1. Suicide in the Central Health Planning Region, 2003-2008 Marc E. Leslie Coordinator, Virginia Violent Death Reporting System Office of the Chief Medical Examiner, Virginia Department of Health Presented by Stephanie Goodman Injury Data and Evaluation Coordinator Office of Family Health Services, Virginia Department of Health The Central Health Planning Region Suicide Prevention Summit June 1, 2011 Chesterfield County, VA

2. Map of the Central Health Planning Region (HPR) 2

3. 3 Pop Quiz In the Central Health Planning Region: 1.Average number of suicides per year? (Hint: average of 133 homicides per year). 2.Percentage of suicide victims who are White males? 3.Median age of a suicide victim? 4.Percentage of male and female suicides by firearm?

4. 4 Suicide in the Central HPR, 2003-2008 Overview of the Problem

5. 5 Suicide in the Central HPR, 2003-2008

6. 6

7. 7 Suicide vs. Homicide (2003-2008) 888 suicides; rate of 11.4 799 homicides; rate of 10.3 Suicide slightly more common than homicide

8. 8 Suicide in the Central HPR, 2003-2008

9. 9

10. 10 Suicide in the Central HPR, 2003-2008 Who is at Risk?

11. 11 Suicide in the Central HPR, 2003-2008 Selected Demographic Elements  Gender  Race  Age

12. 12 Suicide in the Central HPR, 2003-2008 Race and Gender Male (77%, rate of 18.0) White (80%, rate of 14.3) White males (61%, rate of 21.9), White females (19%, rate of 6.8), and Black males (15%, rate of 10.6) are 95% of all suicide victims (remember, overall rate for Central HPR is 11.4)

13. 13 Suicide in the Central HPR, 2003-2008 Age Median age is 46 Ages 45-54 most common age group (23%) and second highest rate (17.1) Highest rate for those 85 and over (17.7)

14. 14 Suicide in the Central HPR, 2003-2008

15. 15 Suicide in the Central HPR, 2003-2008 Race and Gender: Non-Fatal Attempts Most commonly by females (61%, rate of 100.9) Whites still most common and highest risk; but Black risk level rises notably (from rate of 6.3 to 69.6)

16. 16 Suicide in the Central HPR, 2003-2008

17. 17 Suicide in the Central HPR, 2003-2008 Age: Non-Fatal Attempts Median age is 33 Risk increases for all age groups except 85 and over 21 times increase for those ages 15-19 In general, non-fatal attempt rate decreases with age

18. 18 Suicide in the Central HPR, 2003-2008 At ages 85 and older, the fatal rate surpasses the non-fatal rate

19. 19 Suicide in the Central HPR, 2003-2008 Veterans

20. 20 Suicide in the Central HPR, 2003-2008 Veterans 22% of all suicide victims (18 years and older) 21% of males; 1% of all females Unknown if veterans served in combat, but can generally tell if they are currently in the military

21. 21 Suicide in the Central HPR, 2003-2008 Veterans Male veterans older than male non-veterans (median ages of 58 and 44, respectively) Median age suggests that those who are combat veterans generally not in the most recent conflicts 61% of males ages 65 and over are veterans compared to 20% of males ages 18-64

22. 22 Suicide in the Central HPR, 2003-2008 Method of Fatal Injury

23. 23 Suicide in the Central HPR, 2003-2008 Method of Fatal Injury More than one method of fatal injury can be used per suicide (e.g., combining poison and drowning) Firearm, poison, and hanging/suffocation account for 94% of suicides Most poisons are prescribed medications, primarily mental health medications and pain medications

24. 24 Suicide in the Central HPR, 2003-2008

25. 25 Suicide in the Central HPR, 2003-2008 Method of Fatal Injury: Non-Fatal Attempts Most common method for non-fatal attempts is poison (78%) Poison use is defining method difference between fatal and non-fatal attempts

26. 26 Suicide in the Central HPR, 2003-2008 Geography

27. 27 Suicide in the Central HPR, 2003-2008 Geography Central HPR has 27 localities (22 counties and 5 cities) 12 of these localities (44%) have a suicide rate exceeding the rate for Virginia (11.3) In general smaller locality = lower number and higher rate

28. 28 Suicide in the Central HPR, 2003-2008 #Rate Five Highest Suicide Rates Amelia1418.9 New Kent1818.3 Mecklenburg3518.0 Emporia617.7 Prince George3415.9 #Rate Five Lowest Suicide Rates Surry24.7 Greensville45.8 Charles City37.0 Cumberland47.1 Hopewell118.1

29. 29 Suicide in the Central HPR, 2003-2008

30. 30 Suicide in the Central HPR, 2003-2008

31. 31 Suicide in the Central HPR, 2003-2008 Selected Circumstances

32. 32 Suicide in the Central HPR, 2003-2008 Most Common Circumstances Mental health problem (57%) Crisis in past two weeks (39%) Intimate partner problem (36%) Problem with alcohol and/or other substances (25%) Physical health problem (21%)

33. 33 Suicide in the Central HPR, 2003-2008 Circumstances: Mental Health Females (75%) more than males (51%) Most prevalent in ages 55-64 (70%); 33% or more of every age group 87% treated in past two months and/or prior 71% known to take mental health medications currently or in the past* * 2007-2008 data

34. 34 Suicide in the Central HPR, 2003-2008 Circumstances: Crisis in Past 2 Weeks 39% of all persons; 43% of males, 24% of females Most crises (72%) occurred in the past 24 hours* Indicator of reactive suicides 50% or more for age groups 15-19, 20-24, and 25-34 *2007-2008 data

35. 35 Suicide in the Central HPR, 2003-2008 Circumstances: Intimate Partner Problems 36% having problems with current/former intimate partner at time of suicide 39% of males, 29% of females 64% also having a recent life crisis Shows volatility of intimate partner conflict

36. 36 Suicide in the Central HPR, 2003-2008

37. 37 Suicide in the Central HPR, 2003-2008 Circumstances: Alcohol and Other Substance Problems 25% of all persons Peaks at ages 35-44 (34%) and 45-54 (33%) 47% of those with alcohol problems had elevated levels of alcohol in their system (compared to 13% of those without alcohol problems)

38. 38 Suicide in the Central HPR, 2003-2008 Circumstances: Physical Health Problems 21% of all suicide victims; 19% of males, 26% of females Median age of 58 compared to 44 for those without a physical health problem 45% or more of those ages 65 and older

39. 39 Suicide in the Central HPR, 2003-2008 Circumstances: Physical Health Problems Explains majority of elder suicides Problems range from treatable (diabetes, mild pain) to severe (loss of vision, amputations) to terminal diseases and conditions

40. 40 Suicide in the Central HPR, 2003-2008 Circumstances: Warning Signs 50% disclosed intent and/or had prior attempts Most commonly disclosed to intimate partners (53%), family (34%), or friends/acquaintances (18%)* *2007-2008 data

41. 41 Suicide in the Central HPR, 2007-2008 Actions Taken to Prevent Suicide* Sought/encouraged mental health treatment (38%) Limited access to firearms/ammunition (27%) Tried to persuade victim to not commit suicide (18%) Called 911/law enforcement (12%) Checked in on victim (12%) *2007-2008 data (entire slide)

42. 42 Suicide in the Central HPR, 2007-2008 Efforts to Limit Access to Firearms and/or Ammunition* 16 persons had friends or family members who restricted access to firearms or ammunition Includes 7 persons not known to disclose intent, but loved ones acted out of concern Variety of techniques used to restrict (hiding, removing, disassembling) Of these persons, 15 (94%) used a firearm to commit suicide *2007-2008 data (entire slide)

43. 43 Suicide in the Central HPR, 2003-2008 In the fatal suicide, those with prior attempts used less lethal methods than those without prior attempts

44. 44 Suicide in the Central HPR, 2007-2008 Other Warning Signs of Suicide* Sleeping too little (17%) Taking prescribed pain medication (16%) Unusual behavior, past two weeks (8%) Family history of suicide (5%) Family/friends expected suicide (4%) *2007-2008 data (entire slide)

45. 45 Suicide in the Central HPR, 2003-2008 Conclusions Suicide rates are highest among Whites, males, and middle-aged and older adults Most suicides involve use of a firearm to inflict fatal injury The majority of suicide victims have a mental health problem, and most of these persons were being treated

46. 46 Suicide in the Central HPR, 2003-2008 Conclusions 50% of suicide victims are known to talk about plans or desire to commit suicide and/or have a history of suicide attempt(s) Fatal suicide and non-fatal suicide attempts present different pictures of risk and methods of fatal injury

47. 47 Questions, Data Requests, Further Information Marc Leslie, VVDRS Coordinator 737 N. 5 th Street, Suite 301 Richmond, VA 23219 804-205-3855 marc.leslie@vdh.virginia.gov http://www.vdh.virginia.gov/medExam/NVDRS.htm Our goal is to provide data and information that can be used for prevention and education; please let me know how I can help

48. 48 Appendix: Additional Information and Complete Tables

49. 49 Suicide in the Central HPR, 2003-2008 InformationSlide Demographics Gender51 Race51 Ethnicity51 Race/Gender52 Age Group53 Veterans Male Age Group/Veteran56 Method of Fatal Injury Complete List of Methods57 Selected Methods by Age58 Categories of Poison59 Most Common Poisons60 InformationSlide Locality-Specific Number/Rate by Locality62-64 Circumstances Relationship Problems65 Life Stressors65 Alcohol/Other Substances66 Mental Health67-68 Warning Signs of Suicide69 Disclosed Intent70 Actions to Prevent Suicide71-72 Prior Suicide Attempts73 Other Warning Signs74 Index: Fatal Suicide

50. 50 Suicide in the Central HPR, 2003-2008 InformationSlide Non-Fatal Suicide Gender54 Race54 Ethnicity54 Age Group55 Method of Fatal Injury Complete List of Methods61 Index: Non-Fatal Suicide

51. 51 Suicide in the Central HPR, 2003-2008 #%Rate Gender Male68176.718.0 Female 207 23.35.2 Race White 712 80.214.3 Black 161 18.16.3 Asian 9 1.04.8 Native American 3 0.39.7 Other 3 0.3- Ethnicity Hispanic 14 1.65.6 TOTAL 888 100.011.4

52. 52 Suicide in the Central HPR, 2003-2008 #%Rate Selected Race/Gender White male54060.821.9 Black male13014.610.6 White female17219.46.8 Black female313.52.3 The White male suicide rate is more than twice the rate for Black males, 3.2 times the rate for White females, and almost 10 times the rate for Black females.

53. 53 Suicide in the Central HPR, 2003-2008 #%Rate Age Group 10-1491.01.7 15-19414.67.4 20-24758.413.9 25-3410812.210.5 35-4417219.414.6 45-5420122.617.1 55-6413815.516.3 65-74778.715.8 75-84455.113.7 85 and older222.517.7 TOTAL888100.011.4 Highest risk: ages 85 and older Largest percentage of victims: ages 45-54

54. 54 Non-Fatal Suicide Attempts in the Central HPR, 2003-2008 #%Rate Gender Male2,56639.067.6 Female4,00761.0100.9 Unknown1<0.1- Race White4,44667.689.0 Black1,77327.069.6 Asian450.724.0 Native American50.116.2 Other2153.3- Unknown901.4- Ethnicity Hispanic1422.257.0 TOTAL6,574100.084.7

55. 55 Non-Fatal Suicide Attempts in the Central HPR, 2003-2008 #%Rate Age Group 5-960.11.2 10-142423.746.2 15-1988213.4158.9 20-2486613.2160.1 25-341,45122.1140.8 35-441,57323.9133.7 45-541,05616.189.9 55-643485.341.2 65-74851.317.4 75-84520.815.8 85 and older120.29.6 Unknown1<0.1- TOTAL6,574100.084.7 Largest percentage: ages 35-44 Greatest risk: ages 20-24

56. 56 Suicide in the Central HPR, 2003-2008

57. 57 Suicide in the Central HPR, 2003-2008 #% Method of Fatal Injury Firearm54261.0 Hanging/Suffocation15417.3 Poison13615.3 Fall222.5 Drowning131.5 Motor Vehicle80.9 Sharp Instrument80.9 Fire or Burn60.7 Other10.1 94% of all suicides

58. 58 Suicide in the Central HPR, 2003-2008

59. 59 Suicide in the Central HPR, 2003-2008 #% General Category of Poison Prescription Medication9771.3 Carbon Monoxide2115.4 Over-the-Counter Medication2115.4 Alcohol75.1 Street Drugs53.7 Other64.4 Percentages are based on the number of poisoning suicides (n = 136).

60. 60 Suicide in the Central HPR, 2003-2008 #% Most Common Poisons Amitriptyline*1712.5 Methadone**128.8 Propoxyphene**128.8 Morphine**118.1 Diphenhydramine107.4 Acetaminophen107.4 Quetiapine*96.6 Citalopram*96.6 Alprazolam*85.9 Oxycodone**75.1 Bupropion*75.1 Percentages based on the number of poisoning suicides (n = 136). Poisons used by 7 or more persons are listed. * Commonly prescribed for mental health treatment ** Commonly prescribed for pain management

61. 61 Non-Fatal Suicide Attempts in the Central HPR, 2003-2008 #% Method of Fatal Injury Poison5,14478.2 Sharp Instrument1,06716.2 Firearm560.9 Hanging/Suffocation350.5 Fall290.4 Fire or Burn230.3 Motor Vehicle130.2 Hot Object/Substance3<0.1 Drowning1<0.1 Other Natural/Environmental1<0.1 Other1452.2 Unspecified570.9

62. 62 Suicide in the Central HPR, 2003-2008 #Rate Amelia1418.9 Brunswick1312.1 Buckingham1313.6 Charles City37.0 Charlotte79.4 Chesterfield18510.6 Colonial Heights109.5 Cumberland47.1 Dinwiddie2214.4 Emporia617.7 Number and Rate (per 100,000) of Suicides by Locality of Residence

63. 63 Suicide in the Central HPR, 2003-2008 #Rate Goochland1512.7 Greensville45.8 Halifax2712.5 Hanover7312.5 Henrico18510.9 Hopewell118.1 Lunenburg1215.3 Mecklenburg3518.0 New Kent1818.3 Number and Rate (per 100,000) of Suicides by Locality of Residence (continued)

64. 64 Suicide in the Central HPR, 2003-2008 #Rate Nottoway99.6 Petersburg189.2 Powhatan1811.2 Prince Edward129.6 Prince George3415.9 Richmond City13011.1 Surry24.7 Sussex811.0 Central HPR88811.4 Virginia5,14611.3 Number and Rate (per 100,000) of Suicides by Locality of Residence (continued)

65. 65 Suicide in the Central HPR, 2003-2008 #% Relationship Characteristics Intimate Partner Problem31436.2 Non-intimate Relationship Problem758.6 Life Stressor Characteristics Crisis within Two Weeks of Suicide*33438.5 Physical Health Problem18120.9 Financial Problem12113.9 Recent Criminal Legal Problem11313.0 Job Problem10812.4 Death/Suicide of Family/Friend718.2 Perpetrator of Interpersonal Violence687.8 Percentages are based on the number of suicides with at least one known circumstance (n = 868). * Of these, 72% had a crisis in past 24 hours (2007-2008 data)

66. 66 Suicide in the Central HPR, 2003-2008 #% Substance Use Characteristics Problem with Alcohol/Other Substances21925.2 Problem with Alcohol8910.3 Problem with Other Substances809.2 Problem with Alcohol and Other Substances505.8 Percentages are based on the number of suicides with at least one known circumstance (n = 868).

67. 67 Suicide in the Central HPR, 2003-2008 #% Mental Health Problems Current Mental Health Problem49557.0 Diagnosis: Depression38544.4 Diagnosis: Bipolar677.7 Diagnosis: Anxiety Disorder596.8 Diagnosis: Schizophrenia252.9 Mental Health Treatment42949.4 Current Mental Health Treatment38544.4 Noncurrent Mental Health Treatment445.1 Percentages are based on the number of suicides with at least one known circumstance (n = 868). Diagnoses are not exclusive, but represent the most common diagnoses.

68. 68 Suicide in the Central HPR, 2007-2008 #% Use of Prescribed Mental Health Medications Used in Past 31 Days and/or Prior12570.6 Used in Past 31 Days10961.6 Used, But Not in Past 31 Days169.0 Unknown/Never Used5229.4 Percentages are based on the number of victims with a mental health problem (n = 177). Data are from 2007-2008.

69. 69 Suicide in the Central HPR, 2003-2008 #% Warning Signs of Suicide Disclosed Intent/History of Attempts43550.1 Disclosed Intent to Commit Suicide33939.1 History of Suicide Attempts19021.9 Percentages are based on the number of suicides with at least one known circumstance (n = 868).

70. 70 Suicide in the Central HPR, 2007-2008 #% Person to Whom Victim Disclosed Intent Intimate Partner (Current/Former)4153.2 Family Members2633.8 Friends/Acquaintances1418.2 Mental Health Professional56.5 Medical Personnel33.9 Percentages are based on the number of victims who disclosed intent and where this information is known (n = 77). Data are from 2007-2008.

71. 71 Suicide in the Central HPR, 2007-2008 #% Type of Action Taken to Prevent Suicide Sought Mental Health Treatment1338.2 Limited Access to Firearms and/or Ammunition926.5 Tried to Persuade Victim617.6 Called 911/Law Enforcement411.8 Checked on Victim411.8 Monitored Victim25.9 Percentages are based on the number of suicides where someone took action to prevent the suicide (n = 34). Data are from 2007-2008. Some victims had family, friends, or others who reacted to the disclosed intent and tried to prevent the suicide

72. 72 Suicide in the Central HPR, 2007-2008 #% How Firearm Access was Restricted Removed; all firearms642.9 Hidden (not locked)321.4 Involuntary mental health commitment17.1 Removed; all but one firearm17.1 Removed; gave back later17.1 Removed; locked away17.1 Removed; victim purchased a new firearm17.1 Percentages are based on the number of victims where it was known how firearm access was restricted (n = 14). Data are from 2007-2008.

73. 73 Suicide in the Central HPR, 2007-2008 #% Number of Prior Suicide Attempts One3461.8 Two610.9 Three35.5 Four or more11.8 Multiple, unspecified1120.0 Percentages are based on the number of victims with a known number of prior attempts (n = 55). Data are from 2007-2008.

74. 74 Suicide in the Central HPR, 2007-2008 #% Other Warning Signs Sleep Problems5117.6 Sleeping Too Little4917.0 Sleeping Too Much20.7 Took Prescribed Pain Medication, Past Two Months4515.6 Unusual Behavior, Past Two Weeks238.0 Family History of Suicide155.2 Did Not Want to be a Burden103.5 Family/Friends Expected Suicide103.5 Percentages are based on the number of suicides with at least one known circumstance (n = 289). Data are from 2007-2008.