and no single type of suicidal person. Biological Factors Familial Risk Serotonergic Function Neurochemical Regulators Demographics Pathophysiology Immediate Triggers AccessTo Weapons Severe Defeat Major Loss Worsening Prognosis Proximal Factors Hopelessness Intoxication Impulsiveness Aggressiveness Negative Expectancy Severe Chronic Pain Predisposing Factors Major Psychiatric Syndromes Substance Use/Abuse Personality Profile Abuse Syndromes Severe Medical/ Neurological Illness Public Humiliation Shame 12

13 What about depression and suicide risk? (AAS) Depression is the psychiatric diagnosis most commonly associated with suicide but most patients with depression do not kill themselves Lifetime risk of suicide among patients with untreated depression ranges from 2.2% to 15% Those suffering from depression are at 25 times greater risk for suicide than the general population 13

14 United States Preventive Services Task Force (Psych News 6/20/2014) Recommends against suicide screening in primary care (evidence is insufficient) BUT….. Strongly supports screening for major depression in general medical patients, especially the elderly, because of the burden of distress And in adolescents, screen for anxiety + depression (and alcohol abuse in boys) 14

15 Addressing suicide risk in emergency department patients (JAMA 7/16/2014) Studies show that one in five ED patients may be depressed but the Dx is often missed Why? Most patients don’t complain of depression but have somatic depressive Sx Overt suicidal behavior = only 0.6% of ED visits but suicidal thinking ranges from 3-11.6% Enhanced training of emergency MDs is recommended 15

16 Baby boomers and suicide (SPRC 7/25/2014) Adults aged 45-64 have the highest suicide rates (CDC) since 2008 when the recession began Their mood states may be missed because most are working and there is an erroneous assumption that they have proven their resilience Recommendation is for programs specific to them 16

17 National Action Alliance for Suicide Prevention ( In Feb 2014, the NAASP Research Prioritization Task Force released A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives The themes are broad and intersect bench research, community, justice, education, technology and more This report outlines the research areas that show the most promise in reducing the rates of suicide attempts and deaths in the next 5-10 years, if optimally implemented 17

18 Zero Suicide in Health and Behavioral Healthcare http://zerosuicide.actionallianceforsuicideprev http://zerosuicide.actionallianceforsuicideprev June 26-27, 2014 SPRC hosted the first meeting of the academy 16 public and private health care organizations came together to discuss innovative strategies for suicide reduction See webinar slides on the website 18

19 “Preventing Suicide. A Global Imperative” WHO September 2014 056/1/9789241564779_eng.pdf?ua=1 The 92 page report calls for national prevention strategies, better surveillance, and restricting access to lethal means Prevention demands “a comprehensive, multisectorial” strategy because risk of suicide is set in individual, social, community and health system factors (Levin Psych News 10/17/2014) 19

20 AAS Childhood Sexual Abuse and Suicide 2014 “Sexual victimization creates an overwhelming sense of powerlessness, worthlessness, and a felt inability to change or control one’s environment. It creates self-loathing… it facilitates internalized feelings of shame, not the guilt of feeling one has done something bad, but a more pervasive sense of being bad. It creates self-blame.” 20

21 AAS Childhood Sexual Abuse and Suicide 2014 “Sexual abuse is associated with changes in the metabolism of serotonin: ‘the impact of trauma on the brain’s stress response systems can make children more vulnerable to later stressful events and to the onset of pathology… and suicidality’” 21

22 AAS Childhood Sexual Abuse and Suicide 2014 Among those sexually abused as children, odds of suicide attempts were 2-4 times higher among women and 4-11 times higher in men compared to those not abused and controlling for other adversities 22

23 “Peer Victimization, Cyberbullying and Suicide Risk in Children and Adolescents” (Gina and Espelage JAMA 2014) A meta-analysis of 491 studies Peer victimization was found to be related to both suicidal ideation and attempts Strong efforts to prevent or reduce these behaviors are warranted AAP advises pediatricians to screen for bullying experiences in/out home and online, suicidal ideation and behaviors 23

24 “Peer Victimization, Cyberbullying and Suicide Risk in Children and Adolescents” (Gina and Espelage JAMA 2014) Adults should recognize that stress-related physical symptoms could be related to peer conflict or bullying at school Should also talk to parents about gun safety if there are guns in the home Sexual minority and disabled children are more at risk for bullying Parents, teachers, mental and medical health care practitioners and advocates all have a role to play 24

25 The Jed Foundation The Jed Foundation was founded in 2000 by Donna and Phil Satow after they lost their son Jed to suicide It is the leading nonprofit organization addressing issues related to mental health and suicide in the college population. Includes programming and resources that help colleges, students and parents recognize and address emotional health issues and prevent suicide Model for Comprehensive Mental Health Promotion and Suicide Prevention for Colleges and Universities 25

26 What about LGBT youth? (AAS) NOTE: Being LGBT is not a risk factor in and of itself; however many have one or more severe risk factors: more previous attempts at suicide minority stressors such as discrimination and harassment higher rates of major depression, anxiety disorder, conduct disorder, and co-occurring psychiatric disorders than their straight peers high rates of victimization (three quarters reported verbal abuse and about one in seven reported physical attacks) severe family rejection (those who experience this are 8 times more likely to report having attempted suicide than peers from supportive families) 26

27 What about LGBT youth? (AAS) We do not know whether more LGBT youth than straight youth die by suicide because sexual orientation/gender identity data aren’t included on death certificates and often do not show up in psychological autopsy interviews 27

28 What about LGBT youth? (AAS) The Trevor Project is the leading national organization providing crisis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, and questioning youth 28

29 What about the elderly? (AAS) There was one elderly (over the age of 65) suicide every 96 minutes in 2011. There were about 15 suicides each day resulting in 5,353 suicides in among those 65 and older. Elderly white men were at the highest risk with those over age 85 (“old-old”) at most risk 83.5% of elderly suicides were male; the rate of male suicides in late life was about 5.25 times greater than female suicides 29

30 What about the elderly? (AAS) Common risk factors include: The recent death of a loved one Physical illness Uncontrollable pain or the fear of a prolonged illness Perceived poor health Social isolation and loneliness Major changes in social roles (e.g. retirement) 30

31 What about the elderly? (SPRC) Suicide attempts are rarely impulsive, usually involve planning ahead and tend to be lethal Care transitions may be a time of increased risk Good response to psychopharmacology + psychotherapy, especially CBT Optimistic note is the implementation this year of full parity for outpatient mental health treatment in Medicare 31

32 What about the military? 32

33 A salute to…… Michael Orban – author of “Souled Out: A Memoir of War and Inner Peace” 33

34 Some facts In 2005 the rate of suicide among soldiers in the US army began increasing In 2010 and 2011 more soldiers died by their own hands than in combat In 2010, 22 veterans died by suicide every day In 2013, 475 service members died by suicide Both male and female soldiers kill themselves and all races/ethnicities too 34

35 What makes our soldiers vulnerable? (Nock et al, 2013) Psychiatric illness – depression, anxiety, PTSD, impulse control, alcohol/substance use, personality disorders – especially if combined Family history of psychiatric illness and suicidal behavior, childhood abuse Military related stressors – combat exposure, injury, bereavement, negative unit climate, demotion, sexual assault 35

36 What makes our soldiers vulnerable? (Nock et al, 2013) Additional stresses – improvised explosive devices, enemy fire, other dangers in civilian areas, re-exposures to traumatic events, injuries resulting in disfigurement and serious illnesses Acute stressful life events – separation from family, romantic conflicts, family illness and death, financial problems, unemployment Chronic stressful life events – pain, physical illness, intimate partner violence (IPV) Firearm access 36

37 What makes our soldiers vulnerable? (Nock et al, 2013) What about traumatic brain injury (TBI)? Due to exposure to explosive devices and blast injuries – leads to impulsivity, aggression and disinhibition This + more recent knowledge about ‘immature’ prefrontal cortex in adolescence and young adults = emotional dysregulation and impaired decision making 37

38 What are some protective factors? (Nock et al 2013) Religious affiliation, a sense of responsibility to one’s family, being pregnant, young children in the home Unit cohesion, supportive leadership, strong soldier-to-soldier relations Frequent contact with spouse and friends Psychological – resilience, positive adaptation 38

39 Understanding and preventing military suicide (Bryan et al 2012) We must think about suicide from the service member’s perspective Trained to be “warriors” The “warrior ethos” emphasizes honor, integrity, selfless service, duty and courage in the face of adversity Violation of these values leads to shaming by peers and official disciplinary action 39

40 Understanding and preventing military suicide (Bryan et al 2012) Mental toughness = “suck it up” Tolerate pain and discomfort Push away fear, anger, grief and self-doubt (all of which are associated with anxiety and depression!) The very skills that make a tough warrior can inadvertently create a pathway to suicide 40

41 Understanding and preventing military suicide (Bryan et al 2012) Collectivism = the cornerstone of military culture = close, in-group bonds Vs individualism of civilian society Service members are 3x more likely to ask another service member for help than seeking professional services Seeking help from outsiders can be viewed with suspicion and threatens group safety 41

42 Understanding and preventing military suicide (Bryan et al 2012) The culture of self-sacrifice in defending one’s country can distort thinking – suicide may become an honorable ‘self-sacrifice’ for the greater good of the group (which it never is) “Perceived burdensomeness” (Joiner) becomes a dangerous line of thinking This plus a ‘fearlessness’ about death are two linkages attributed to suicide (Joiner) 42

43 Understanding and preventing military suicide (Bryan et al 2012) Approaching suicide prevention from the military mindset Must adopt a strengths-based approach emphasizing mental fitness, resilience building, cognitive restructuring, finding meaning in life, self-building Model = US Air Force 1997, public health perspective improving the health of all = reduced suicide deaths by 1/3 43

44 Understanding and preventing military suicide (Bryan et al 2012) Prevention strategies must be specific, concrete and action-oriented Mental health professionals must use empirically supported treatments for anxiety, depression, suicidality DBT (Dialectical Behavior Therapy), CT (Cognitive Therapy), CAMS (Collaborative Assessment and Management of Suicidality) 44

45 Army study to assess risk and resilience in service members (Friedman MJ 2014) A significant number of enlisted soldiers do not disclose their pre-enlistment mental challenges Deployment is a factor, especially multiple and extended tour of duty, with short length of ‘dwell time’ Never deployed soldiers also had an elevated risk of suicide Married soldiers more at risk than never married 45

46 “Military Suicide Awareness or Healing Awareness?” from Wounded Times Dedicated to defeating combat PTSD 46

47 Jacob Sexton Military Suicide Prevention Act Named after Indiana National Guardsman who died by suicide in 2009 while home on a 15-day leave from Afghanistan Passed the Senate Armed Services Committee in May 2014 and will be considered by the full Senate later this year This will ensure that every member of the military – Active, Guard or Reserve – receives a mental health assessment every year and has better access to help 47

48 Blue Star Families “National, nonprofit network by and for military families from all ranks and services, including the National Guard and reserves” “Strengthens military families and our nation by connecting communities and fostering leadership” “Hosts a robust array of morale, empowerment, education and employment programs” 48

49 What about physicians? 49

50 50 Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians. A consensus statement. JAMA 2003;289: 3161-3166. Suicide is a disproportionately high cause of mortality in physicians, with depression as a major risk factor Depression is more common in female physicians than male physicians, including a suicide rate that is much higher than other females and approximates that of male physicians 50

51 51 Struggling in Silence: Physician Depression and Suicide (PBS Documentary 2008, DVD available “Every year, three to four hundred physicians take their own lives — the equivalent of two to three medical school classes” 51

52 Most common illnesses in MDs 1.Depression and bipolar illness 2.Substance use disorder 3.Dual diagnosis of 1. and 2. 4.Severe and unrelenting burnout 5.Underlying personality disorder 6.Chronic, worsening, painful and debilitating medical illness 52

53 53 Personality traits are significant Perfectionism – works for and against physicians – may become severe and a dangerous predisposing factor in suicidality – i.e. unforgiving of self Need for autonomy – wants to set his/her own agenda, eschews intrusion of others, knows what is best for self Rugged individualism – from childhood – a way of going through life 53

54 What else puts MDs at risk? Family history of disabling psychiatric illness and suicide Knowledge of toxicology and access to drugs Internalized stigma associated with facing psychiatric illness in ourselves and accepting the need for treatment Not receiving exemplary treatment 54

55 55 SUICIDE RISK FACTORS IN MD S Personal history of a depressive episode Previous suicide attempt (may be denied) Family history of mood disorder/suicide Introversion and professional isolation Lawsuits and/or medical license investigation Poor treatment adherence Refractory ‘malignant’ psychiatric illness 55

56 56 Remember There are many physicians living with a mood disorder and/or substance dependence who escape attention Many are untreated or self-treated Many who are in treatment are undertreated – and/or have not been fully forthcoming with their treating clinician about suicidal ideation and a plan 56

57 Protective strategy (NY Times Letter) “Why Do Doctors Commit Suicide?,” by Pranay Sinha (Op-Ed, Sept. 5), is a heartfelt and honest testimonial to the two young physicians who recently died here in New York City. He is spot on when he describes the doubts and fears that are ubiquitous in newly minted physicians and the dangerous isolation that can occur. He advocates a medical culture that stresses openness about vulnerabilities and fosters connection.Why Do Doctors Commit Suicide? I salute his initiative and take it one step further. We who are the supervisors and mentors of these young doctors must set an example. We, too, need to share our insecurities — old and new — and unmask our humanity. This includes disclosing our own psychiatric treatment. This kind of intimacy and lovingkindness will help save lives. MICHAEL MYERS Brooklyn, Sept. 5, 2014 57

58 What about survivors of suicide attempts? The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience Prepared by the Suicide Attempt Survivors Task Force of the National Action Alliance for Suicide Prevention July 2014 58

59 What about survivors of suicide attempts? In 2012, 11.5 million people in the US seriously considered suicide 4.8 million made a suicide plan 2.5 million made a suicide attempt 59

60 What about survivors of suicide attempts? “I’m tired of hiding, tired of misspent and knotted energies, tired of the hypocrisy, and tired of acting as though I have something to hide” Kay Jamison in An Unquiet Mind, 1997 60

61 Survivor of suicide attempt to share her story Kristen Anderson will share her story at 6 p.m. Wednesday, Oct. 22, at the Wisconsin Rapids Mid-State Technical College, 500 32nd St. S., in the campus auditorium (L Building). Wisconsinrapidstribune. com 61

62 A Voice at the Table A 35 minute documentary highlighting the stories of suicide attempt survivors, those with lived experience Those with lived experience are an inspiration to those who are or who have been suicidal Their words educate all of us working toward suicide prevention 62

63 What about survivors of suicide loss? 63

64 Kay Redfield Jamison, PhD, Professor of Psychiatry, Johns Hopkins Medical School “No one who has not been there can comprehend the suffering leading up to suicide, nor can they really understand the suffering of those left behind in the wake of suicide” from the Foreword “Touched By Suicide: Hope and Healing After Loss” by Michael F. Myers and Carla Fine 64

65 How is the grief of suicide different than that of natural causes or accidents? (Jordan JR 2001) You struggle with trying to make sense of an act that goes against life and living at all costs You are flooded with feelings of guilt, blame and responsibility for your loved one’s death You wrestle with feeling abandoned by your loved one You are confused by (or guilty about) your anger at your deceased loved one for killing himself/herself 65

66 How is the grief of suicide different than that of natural causes or accidents? (Jordan JR 2001) You may feel isolated, alone and stigmatized The social stigma attached to suicide spills over onto you – lying is common You may feel less supported or understood than individuals who have lost their loved one by natural causes or accidents Your friends and colleagues may actually care but are confused and uncertain and don’t come forward to support you 66

67 How is the grief of suicide different than that of natural causes or accidents? (Jordan JR 2001) Survivor families tend to be more vulnerable and you may withdraw from your network of friends because you feel ashamed Unfortunately this may cause your friends to pull away from you because they feel rejected = a vicious cycle Suicide deaths may tear apart even the healthiest of families, especially after the acute phase and over the first year or two 67

68 How is the grief of suicide different than that of natural causes or accidents? (Jordan JR 2001) If your family is already ‘a bit dysfunctional’ before the suicide, it may seem worse after You may actually feel relief, at least partly, if your loved one was sick for a long time and had many suicide attempts (he/she’s at peace) Or you may feel relieved if your family member was ‘a bad apple’ – abusive, violent, controlling, a criminal, etc. 68

69 Important to know….. There are higher rates of depression, PTSD and sometimes, risk of another family member dying of suicide This is why it is so important to try to learn as much about the aftermath of suicide as possible and to be informed, to know what to watch for and how to get help 69

70 Challenges and frustrations The suicide rate in the United States has been steadily increasing since 2000 in both men and women Despite much research and many resources, the suicide death rate of servicemen and women is not decreasing Efforts to diminish access to firearms or promote gun safety and restriction have been thwarted in many jurisdictions 70

71 Challenges and frustrations Access to care – timely comprehensive treatment combining medication + psychotherapy is extremely variable Stigma – although we are making some progress, the shame associated with mental illness (and associated suicidal behavior) remains rampant in some occupational, racial and ethnic groups – resulting in unacceptable suffering and death 71

72 Challenges and frustrations Competence – “We expect well-informed treatment for cancer or heart disease; it matters no less for depression.” (Jamison, NY Times 8/15/2014) Studies have tested suicide prediction models based on standard risk criteria – none has demonstrated any ability to predict suicide “No harm” contracts being overused and creating a false sense of security 72

73 Challenges and frustrations Although it is well known that a cluster of suicides occur within a few days to one month after hospitalization, follow up measures are not being standardized or monitored for compliance – too many patients are falling through the cracks Too many survivors are not getting the kind of empathic and all-inclusive care that they deserve 73

74 Good News More and more research findings are being disseminated to the general public and a range of professionals (like yourselves) aimed at prevention and early intervention More therapists are receiving training and Certification in Clinical Suicidology (AAS) and Assessing and Managing Suicide Risk: Core Competencies for Mental Health Professionals (SPRC) – Brad Munger 74

75 Good News More therapists are being trained to assess and treat survivors and their families We know much more about the protective factors that prevent or abort suicide attempts – 1-800-273- TALK, connectedness to other people, long term medication maintenance and monitoring, specific and manualized therapies targeting suicidal thoughts and actions, post-discharge telephone calls, religious and spiritual affiliation (in some), pets and so forth 75

76 Action Alliance Framework for Successful Messaging = website The Framework is a research-based resource that outlines four key factors to consider when developing public messages about suicide: 1.Strategy 2.Safety 3.Conveying a “Positive Narrative” 4.Following applicable guidelines 76

77 What is conveying a “Positive Narrative”? Ensuring that the collective voice of the field is “promoting the positive” in the form of actions, solutions, successes and resources For too long, the public message has been about describing or sensationalizing the problem without delineating actions to combat the issue or outlining possible solutions 77

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80 Positive Messaging…… Suicide Prevention Investment Needed to Reverse Trend of Increasing Suicide American Foundation for Suicide Prevention Statement on Latest CDC Report 10/08/2014 NEW YORK (October 8, 2014) – In a report released today by the US Centers for ……. 80

81 "Suicide prevention is everyone's business" – Surgeon General Dr David Satcher 2001 81

82 Resources American Association of Suicidology ( American Foundation for Suicide Prevention ( Suicide Prevention Resource Center ( CDC ( NIMH ( National Action Alliance for Suicide Prevention ( National Suicide Prevention Lifeline ( 82

83 Remember “Yes, a smile would have most definitely helped in my case……. that person… could well save a life” words of Kevin Hines, survivor of suicide attempt from “Just a smile and a hello on the Golden Gate Bridge” (Simon RI 2007) 83

84 Thank you for being here 84

85 Creative Q & A 85

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