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1 Developed by Ellen Anderson, Ph.D., SPCC, 2003-2008
SAVING LIVES: Understanding Depression And Suicide In Young People – A Training For School Personnel Sponsored by the Ohio Department of Mental Health in Partnership with the Ohio Suicide Prevention Foundation Developed by Ellen Anderson, Ph.D., SPCC,

2 Youth Depression and Suicide
Training Objectives Increase knowledge about the impact of suicide within the community Learn the connection between depression and suicide Dispel myths and misconceptions about suicide Learn risk factors and signs of suicidal behavior in youth Learn to assess risk and find help for those at risk – Asking the “S” question The training objectives help provide an overview of the presentation. Gain knowledge of the causes of suicidal death within the faith community Dispel myths and misconceptions about suicide Learn risk factors/early warning signs of suicidal behavior Acquire knowledge regarding how to assess risk and get assistance for at-risk people Learn about the impact of faith and church connection on depression and suicide, and also the reverse Youth Depression and Suicide

3 Suicide Is The Last Taboo – We Don’t Want To Talk About It
Suicide has become the Last Taboo – we can talk about AIDS, sex, incest, and other topics that used to be unapproachable. We are still afraid of the “S” word Understanding suicide helps communities become proactive rather than reactive to a suicide once it occurs Reducing stigma about suicide and its causes provides us with our best chance for saving lives Ignoring suicide means we are helpless to stop it Talking about suicide is scary. It’s hard to get people to come to trainings about suicide. In fact, many people ask the question, “Aren’t you opening a can of worms?” By making people more aware of and less afraid of suicide, we hope to assist communities to be proactive in preventing suicide, rather than reactive to a suicide that has occurred. Suicide is something that many think about at some point in life but no one wants to talk about. Pretending it doesn’t exist won’t make it go away. Not learning about suicide means we are helpless to stop it. In some churches, suicide is viewed as a failure of faith, a lack of trust in God, even a sin, not caring for the body and the life God has given us. Talking about suicide, its causes and associated feelings provides us with our best opportunity for prevention. Youth Depression and Suicide

4 Why Should I Learn About Suicide Prevention?
It is the 3rd largest killer of youth ages 10-24 Up to 25% of adolescents consider suicide seriously at some point in their lives No one is safe from the risk of suicide – wealth, education, intact family, popularity cannot protect us from this risk A suicide attempt is a desperate cry for help to end excruciating, unending, overwhelming pain, sometimes called psychache (Schneidman, 1996) People kill themselves for a lot of reasons, but the biggest one is the terrible, unending, unendurable pain sometimes called psychache. We tend to think that suicidal kids are just “seeking attention’ at this stage of their lives, but the reality is they may be suffering terrible emotional pain. In fact, the so-called manipulative, attention-seeking folks are just as likely to die as those who are not. You are with kids every day, and may be more likely than any other adult, including their parents, to see the kind of pain they are in. Youth Depression and Suicide

5 Youth Depression and Suicide
The Gender Issue Women perceived as being at higher risk than men Women do make attempts 4 x as often as men But - Men complete suicide 4 x as often as women These ratios are similar for girls and boys Women’s risk rises until midlife, then decreases Men’s risk, always higher than women’s, continues to rise until end of life Youth Depression and Suicide

6 Youth Depression and Suicide
Youth Suicide Persons under age 25 accounted for 13.6% of all suicides in 2003 Every year we lose more than 4,000 young people to suicide, and 90% of them are experiencing depression- a preventable disease In 2 NW Ohio counties, 27% of high school students admitted to experiencing significant suicidal thoughts within the past year (President’s New Freedom Council Report, 2003) Persons under age 25 accounted for 15% of all suicides in People under age 25 account for only 13% of the population but 15% of the suicides. Suicide is the third leading cause of death for young people age According to the CDC, Suicide is only outnumbered by accidents and homicides. Young people don’t tend to die of natural causes. Instead, their deaths are often violent. Youth Depression and Suicide

7 What Factors Put A Kid At Risk For Suicide?
Factors include biological, psychological, and social issues A family history of suicide increases risk by 6 times Access to firearms – people who use firearms in their suicide attempt are more likely to die A significant loss by death, separation, divorce, moving, or breaking up with a boyfriend or girlfriend Shock or pain can affect the brain, increasing stress related hormones that damage the brain These are only a few of the factors, but are probably the most significant. Youth Depression and Suicide

8 Youth Depression and Suicide
Social Isolation: people who are rejected because they are “weird”, because of their sexual orientation, or because they just don’t fit in Aggressiveness or impulsiveness-people with these traits may not stop and think about the real consequences of their death The 2nd biggest risk factor is having an alcohol or drug problem. However, many people with alcohol and drug problems are significantly depressed, and are self-medicating for their pain (Surgeon General’s call to Action, 1999, Berman & Jobes, 1992) People who are socially isolated tend to be very lonely. We know from other types of studies among primates, for example, that loneliness, literally, can kill you. We are a social animal, and we need contact with others. When we don’t get it, we become even more inappropriate in our behavior, more depressed, and less likely to see a reason for living. In some tribes, shunning, or ostracism, can lead to the death of the person who is shunned. They simply sit down, give up, and die. Youth Depression and Suicide

9 Youth Depression and Suicide
The biggest risk factor for suicide completion? Having a Depressive Illness Someone with clinical depression often feels helpless to solve his or her problems, leading to hopelessness At some point, suicide seems like the only way out of the pain and suffering Many Mental health diagnoses have a component of depression: anxiety, PTSD, Bi-Polar, etc 90% of suicide completers have a depressive illness (Lester, 1998) We really need to understand depression better, since it is the single biggest factor in suicide. Youth Depression and Suicide

10 What Is Mental Illness? Prior to our understanding of illness caused by bacteria, most people thought of any illness as a spiritual failure or demon possession Contamination meant spiritual contamination People were frightened to be near someone with odd behavior for fear of being contaminated Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 10

11 What Is Mental Illness? What do we say about someone who is odd?
Looney, batty, nuts, crazy, wacko, lunatic, insane, fruitcake, psycho, not all there, bats in the belfry, gonzo, bonkers, wackadoo, whack job Why would anyone admit to having a mental illness? So much stigma makes it very difficult for people to seek help or even acknowledge a problem Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 11

12 What Is Mental Illness? We know that illnesses like epilepsy, Parkinson's and Alzheimer’s are physical illness in the brain Somehow, clinical depression, anxiety, Bi-Polar Disorder and Schizophrenia are not considered illnesses to be treated We confuse brain with mind Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 12

13 The Feel of Depression “I am 6 feet tall. The way I have felt these past few months, it is as though I am in a very small room, and the room is filled with water, up to about 5’ 10”, and my feet are glued to the floor, and its all I can do to breathe.” Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 13

14 Is Suicide Really a Problem?
83 people complete suicide every day 32,466 people in 2005 in the US Over 1,000,000 suicides worldwide (reported) This data refers to completed suicides that are documented by medical examiners – it is estimated that 2-3 times as many actually complete suicide (Surgeon General’s Report on Suicide, 1999) Many people do not think of suicide as a significant health issue in this country, but as you can see, we are losing many people to a completely treatable illness. If you think it is not important, consider that we lose 3 people to suicide for every 2 we lose to homicide, a statistic that has been stable for the past 100 years. Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 14 14

15 Depression Is An Illness
Suicide has been viewed for countless generations as: a moral failing, a spiritual weakness an inability to cope with life “the coward’s way out” A character flaw Our cultural view of suicide is wrong - invalidated by our current understanding of brain chemistry and it’s interaction with stress, trauma and genetics on mood and behavior Suicide’s direct link with depression is important to understand. What we have learned in the last 20 years is the way in which depression is a physical illness, one that can be cured with treatment. It is not a failure of faith, anymore than heart disease is a failure of faith. Youth Depression and Suicide Gatekeeper Training- Dr. Ellen Anderson 15 15

16 Youth Depression and Suicide
The research evidence is overwhelming- what we think of as depression is far more than a sad mood. It includes: Weight gain/loss Sleep problems Sense of tiredness, exhaustion Sad mood Loss of interest in pleasurable things, lack of motivation Irritability Confusion, loss of concentration, poor memory Negative thinking Withdrawal from friends and family Sometimes, suicidal thoughts (DSMIVR, 2002) The DSM–IV, the diagnostic and statistical manual of mental health disorders, is quite clear on the group of symptoms that can be diagnosed as a depressive disorder. Although we do not have blood tests for this problem, the listed criteria can be easily determined, as long as the patient is telling the truth about their symptoms. Many come in with vague somatic complaints because, for many, the body literally aches. The surgeon general’s report says that an assessment of depressive symptoms is as accurate and reliable as many blood tests currently the standard for assessment. Youth Depression and Suicide

17 20 years of brain research teaches that these symptoms are the behavioral result of
Changes in the physical structure of the brain Damage to brain cells in the hippocampus, amygdala and limbic system As Diabetes is the result of low insulin production by the pancreas, depressed people suffer from a physical illness – what we might consider “faulty wiring” (Braun, 2000; Surgeon General’s Call To Action, 1999, Stoff & Mann, 1997, The Neurobiology of Suicide) Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 17

18 Faulty Wiring? Damage to nerve cells in our brains - the result of too many stress hormones – cortisol, adrenaline and testosterone – the hormones activated by our Autonomic Nervous System to protect us in times of danger Chronic stress causes changes in the functioning of the ANS, so that high levels of activation occur with very little stimulus Creates changes in muscle tension, imbalances in blood flow patterns leading to certain illnesses such as asthma, IBS and depression (Braun, 1999) As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes. For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again. Youth Depression and Suicide Gatekeeper Training- Dr. Ellen Anderson 18 18

19 Youth Depression and Suicide
Faulty Wiring? Every time something upsets us it causes the ANS to activate – without a way to detach and go back to a baseline of rest, stresses accumulate and keep us in a state of high arousal – stress hormones build up People with genetic predispositions, placed in a highly stressful environment will experience damage to brain cells from stress hormones This leads to the cluster of thinking and emotional changes we call depression (Goleman, 1997; Braun, 1999) As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes. For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again. Youth Depression and Suicide

20 One of Many Neurons Neurons make up the brain and their action is what causes us to think, feel, and act Neurons must connect to one another (through dendrites and axons) Stress hormones damage dendrites and axons, causing them to “shrink” away from other connectors As fewer and fewer connections are made, more and more symptoms of depression appear As dendritic branches die back, the result of onslaught by stress hormones, fewer and fewer connections can be made in these brain areas Youth Depression and Suicide Gatekeeper Training- Dr. Ellen Anderson 20 20

21 Renewed dendrites increase the number of neuronal connections
The more connections, the more information flow, the more flexibility the brain will have Why does increasing the amount of serotonin, as many anti-depressants do, take so long to reduce the symptoms of depression? It takes 4-6 weeks to re-grow dendrites & axons (Braun, 1999) Gatekeeper Training- Dr. Ellen Anderson Youth Depression and Suicide 21

22 Youth Depression and Suicide
As damage occurs, thinking changes in the predictable ways identified in our list of 10 criteria “Thought constriction” can lead to the idea that suicide is the only option How do antidepressants affect this “brain damage”? They may counter the effects of stress hormones We know now that antidepressants stimulate genes within the neurons (turn on growth genes) which encourage the growth of new dendrites (Braun, 1999) Youth Depression and Suicide

23 Youth Depression and Suicide
Renewed dendrites: increase the number of neuronal connections allow our nerve cells to begin connecting again Why does increasing the amount of serotonin, as many anti-depressants do, take so long to reduce the symptoms of depression? It takes 4-6 weeks to re-grow dendrites & axons (Braun, 1999) Youth Depression and Suicide

24 How Does Psychotherapy Help?
Stress alone is not the problem, but our interpretation of events as stressful Medications may relieve suffering and improve brain function, but do not change how we interpret stress Psychotherapy, especially cognitive or interpersonal therapy, helps people change the (negative) patterns of thinking that lead to depressed and suicidal thoughts Research shows that cognitive psychotherapy is as effective as medication in reducing depression and suicidal thinking Changing our beliefs and thought patterns alters our response to stress – we are not as reactive or as affected by stress at the physical level (Lester, 2004) Youth Depression and Suicide

25 How Does Psychotherapy Help?
Changing our beliefs and thought patterns alters our response to stress – we are not as reactive or as affected by stress at the physical level (Lester, 2004) More recent research is leading to a better understanding of just how “plastic” the adult brain is What and how we think can cause connectors to grow and expand in the areas those thoughts use Thinking negatively leads to an increase in the part of the brain where those thoughts occur Youth Depression and Suicide

26 Youth Depression and Suicide
No Happy Pills For Me The stigma around depression leads to refusal of treatment Taking medication is viewed as a failure by the same people who cheerfully take their blood pressure or cholesterol meds Medication is seen as altering personality, taking something away, rather than as repairing damage done to the brain by stress hormones Youth Depression and Suicide

27 Therapy? Are You Kidding? I Don’t Need All That Woo-Woo Stuff!
How can patients seek treatment for something they believe is a personal failure? Acknowledging the need for help is not popular in our culture (Strong Silent type, Cowboy) People who seek therapy may be viewed as weak Therapists are viewed as crazy They’ll just blame it on my mother or some other stupid thing Youth Depression and Suicide

28 What Happens If We Don’t Treat Depression?
Significant risk of increased alcohol and drug use Significant relationship problems Increased school problems – lowered grades, behavior problems, tardiness and absenteeism High risk for suicidal thoughts, attempts, and possibly death (Surgeon General’s Call To Action, 1999) Relationship problems include relationships with parents and with friends. As one’s behavior changes, one may change friendship circles, particularly if one is using drugs or alcohol excessively. Parents may mistake the surly, angry teenager in their midst for someone simply going through hormonal changes. Teachers may find students sleepy, uncaring, no homework completion, no studying for tests. Some students may be oppositional and defiant, refusing to care about school, but many may be depressed. Youth Depression and Suicide

29 Youth Depression and Suicide
Depression is a medical illness that will likely affect the youth later in life, even after the initial episode improves Youth who experience a major depressive episode have a 70% chance of having a second major depressive episode within five years Many of the same problems that occurred with the first episode are likely to return, and may worsen (Oregon SHDP) Youth Depression and Suicide

30 SSRI’s And Suicide More Mythology?
Media has sensationalized the idea that “Prozac” causes suicide in teens There is a very low risk that SSRI’s can induce suicidal agitation in a very few individuals Many teens on SSRI’s are, in fact already suicidal, and meds may not work well enough, or in time The FDA has recently banned the use of Paxil for depression in adolescents, but Prozac has been approved for use in teens SSRI stands for Selective Serotonin Reuptake Inhibitor, which refers to the action of the drug on the synapses in the brain – it stops Serotonin from being reabsorbed into the brain and makes it more available to the brain cells. This type of drug has been available about 20 years, and has the advantage of fewer side effects and more effectiveness than older style anti-depressants. It is difficult to understand how one SSRI could cause these problems and another be acceptable, since their actions are, to all intents and purposes, the same. Youth Depression and Suicide

31 Youth Depression and Suicide
The American College of Neuropsychopharmacology's Task Force report from January 21, 2004, which reviewed all clinical trials, epidemiological studies and toxicology studies in autopsies did not find evidence for a link between SSRI's and increased risk of suicide in children and adolescents In a recent preliminary study of 49 adolescent suicides, researchers found that 24% had been prescribed antidepressants, but none had any trace of SSRI's in their system at the time of their death There is an increased risk of suicide in depressed individuals who do not take their medication; which is a factor common to adolescents A 2003 World Health Organization study in over fifteen countries found a significant reduction, averaging about 33%, in the youth suicide rate that coincided with the introduction of SSRI's (Altesman, 2005) Youth Depression and Suicide

32 Youth Depression and Suicide
A review of all the research on this topic was conducted recently CONCLUSION: “No increased susceptibility to aggression or suicidality can be connected with fluoxetine or any other SSRI. In fact SSRI treatment may reduce aggression toward self or others” “In the absence of any convincing evidence to link SSRI’s causally to violence and suicide, the recent media reports are potentially dangerous, unnecessarily increasing the concerns of depressed patients who are prescribed antidepressants” (Goldberg, 2003) Newsweek, Jan, 2008 – prescription rates for teens cut in half in 03 and 04 – completion rates rise 18% in those years Youth Depression and Suicide

33 What Should Teachers Be Looking For
1. Depressed or irritable mood—look for: Directly and indirectly says "I hate my life" Easily irritated Rebellious behavior Seldom looks happy Frequent crying spells Wears somber clothes Listens to music or has themes in writing with depressive or violent undertones Has friends who appear depressed or irritable Some people may not identify the feeling as sadness – flat, bored, numb, exhausted may be the words they choose Youth Depression and Suicide

34 Youth Depression and Suicide
4. Significant change in appetite or weight—look for: Becomes a picky eater Snacks frequently and eats when stressed Quite thin or overweight compared to peers 5. Significant changes in sleeping habits— look for: Takes more than an hour to fall asleep Multiple awakenings Wakes in early morning hours and can’t return to sleep Sleeps more than normal (Oregon SHDP) 2. Marked decrease in interest or pleasure in activities—look for: Frequently says "I’m bored" Withdraws or spends much time in his or her bedroom Declining hygiene Changes to a more troubled peer group 3. Psychomotor agitation or slowing— look for: Agitated, always moving Mopes around the house or school People stop doing things they used to enjoy. People may gain or lose significant amounts of weight, and may have trouble sleeping, even though they are extremely tired. Alcohol use almost always increases at this point. Irritability and negative thoughts are common, and people can become very difficult to be around Youth Depression and Suicide

35 Youth Depression and Suicide
6. Fatigue or loss of energy—look for: Too tired to do schoolwork, play or work Comes home from school exhausted Too tired to cope with conflict 7. Feelings of worthlessness or inappropriate guilt—look for: Describes self as "bad" or "stupid" Has no hope or goals for the future Always trying to please others Blames self for causing divorce or a death, when not to blame 8. Decreased concentration or indecisiveness —look for: Often responds "I don’t know" Takes much longer to get work done Drop in grades Headaches, stomachaches Poor eye contact (Oregon SHDP) Youth Depression and Suicide

36 Depression May Look Different In Teens
It is important to understand that the brain determines one’s mood, thoughts, actions and judgment Many adults view youth who are irritable or who act out as behavior-problem youth, without being aware that a very treatable underlying cause such as depression may be affecting the youth While youth must be held accountable for their actions, it is equally important that depression, if present, be recognized, evaluated and treated (Schneidman, 1996) Behavioral problems may be the way that depression expresses itself in younger people. Irritability and withdrawal from family are key factors here. The seething anger we sometimes see in young people may be fueled by a significant clinical depression. Kids with Conduct Disorder, a behavior disturbance that often leads to aggression and violence, have a high risk of suicide. Youth Depression and Suicide

37 High Risk Behaviors and Suicide
Miller and Taylor (2000) analyzed high risk behaviors in 9th-12th graders and found a correlation with suicide ideation and attempts High risk health behaviors included High Risk Sex (multiple partners, before age 14) Binge Drinking (5 or more in several hours) Drug Use Disturbed eating patterns (boys do not get asked about this) Smoking Violence (girls do not get asked about this) Youth Depression and Suicide

38 Youth Depression and Suicide
The 17% of youth with more than three problem behaviors were the youth who acted They accounted for 60% of medically treated suicidal acts Compared to adolescents with zero problem behaviors, the odds of a medically treated suicide attempt were 2.3 times greater among respondents with one 8.8 with two 18.3 with three 30.8 with four 50.0 with five 227.3 with six A count of problem behaviors may offer a reliable way to identify suicide risk (Miller & Taylor, 2000) Youth Depression and Suicide

39 How Do I Know If Someone Is Suicidal?
Now we understand the connection between depression and suicide We have reviewed what a depressed person looks like Not all depressed people are suicidal – how can we tell? Suicides don’t happen without warning - verbal and behavioral clues are present, but we may not notice them This first should seem obvious, and is the most highly correlated to actual completion, but many dismiss it as attention seeking behavior. Yet most who complete suicide have made one or more attempts in their past. We need to think of this as a first step that may lead to more attempts. Some disagree that suicides don’t happen without warning, and maybe there are a few – but if we look at the symptom list, and the behaviors we have seen before the suicide, it may become apparent that we did not know what we were seeing. Youth Depression and Suicide

40 Youth Depression and Suicide
Verbal Expressions Common statements I shouldn't be here I'm going to run away I wish I were dead I'm going to kill myself I wish I could disappear forever If a person did this or that…., would he/she die Maybe if I died, people would love me more I want to see what it feels like to die Sometimes red flags come in the form of what people say. It is not always the words, sometimes it is the tone of voice – flat, “dead”, muted speaking. Sometimes statements are direct and to the point, such as: “I wish I were dead.” “I am going to kill myself.” “I’m going to end it all.” “I don’t want to live anymore.” Indirect statements can be more subtle. These may include such things as: “No one cares if I live or die.” “Does it hurt to die?” “You’d be better off without me.” “They’ll be sorry when I am gone.” These comments should not be ignored, or considered attention seeking. These are clear indicators that someone no longer believes life is worth living. This is not a temporary funk, but a serious medical condition which may lead to death. People who talk about killing themselves are preparing themselves, and everyone else, for the actual act. Youth Depression and Suicide

41 Some Behavioral Warning Signs
Common signs Previous suicidal thoughts or attempts Expressing feelings of hopelessness or guilt (Increased) substance abuse Becoming less responsible and motivated Talking or joking about suicide Giving away possessions Having several accidents resulting in injury; "close calls" or "brushes with death" Youth Depression and Suicide

42 Further Behaviors Often Seen in Kids
Preoccupation with death/violence; TV, movies, drawings, books, at play, music Risky behavior; jumping from high places, running into traffic, self-cutting School problems – a big drop in grades, falling asleep in class, emotional outbursts or other behavior unusual for this student Wants to join a person in heaven Themes of death in artwork, poetry, etc Youth Depression and Suicide

43 Youth Depression and Suicide
What On Earth Can I Do? We are reluctant to ask questions of depressed people Depression is an illness, like heart disease, and suicidal thoughts are a crisis, like a heart attack If you saw someone having a heart attack you would make some attempt to administer CPR Anyone can learn to ask the right questions to help a depressed and suicidal person Many people feel that talking to someone about suicide is just too hard. The “S” question is one that many clinicians have trouble asking, because to get a yes answer gives us a tremendous responsibility. We don’t have to ask a heart attack victim if they are dying – we can see it, yet we would not hesitate to help. Nor would we take the blame if, having tried CPR, a heart attack victim died anyway. We are fearful of the awesome responsibility of keeping a suicidal, depressed person alive. If not us, who? Yes, we are our brother/sister’s keeper. And yes, we can learn to ask. Youth Depression and Suicide

44 Youth Depression and Suicide
What Stops Us? Most of us still believe suicide and depression are “none of our business” Most are fearful of getting a yes answer What if we could recognize depression symptoms like we recognize symptoms of a heart attack? What if we could ask for help for ourselves, our parents, our children, without shame? What if we recognized feelings of despair and hopelessness as symptoms of a brain disorder? Youth Depression and Suicide

45 Youth Depression and Suicide
Reduce Stigma Stigma about having mental health problems keeps students from seeking help or even acknowledging their problem Reducing the fear and shame we carry about having such “shameful” problems is critical People must learn that depression is atreatable disorder– not something to be ashamed of Learning about suicide (and teaching our students) makes it possible for us to overcome our fears about asking the “S” question Youth Depression and Suicide

46 Learning “QPR” – Or, How To Ask The “S” Question
It is essential, if we are to reduce the number of suicide deaths in our country, that community members/gatekeepers learn “QPR” First identified by dr. Paul Quinnett as an analogue to CPR, “QPR” consists of Question – asking the “S” question Persuade– getting the person to talk, and to seek help Refer – getting the person to professional help (Quinnett, 2000) 40 years ago someone thought it would be a good idea if the average American could learn some basics that would keep a person who was having a heart attack alive until the ambulance arrived. Millions of us have learned CPR, and many have been saved who might otherwise have died. Now we need to learn how to do it again, all of us, to stop the unnecessary deaths caused by depression and mental illness. Both on and off the job, if we all learned QPR, we could save a lot of lives. Youth Depression and Suicide

47 Youth Depression and Suicide
Ask Questions! You seem pretty down Do things seem hopeless to you? Have you ever thought it would be easier to be dead? Have you considered suicide? Remember, you cannot make someone suicidal by talking about it. If they are already thinking of it they will probably be relieved that the secret is out. If you get a yes answer, don’t panic - Ask a few more questions Learn to ask questions when you see signs of depression and suicidal thinking, as discussed before If they are not thinking about it, they will simply tell you so. Youth Depression and Suicide

48 Youth Depression and Suicide
How Much Risk Is There? Assess lethality You are not a doctor, but you need to know how imminent the danger is Has he or she made any previous suicide attempts? Does he or she have a plan? How specific is the plan? Do they have access to means? This can be done by asking a series of questions: One sign is seldom enough to predict suicidal thoughts. Look for many of the previously mentioned signs – giving things away, sadness, etc. Has the person made previous attempts? This is one of the biggest risk factors Does the individual have a plan? If there is a plan, there is an increased risk of suicidal behavior Does the individual have access to means that would assist in carrying out the plan? Having the means to carry out the plan further increases risk, and signifies that action should be taken immediately to ensure the safety of the individual. Youth Depression and Suicide

49 Youth Depression and Suicide
Do . . . Talk openly- reassure them that they can be helped - Try to instill hope Listen without passing judgment Make empathic statements Use warning signs to get help early for the individual Stay calm, relaxed, rational The best way to get them to open up to you is to ask specific questions and to listen without passing judgment. People are already ashamed of their suicidal thoughts, and if they experience judgment from you, they are likely to stop talking. If you can’t think of anything to say, simply invite more information by saying, “Tell me more about that.” Empathic statements can be as simple as “I can see how you might feel that way”, “it must have been hard for you” Your calmness is crucial. Suicidal people are in a crisis, and see no hope. If you get upset and anxious, this will confirm their fears. If you can stay calm and rational, they will de-escalate also, and begin to see there might be help if they tell someone what they are feeling. Youth Depression and Suicide

50 Youth Depression and Suicide
Don’t… Make moral judgments– don’t argue or lecture Encourage guilt Promise total confidentiality/offer reassurances that may not be true Offer empty reassurances – “you’re luckier than most people” won’t help Minimize the problem/offer simplistic solutions(e.g. “all you need is a good night’s sleep”) Dare the suicidal person (e.g.“You won’t really do it.”) Use reverse psychology (e.g. “Go ahead and kill yourself.”) Leave the youth alone Make moral judgments – no arguing or lecturing Encourage guilt (e.g. your children will be sad, and you don’t want them to have to grieve over your death) This is also not helpful, and not what the individual needs. Promise total confidentiality/offer reassurances that may not be true For most professionals confidentiality is required to be broken when individuals state their intentions to harm themselves or others. Even if you do not have this requirement as part of your profession, suicide should never be kept a secret. Offer empty reassurance – a person in terrible pain cannot hear that others are worse off – this may actually may make them feel more guilty (I can’t even do this right!) Minimize the problem/offer simplistic solutions If they believed a simple solution would work they would not be suicidal. This assumes they haven’t really thought about things, which is seldom true. Most helpful is validating the problem with empathetic listening (I.e. do your best to understand the problem from “their perspective”, and show them you understand. Dare the person (e.g.“You won’t really do it.”) This may expedite suicidal behavior and/or be the deciding factor for those individuals who are teetering. Use reverse psychology (e.g. “Go ahead and kill yourself.”) This sometimes works with different situations, but is not worth the risk when the consequences are life and death. Leave the person alone This is critical, especially if your risk assessment has lead to a high probability of completion. Youth Depression and Suicide

51 Youth Depression and Suicide
Never Go It Alone! Collaborate with others The person him/herself Family and friends School Personnel or Co-workers Community Agencies Family doctor Crisis Hotline Others with whom to collaborate may seem obvious, but here they are: This is not an exhaustive list, but the main point is that you don’t have to go it alone! Youth Depression and Suicide

52 Youth Depression and Suicide
Getting Help Refer for professional help When youth exhibit signs of depression When risk is present (e.g. specific plan, available means) Know your community resources Maintain collaboration with treating agency to provide behavioral information to therapists Yes, it is true the therapist may be unable to share information with you, but they are bound by law to maintain silence without express permission from the client However, they will be glad to hear from you about what you are seeing and hearing At what point should you make a referral for professional help? Signs of depression may indicate the student is at risk for suicidal ideation. Depression is a very treatable illness, and no one should have to suffer with untreated depression. When risk is present (e.g. specific plan, available means) Err on the side of over-referral, remember the consequences here are high stakes! Know your community resources Educate yourself on these, or at a minimum be aware of someone who does have these resources Maintain collaboration with treating agency: You may have behavioral information that will assist the therapist Youth Depression and Suicide

53 Bereavement After A Suicide Loss
Compared with homicide, accidental death or natural death, suicide death is the most difficult for family members and friends to resolve Friends of youth who complete suicide may experience: Great pain More difficulty finding meaning in the death More difficulty accepting the death Less support and understanding More need for mental health care Teachers are often the only source of support for friends of suicide completers (Smith, Range & Ulner, 1991) Much research has been done on the impact of suicide on family and close friends. It is difficult to overestimate how painful such a death is, and how much risk it sets up for family members regarding their own suicidal thinking. Youth Depression and Suicide

54 Helping Your Students Through A Suicide At Your School
Suicidal death is so stigmatized that many people never talk about it, creating a “conspiracy of silence” that keeps people hurting Teach your students about the seriousness of untreated depression – help them understand they are not at fault if a friend dies (Anderson, 1999) Suicide loss is stigmatized: As a culture, we are unable to respond effectively to suicidal death. We know how to take a hot dish to a grieving family after a car accident or death from cancer, but survivors are left on their own. People tend to shy away, not knowing what to say or do. As a result, families and friends feel lost, alone, ashamed, and unable to grieve. When people are unable to grieve effectively it can create tremendous stress on relationships. Parents blame each other and end up in divorce, siblings are at higher risk for suicide themselves if they are not allowed to talk about their lost brother or sister. Suicide survivors frequently talk about the lack of support from friends and others, who simply do not know what to say. Young people may be completely at a loss, since they have less exposure to any kind of death. Knowledge really is power. Helping students understand what happened to their friend, that they were suffering from untreated depression, can really remove a lot of burden. Assist the rest of your students in understanding what depression is and why it can end in death. Help them learn how to talk with each other, and their friend’s family, and provide support. Many family members talk about friends asking “what did you do?”, none of which is very helpful. Talk about depression and suicide to reduce stigma about mental health issues in your school. Youth Depression and Suicide

55 Youth Depression and Suicide
Help them understand about the unendurable psychache their friend experienced so they can resolve some of their anger Assist other people in supporting the family, since lack of support is the biggest problem survivors of suicide face Reduce the stigma against depression in your school, so kids will feel safer talking about their loss Youth Depression and Suicide

56 Teachers Are Also Survivors
Remember, you too, are a survivor and it can be difficult to maintain your professional stance while trying to help your students Many professionals know the pain of losing a young person to suicide, and the struggle to be supportive to those who depend on you while you are hurting Do not be too hard on yourself if you are not sure what to do or say – we are all struggling These problems happen to professionals, too, and can really impact their behavior in the workplace. Professional survivors of suicide go through a lot of the same struggles that family members do, because we tend to feel responsible for people in our care. Be aware of co-workers who are experiencing difficulty after a suicide death. You might notice absenteeism, increased drinking, irritability, especially with supervisors, anger, loss of concentration and focus, or isolation and withdrawal. Talk about depression and suicide in your workplace to reduce stigma in your community, and to help one another deal with this unsettling death. Youth Depression and Suicide

57 Consider A School-wide Suicide Prevention Program
Impact the entire school environment by: Developing written policies and procedures for responding to suicidal warning signs, gestures, threats, attempts, and completions Training every member of the school staff, not just teachers and counselors, in how to recognize, respond to, and refer youth at high suicide risk Educating parents to take all talk of suicide seriously and to know how to help their child Giving students the knowledge to get help for a suicidal friend A district-wide program could go a long way to reducing suicide risk in your school, by creating a comprehensive program to reduce stigma, educate staff, and make suicide something we can all talk about. If we can’t talk about it we can’t help! Youth Depression and Suicide

58 Permanent Solution- Temporary Problem
Remember a depressed person is physically ill, and cannot think clearly about right or wrong, cannot think logically about their value to friends and family You would try CPR if you saw a heart attack victim. Don’t be afraid to “interfere” when someone is dying more slowly of depression Most kids, when treated, are able to overcome their suicidal thoughts, and recover from their depression Depression is a treatable disorder Suicide is a preventable death This well-known quote, from Dr. Edwin Schneidman, the founder of suicidology, is a key idea that helps us stay focused on our goal. WE need to help people understand there are other solutions available, no matter how difficult the problem may be. Youth Depression and Suicide

59 Websites For Additional Information
Ohio Department of Mental Health NAMI National Institute of Mental Health American Association of Suicidology Suicide Awareness/Voice of Education American Foundation for Suicide Prevention Suicide Prevention Advocacy Network Suicide Prevention Resource Center Youth Depression and Suicide

60 Youth Depression and Suicide
A Brief Bibliography Altesman, R., Statement from the American Academy of Child and Adolescent Psychiatry for the Food and Drug Administration Joint Meeting : Anderson, E. “The Personal and Professional Impact of Client Suicide on Mental Health Professionals. Unpublished Doctoral dissertation, U. of Toledo, 1999 Berman, A. L. & Jobes, D. A. (1996) Adolescent Suicide: Assessment and Intervention. Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. American Psychiatric Press. Goldberg, I. SSRI’s and Suicide: Results of a MELINE Search. At: ttp://www.psycom.net/depression.central.ssri-suicide.html Jacobs, D., Ed. (1999). The Harvard Medical School Guide to Suicide Assessment and Interventions. Jossey-Bass. Youth Depression and Suicide

61 Youth Depression and Suicide
Jamison, K.R., (1999). Night Falls Fast: Understanding Suicide. Alfred Knopf  Lester, D. (1998). Making Sense of Suicide: An In-Depth Look at Why People Kill Themselves. American Psychiatric Press Oregon Health Department, Prevention. Notes on Depression and Suicide: ttp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cfm President’s New Freedom Council on Mental Health, 2003 Quinnett, P.G. (2000). Counseling Suicidal People. QPR Institute, Spokane, WA Schneidman, E.S. (1996). The Suicidal Mind. Oxford University Press. Youth Depression and Suicide

62 Youth Depression and Suicide
Signs of Depression in Youth. Oregon State Dept. of Health. ipe/depression/signs.cfm Stoff, D.M. & Mann, J.J. (Eds.), (1997). The Neurobiology of Suicide. American Academy of Science Styron, W. (1992). Darkness Visible. Vintage Books Surgeon General’s Call to Action (1999). Department of Health and Human Services, U.S. Public Health Service. Tang, T.Z. & De Rubeis, R.J. ((1999). “Sudden Gains and critical sessions in cognitive-behavioral therapy for depression”. Journal of Consulting and Clinical Psychology 67: Youth Depression and Suicide


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