1. A discussion about depression and suicide Dr. Maria Lorente-Foresti San Mateo County Office of Diversity and Equity www.smchealth.org/ode

2. Workshop Description: Goals: Goals: To learn about how depression is diagnosed and affects those around us.To learn about how depression is diagnosed and affects those around us. To learn about suicide and how to respond when an individuals expresses suicidal ideation.To learn about suicide and how to respond when an individuals expresses suicidal ideation.

3. . What comes to mind when you hear the word “mental health”?

4. . 1:4

5. Prevalence of any mood disorder among adults. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

6. Prevalence of Major Depression among adults.. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

7. . The economic burden of mental illness in the United States is substantial—about $300 billion in 2002. Mental illness is an important public health problem in itself—about 25% of U.S. adults have a mental illness—but also because it is associated with chronic medical diseases such as cardiovascular disease, diabetes and obesity.The economic burden of mental illness in the United States is substantial—about $300 billion in 2002. Mental illness is an important public health problem in itself—about 25% of U.S. adults have a mental illness—but also because it is associated with chronic medical diseases such as cardiovascular disease, diabetes and obesity. Other published studies report that about 25% of all U.S. adults have a mental illness and that nearly 50% of U.S. adults will develop at least one mental illness during their lifetime.Other published studies report that about 25% of all U.S. adults have a mental illness and that nearly 50% of U.S. adults will develop at least one mental illness during their lifetime. MMWR/September 2, 2011/Vol. 60: Mental Illness Surveillance Among Adults in the United States

8. Depression and Suicide Signs and Symptoms of Depression Emotions: Sadness, anxiety, guilt, anger, mood swings, lack of emotional responsiveness, feelings of helplessness, hopelessness and irritabilitySadness, anxiety, guilt, anger, mood swings, lack of emotional responsiveness, feelings of helplessness, hopelessness and irritabilityThoughts: Frequent self-criticism, self-blame, pessimism, impaired memory and concentration, indecisiveness and confusion, tendency to believe others see one in a negative light and thoughts of death and suicideFrequent self-criticism, self-blame, pessimism, impaired memory and concentration, indecisiveness and confusion, tendency to believe others see one in a negative light and thoughts of death and suicide From the Mental Health First Aid Curriculum

9. . Signs and Symptoms of Depression Behaviors: Crying spells, withdrawal from others, neglect of responsibilities, loss of interest in personal appearance, loss of motivation, slow movement and use of drugs and alcoholCrying spells, withdrawal from others, neglect of responsibilities, loss of interest in personal appearance, loss of motivation, slow movement and use of drugs and alcoholPhysical: Fatigue, lack of energy, sleeping too much or too little, overeating or loss of appetite, constipation, weight loss or gain, headaches, irregular menstrual cycle, loss of sexual desire andunexplained aches and painsFatigue, lack of energy, sleeping too much or too little, overeating or loss of appetite, constipation, weight loss or gain, headaches, irregular menstrual cycle, loss of sexual desire andunexplained aches and pains From the Mental Health First Aid Curriculum

10. Depression in the workplace Decreased productivityDecreased productivity Morale problemsMorale problems Lack of cooperationLack of cooperation Safety problems, accidentsSafety problems, accidents Absenteeism or presentteeismAbsenteeism or presentteeism Being tired all the timeBeing tired all the time Complains of unexplained aches and painsComplains of unexplained aches and pains Alcohol or other drug misuseAlcohol or other drug misuse From the Mental Health First Aid Curriculum

11. Types of mood disorders Major Depressive DisorderMajor Depressive Disorder Bipolar DisorderBipolar Disorder Postpartum DepressionPostpartum Depression Seasonal Affective DisorderSeasonal Affective Disorder From the Mental Health First Aid Curriculum

12. Major depressive disorder 5 of the following symptoms, must include one of the first two, occurring almost every day for two weeks Depressed mood Depressed mood Loss of pleasure of interest Loss of pleasure of interest Appetite change Appetite change Sleep disturbance Sleep disturbance Behavioral activation or slowing Behavioral activation or slowing Feelings of worthlessness or guilt Feelings of worthlessness or guilt Difficulty concentrating or making decision Difficulty concentrating or making decision Recurrent thoughts of death Recurrent thoughts of death Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; APA, 2000

13. Depressive symptoms mnemonic: Space Drags S leep disturbance S leep disturbance P leasur/interst (lack of) P leasur/interst (lack of) A gitation A gitation C oncentration C oncentration E nergy E nergy D epressed mood D epressed mood R uns slow R uns slow A ppetite disturbance A ppetite disturbance G uilt, worthless, useless G uilt, worthless, useless S uicidal thoughts S uicidal thoughts

14. Mood Disorder prevalence Disorders: Major DepressionMajor Depression Bipolar IBipolar I Bipolar IIBipolar II Postpartum DepressionPostpartum Depression Seasonal Affective DisorderSeasonal Affective DisorderPrevalence:4.9%3.2%0.8%0.5%13%

15. Risk factors for depression Distressing or uncontrollable eventDistressing or uncontrollable event Exposure to stressful life eventExposure to stressful life event Difficult childhoodDifficult childhood Ongoing stress and anxietyOngoing stress and anxiety Another mental illnessAnother mental illness Previous episode of depressionPrevious episode of depression Family historyFamily history More sensitive emotional natureMore sensitive emotional nature From the Mental Health First Aid Curriculum

16. Risk factors for depression Illness that is life threatening, chronic or associated with painIllness that is life threatening, chronic or associated with pain Medical conditionsMedical conditions Side effects of medicationsSide effects of medications Recent childbirthRecent childbirth Premenstrual changes in hormone levelsPremenstrual changes in hormone levels Lack of exposure to bright light in winterLack of exposure to bright light in winter Chemical (neurotransmitter) imbalanceChemical (neurotransmitter) imbalance Substance misuseSubstance misuse From the Mental Health First Aid Curriculum

17. What would you do? During a phone call a friend tells you that she’d rather not wake up or she wished she was never born. (Someone told you about a week ago that she broke up with her partner). What would you do? Please break into small groups and discuss your thoughts. Please break into small groups and discuss your thoughts. From the Mental Health First Aid Curriculum

18. suicide 10 th leading cause of death in the US (38,364 people a year) ~ 2001.10 th leading cause of death in the US (38,364 people a year) ~ 2001. One person dies by suicide every 13.7 minutes in the US.One person dies by suicide every 13.7 minutes in the US. Among people aged 15 to 24, suicide is the 3 rd leading cause of death.Among people aged 15 to 24, suicide is the 3 rd leading cause of death. The suicide rate for young men in the US is the highest in the world.The suicide rate for young men in the US is the highest in the world. Research shows that during our lifetime 20% of us will have a suicide with in our immediate family and 60% of us will personally know someone who dies by suicide.Research shows that during our lifetime 20% of us will have a suicide with in our immediate family and 60% of us will personally know someone who dies by suicide. Firearms are the most commonly used suicide method accounting for 49% of suicide deaths.Firearms are the most commonly used suicide method accounting for 49% of suicide deaths. 90% of suicides are committed by people suffering from psychological disorders90% of suicides are committed by people suffering from psychological disorders 60% are associated with mood disorders60% are associated with mood disorders 25% to 50% with alcohol use and abuse25% to 50% with alcohol use and abuse 10% Borderline Personality Disorder10% Borderline Personality Disorder With all that we know… suicide is not predictable. Individuals of all races, creeds, incomes and educations levels due by suicide. Individuals of all races, creeds, incomes and educations levels due by suicide. McIntosh, J. L., & Drapeau, C. W. (for the American Association of Suicidology). (2012). U.S.A. suicide 2010: Official final data. Washington, DC: American Association of Suicidology, dated November 28, 2012, downloaded from http://www.suicidology.org.

19. US suicide rates over time. From American Foundation for Suicide Prevention

20. Assess for risk of suicide or harm The most common crisis to assess for with depression symptoms are: The most common crisis to assess for with depression symptoms are: Suicidal thoughts and behaviors Suicidal thoughts and behaviors Non-suicidal self-injury Non-suicidal self-injury From the Mental Health First Aid Curriculum

21. Suicide risk assessment GenderGender MaleMale AgeAge Increasing in adolescence and elderlyIncreasing in adolescence and elderly CultureCulture White and rising rates in Native AmericansWhite and rising rates in Native Americans Chronic physical illnessChronic physical illness Mental illnessMental illness Living aloneLiving alone Marital StatusMarital Status Widowed, divorcedWidowed, divorced Use of alcohol or other substancesUse of alcohol or other substances Less social supportLess social support Previous attemptPrevious attempt Organized planOrganized plan Easy access to lethal meansEasy access to lethal means From the Mental Health First Aid Curriculum

22. Warning signs of suicide Threatening to hurt of kill oneselfThreatening to hurt of kill oneself Seeking access to meansSeeking access to means Talking or writing about death, dying or suicideTalking or writing about death, dying or suicide Feeling hopelessFeeling hopeless Feeling worthless or engaging in risky activitiesFeeling worthless or engaging in risky activities Feeling trappedFeeling trapped Increasing alcohol or drug useIncreasing alcohol or drug use Withdrawing from family, friends, societyWithdrawing from family, friends, society Demonstrating rage and anger or seeking revengeDemonstrating rage and anger or seeking revenge Appearing agitatedAppearing agitated Having a dramatic change in moodHaving a dramatic change in mood Giving things awayGiving things away From the Mental Health First Aid Curriculum

23. Myths and facts People who talk about killing themselves rarely commit suicide.People who talk about killing themselves rarely commit suicide. The suicidal person wants to die and feels there is no turning back.The suicidal person wants to die and feels there is no turning back. If you ask someone about their suicidal intentions, you will only encourage them to kill themselvesIf you ask someone about their suicidal intentions, you will only encourage them to kill themselves All suicidal people are deeply depressedAll suicidal people are deeply depressed Suicidal people rarely seek medical attention.Suicidal people rarely seek medical attention. Most people who die by suicide have given some verbal clues or warning signs.Most people who die by suicide have given some verbal clues or warning signs. Suicidal people are ambivalent about dying; they may desperately want to live but can’t see alternative to problems.Suicidal people are ambivalent about dying; they may desperately want to live but can’t see alternative to problems. Asking lowers their anxiety & helps deter suicidal behavior. It also allows for accurate risk assessment.Asking lowers their anxiety & helps deter suicidal behavior. It also allows for accurate risk assessment. Not all suicidal people are depressed. Once they make the decision, they may appear happier/carefree.Not all suicidal people are depressed. Once they make the decision, they may appear happier/carefree. 75% of suicidal individuals will visit a physician within the month before they kill themselves75% of suicidal individuals will visit a physician within the month before they kill themselves MYTHFACT

24. Questions to ask Ask the person directly whether he or she is suicidal:Ask the person directly whether he or she is suicidal: Are you having thoughts of suicide?Are you having thoughts of suicide? Are you thinking of killing yourself?Are you thinking of killing yourself? Ask the person whether he or she has a plan:Ask the person whether he or she has a plan: Have you decided how you are going to kill yourself?Have you decided how you are going to kill yourself? Have you decided when you would do it?Have you decided when you would do it? Have you collected the things you need to carry out your plan?Have you collected the things you need to carry out your plan? From the Mental Health First Aid Curriculum

25. How to talk with a person who is suicidal Discuss your observations with the personDiscuss your observations with the person Ask the questions without dreadAsk the questions without dread Do not express a negative judgmentDo not express a negative judgment Appear confident, as this can be reassuringAppear confident, as this can be reassuring Check for Two Other Risks: Has the person been using alcohol or other drugs?Has the person been using alcohol or other drugs? Has she or he made a suicidal attempt in the past?Has she or he made a suicidal attempt in the past? From the Mental Health First Aid Curriculum

26. How to Help Let the person know you are concerned and are willing to help.Let the person know you are concerned and are willing to help. Express empathy for what the person is going through.Express empathy for what the person is going through. Encourage the person to do most of the talking.Encourage the person to do most of the talking. State that thoughts of suicide are often associated with a treatable mental disorder.State that thoughts of suicide are often associated with a treatable mental disorder. Tell the person that thoughts of suicide are common and do not have to be acted on.Tell the person that thoughts of suicide are common and do not have to be acted on. From the Mental Health First Aid Curriculum

27. Keeping the person safe Provide a safety contact number that is available at all timesProvide a safety contact number that is available at all times Help the person think about people or things that have been supportive in the pastHelp the person think about people or things that have been supportive in the past Find out whether those supports are still availableFind out whether those supports are still available Do Not: Leave an actively suicidal person aloneLeave an actively suicidal person alone Use guilt and threats to try to prevent suicideUse guilt and threats to try to prevent suicide You will go to hell. You will go to hell. You will ruin other people’s lives if you die by suicide You will ruin other people’s lives if you die by suicide Agree to keep their plan a secretAgree to keep their plan a secret From the Mental Health First Aid Curriculum

28. Keeping the person safe Mental health professionals always advocate seeking professional help for someone who has suicidal thoughts.Mental health professionals always advocate seeking professional help for someone who has suicidal thoughts. The person may be very reluctant to involve a professional helper.The person may be very reluctant to involve a professional helper. Try to involve the person in the decisions making about what should be done, who should be told and how to seek professional help.Try to involve the person in the decisions making about what should be done, who should be told and how to seek professional help. If the person has a weapon or is behaving aggressively, call law enforcement.If the person has a weapon or is behaving aggressively, call law enforcement. From the Mental Health First Aid Curriculum

29. Help is available National suicide hotline: 1-800-273-TALK (8355)National suicide hotline: 1-800-273-TALK (8355) San Mateo County Suicide Prevention Center: 650-579- 0359San Mateo County Suicide Prevention Center: 650-579- 0359 San Mateo County ACCESS line: 1-800-686-0101San Mateo County ACCESS line: 1-800-686-0101 Call 911Call 911 If safe to do so, take person to the nearest emergency roomIf safe to do so, take person to the nearest emergency room Seek help from a mental health professionalSeek help from a mental health professional

30. Mental health first aid What is Mental Health First Aid? First aid is the help given to an injured person before medical treatment can be obtained. Mental Health First Aid is the help provided to a person developing a mental health problem or in a mental health crisis. The first aid is given until appropriate professional treatment is received or until the crisis resolves. In a FREE 12 to 16 hour course, learn about: A 5 ‐ step action plan to help an individual in crisis.A 5 ‐ step action plan to help an individual in crisis. The warning signs of emotional distress.The warning signs of emotional distress. The resources available.The resources available. For more information please contact: Dr. Jei Africa at 650-573-2714 or Jafrica@smcgov.org Jafrica@smcgov.org Office of Diversity & Equity ~ www.smchealth.org/ODE Office of Diversity & Equity ~ www.smchealth.org/ODEwww.smchealth.org/ODE