Suicide Prevention Signs, Symptoms, and Solutions

There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy. All the rest -- comes afterward. These are games; one must first answer. ALBERT CAMUS An Absurd Reasoning French author, journalist & philosopher ( )

Mick Jagger, nominated for a Golden Globe for his music in "Hotel Rwanda" arrives with L'Wren Scott for the 62nd Annual Golden Globe Awards on Sunday, Jan. 16, 2005, in Beverly Hills, Calif. (KEVORK DJANSEZIAN/AP) ANDREW RYAN The Globe and Mail Published Friday, Mar , 10:07 AM EDT at jagger-and-nothing-to-her-siblings/article / Accessed March 28, jagger-and-nothing-to-her-siblings/article /

49-year-old L’Wren Scott was found dead in her Manhattan apartment on March 17. The New York City medical examiner determined that “she killed herself by hanging.” “According to public records, Scott’s personal estate was worth approximately $9 million” ANDREW RYAN The Globe and Mail Published Friday, Mar , 10:07 AM EDT at news/the-a-list/lwren-scott-leaves-9-million-estate-to-mick-jagger-and-nothing-to-her- siblings/article / Accessed March 28, news/the-a-list/lwren-scott-leaves-9-million-estate-to-mick-jagger-and-nothing-to-her- siblings/article / Beautiful and elite, this celebrity fashion designer’s world crashed The day after Scott’s death, Jagger wrote on his website, “I am still struggling to understand how my lover and best friend could end her life in this tragic way. We spent many years together and had made a great life for ourselves. She had great presence and her talent was much admired, not least by me... I will never forget her." Accessed April 4, 2014www.mickjagger.com

We ask … How can this happen? How can someone make a decision against life? Stunned loved ones wonder what they missed, what they could’ve done, left behind to feel guilt, shame, bewilderment. American individualism? Or are communal values the priority?

Suicide Blue collar, white collar, rich, poor, homeless Men more than women (women make more attempts) Caucasian and Native Americans (more than African-Americans and Asians) Firearms most commonly used, followed by hangings

Suicide affects our community Causes and reflects immeasurable pain, suffering, and loss to individuals, families, and communities nationwide. For every suicide more than 30 others attempt suicide annually Each attempt and death affects countless other individuals. Family members, friends, coworkers, and others suffer the long-lasting consequences of suicidal behaviors. SAMSHA 2012 National Strategy Overview at prevention/overview.pdf. Accessed April 4, prevention/overview.pdf

Cultural and Historical Aspects Honor/shame  Some religious and cultural traditions sanction suicide (Islamic sects, Hindu widows, Japanese disgrace, Chinese political corruption) Use of insecticides Western Judeo-Christian culture  Common Era church leaders concerned by high rates of suicide related to martyrdom. St Augustine’s City of God proscription Romans  initially accepted suicide but later outlawed all manners of reducing the population

England and colonial United States England and colonial U.S.  King Edgar proclaims goods of a person who dies by suicide are forfeited.  Henry de Bracton (13 th century jurist) declares suicide a crime  17 th century suicides considered criminal even if there was evidence of mental illness This history provides the backdrop for our modern perspectives of suicide IOM,2002. Reducing Suicide pp 24-5.

Yet over the last millennium the associations still very similar Serious mental illness  Depression, Schizophrenia, Bipolar Disorder, Personality DO Alcohol and substance abuse Medical co-morbidities  Head trauma, neurological d/o, HIV, cancer Childhood loss Loss of a loved one Fear of humiliation Economic dislocation Insecurity IOM, Reducing Suicide p 21

Emotional and Economic costs in U.S. Suicide outnumbers homicides by 2:1 now  >38,000 per year; >1 person every 15 minutes Suicide outnumbers death from AIDS Suicide outnumbers deaths from war Lost productivity; $11 billion to 25 billion The loss in terms of emotional, spiritual life is beyond calculation Contagion

Stigma makes it worse Suicidal behaviors are often met with silence and shame Families of suicide victims often experience the same The stigma of suicide can be a formidable barrier to providing care and support to individuals in crisis and to those who have lost a loved one to suicide. SAMSHA 2012 at

Suicide is a serious public health problem 1958 U.S. Public Health Service first suicide prevention center 1966 Center for Suicide Studies (NIMH) 1980s CDC task force; youth violence 1990s World Health Organization concern 1996 Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies by the UN and WHO 1998 Private/public partnerships respond Federal commitment Healthy People 2010 to reduce rate to 6/100,000 (1/2 current)

The 1999 Surgeon Generals Call to Action David Satcher MD Reduce the suicide rate to 6 by 2010 Begin educational efforts for suicide prevention, target mental illness while program being developed Followed by the 2001 National Strategy for Suicide Prevention published by U.S. DHHS and Public Health Service.

The Public Health Approach Public health model  Define the problem--surveillance  Identify causes--risk and protective factor research  Develop and test interventions  Implement intervention  Evaluate effectiveness Effectiveness is difficult to measure; no control, no placebo group, may take decades

National Strategy for Suicide Prevention “The National Strategy provides a framework that helps communities to devise their own broad-based empowering strategies for reducing suicides. It employs the public health approach, which has helped the nation effectively address problems as diverse as tuberculosis, heart disease, and unintentional injury.” suicide-prevention/index.html

The Assumption The approach assumes that raising general public awareness about the extent to which suicide is a problem, and about the ways in which it can be prevented, can reduce suicide and suicidal behaviors.

The Second Wave is now here The initial 2001 publication was by the National Institute of Mental Health (NIMH) The 2012 National Strategy is a joint effort by the Office of the U.S. Surgeon General and the National Action Alliance for Suicide Prevention (Action Alliance), intended to guide prevention activities the next 10 years.

Important achievements the past 10 years Garrett Lee Smith Memorial Act Creation of the National Suicide Prevention Lifeline ( TALK/8255) Partnership with the Veterans Crisis Line Establishment of the Suicide Prevention Resource Center (SPRC) Clinician trainings, community members, collaboration between public and private sectors.

Activity in the field of suicide prevention has grown dramatically since the National Strategy was issued in 2001 Government agencies at all levels Schools Nonprofit organizations Businesses

A Plethora of Organizations are involved! Department of Health and Human Services Centers for Disease Control National Institutes of Health and NIMH Department of Defense Dept of Veterans Affairs

A Big push the last 10 years American Foundation for Suicide Prevention Suicide Awareness Voices of Education American Association of Suicidology

Social Media is a piece of this cooperation

Public/Private organizations are involved now Action for Alliance  >200 National Leaders Private organizations and entities  Facebook  Universities of Chicago, Rochester, Calgary  Entertainment Industries Council  Mental Health Association of San Francisco  National Organization of People Against Suicide  Samaritans USA  Suicide Awareness Voices of Education  Jason Foundation  Jed Foundation  Henry Ford used in Sedg Co

School-Based Prevention Programs SOS Signs of Suicide® Prevention Program (SOS)

/youth-prevention-programs/sos/ The SOS High School Program is the only school- based suicide prevention program listed on the Substance Abuse and Mental Health Services Administration’s National Registry of Evidence- based Programs and Practices that addresses suicide risk and depression, while reducing suicide attempts. In a randomized control study, the SOS program showed a reduction in self-reported suicide attempts by 40% (BMC Public Health, July 2007).

USD 259 Yellow Ribbon Evaluation of pre/post program surveys Improvement in knowledge and confidence in engagement in help seeking behaviors May be especially useful for middle school boys No harm

International Drive International Association for Suicide Prevention

Spin off policies and programs Access to weapons; Firearms, packaging meds Mental Health programs  APA’s Vision for Mental Health System  The President’s New Freedom Commission The Interim Report of the President’s New Freedom Committee On Mental Health caution the nation about the impending mental health catastrophe if the attitude of denial and neglect continues unchanged  APA Suicide Treatment Guidelines Population based studies/Centers/Youth resiliency

The 2012 National Strategy for Suicide Prevention is a joint effort The Office of the Surgeon General The National Action Alliance for Suicide Prevention (Action Alliance, NAASP) 4 strategic directions/13 goals/60 objectives  Creating supportive environments and promoting healthy empowered families and communities  Enhancing clinical and community preventive services  Promoting available and timely treatment and support services  Improve suicide prevention surveillance collection, research, and evaluation SAMHSA 2012 NSSP Overview

National Strategy for Suicide Prevention AAwareness of the problem and risks Now under Healthy and Empowered Individual, Families, and Communities IIntervention to solve the problem Spread against 3 strategic directions MMethodology to monitor the populations at risk Expanded to include surveillance and program evaluation

Our Duck Pond State of Kansas Suicide Prevention Task Force asked Sedgwick County members to start a local task force The Suicide Prevention Task Force became a Coalition in 2009 A recent local addition of the American Foundation for Suicide Prevention

Key gatekeepers Teachers and school staff School health personnel Clergy Police officers Correctional personnel Supervisors in occupational settings Natural community helpers Hospice and nursing home volunteers Primary health providers Mental healthcare and substance abuse treatment providers Emergency healthcare personnel. 2001, DHHS. NSSP p78

I. Define the Problem Surveillance of suicide attempts is fraught with concerns about nomenclature, accuracy in reporting, lack of systematic or mandatory reporting  Educated and not so educated guesses. KS counties Definitions lacking-population differences  Assisted suicide is a “separate issue”-should not be included in the rate

Various agencies utilize different data Death certificates Coroner reports Data may be gathered by county of residence or by site of death Field reporters obtain the personal data and interview the families

Suicides are tracked by using a Rate No. of suicides per 100,000 persons Overlaps other injury data (ODs, MVAs) The Rate:  Is influenced by economic, spiritual, political factors  An indicator of a country’s health, hope, stability, and culture.  10 th on the list of U.S. Health Indicators

Comparing Suicide Rates Nine of the 10 highest suicide rates worldwide are in Europe. The average suicide rate in Europe is 13.9  Rates as high as 30.7 in Lithuania (41.9 in 2001; males at 73.8), 21.5 in Hungary (43 in 1999), and 18.5 in Finland and 18.4 in Slovenia. Russian Federation rate in 1998 was , IOM. Reducing Suicide p 35

Who Crunches the Numbers? National Suicide Prevention Resource Center CDC utilizes Injury and Violence Data National Violent Death Reporting System  Model: National Highway Traffic Safety Administration’s system for motor vehicle deaths

National Violent Death Reporting System (NVDRS) Harvard-designed to collect information on homicides and suicides and firearms deaths Based on FARS and the National Violent Injury Statistics System (NVISS) Testing at 10 sites-information from death certificates, coroner/medical examiner reports, police Uniformed Crimes Reports, crime laboratories  Expected to allay irregular quality of data available through the coroner system  Currently collects data in only 18 states

Comparisons Suicide Rates per 100, Sedg Co KS USA

Despite efforts at prevention the last 15 years … The suicide rate has actually increased Despite the use of antidepressants and improved healthcare and mental healthcare Despite the economy Despite our rich heritage and freedoms Is this an indication of whether our programs are working or not?

Public health program concerns Anti-smoking, cancer screening, AIDs prevention can point to success in lives saved Suicide rate however has increased in the U.S. The risk factors for suicide have a wide distribution, are large in number, have a high prevalence, and inherent challenges that make mounting large scale prevention programs difficult. Societal targets (limiting access to lethal means, improving community detection and treatment) have as yet been unsuccessful in achieving a reduction Baker SP, 2013

The Disconnect 1990s—The Decade of the Brain Suicidality has a life apart from mental illness No professional has been able to consistently predict individuals’ suicide Mental health tools have been unproven in terms of affecting suicidality

The association of suicide with mental illness … Is a “conundrum” 80-90% of people who commit suicide have “depression” 95% of mentally ill do not suicide (6-15% of depressed patients commit suicide, 7% with alcohol dependence, 4% with schizophrenia) (IOM p394)

My Friend Middle-aged Vietnam veteran who struggled with PTSD from childhood trauma, alcohol abuse, and depression Was hospitalized after cutting his wrists in a suicide attempt when I first met him. Struggled with his pain for 10 more years, while in and out of treatment at VA MHC Died of an overdose on his medications and alcohol in his 50s

People who commit suicide Frequently do not tell others or professionals Are not identifiable on individual basis Are frequently different from those with para- suicidal behavior and frequent attempts Are from widely varying populations (young divorced male versus dialysis patient refusing treatment) IOM 2002 Reducing Suicide

“The stark facts” Jan Fawcett MD: “Suicide isn’t predictable in individuals; Preventive efforts aren’t very effective; Suicidal communications aren’t often made by patients to physicians or counselors; Denial of suicidal intent doesn’t mean a patient won’t do it” IOM 2002 Reducing Suicide

II. Identify Causes Risk factors:  Acute: anxiety, panic attacks, recent alcohol  Chronic factors: demographic info  First year post discharge  Traditional risk factors did not predict for year one—but did for years 2-10 Protective factors:  Resiliency  Social support

Theories Social theories Charles Durkheim Freud: Anger turned inwards Aaron Beck Hopelessness

Biology Low serotonin and impulsivity Brain serotonin bounces back very high right after suicide attack No genetic tests are helpful as of yet

SYMPTOMS SHORT-TERM RISK FACTORS  Loss (loved one, relationship, job, pride, health)  Hopelessness  Anxiety  Agitation and Impulsiveness  Intoxication with alcohol or substances LONG-TERM RISK FACTORS  Elderly caucasian male who drinks

The 4 Rs Relief of pain—emotional and/or physical Rejoining a lost one Reality testing loss (voices, command hallucinations, God’s desire) Revenge

“Some people think that if we just get suicidal people into treatment we’d prevent suicide. But we’re not good at it” More than 50% of suicides occur while patients are in active treatment 69% of patients do communicate intent to a spouse, with friends, or coworker … “so we damn well better talk to the significant others --and believe what they say” IOM 2002 Reducing Suicide

III. Develop and Test IV. Implement Interventions Yellow Ribbon and school-based programs Air Force Program Suicide scales: Scale for Suicide Ideation (Beck 1979), Suicide Intent Scale (Beck 1974), Beck Depression Inventory, HAM A, Beck Hopelessness Scale Scales often have high FN and FP rates, poor positive predictive value

SADPERSONS Scoring for Suicide Risk SSex = male1 point AAge > 45 or <191 point DDepression / hopelessness2 points PPrior attempts / Psychiatric illness1 point EExcessive Alcohol / Drugs1 point RRational thinking loss2 points SSeparated widowed or divorced1 point OOrganized or serious attempt2 points NNo social support1 point SStated future intent2 points Score > 9 = high risk and probable need for inpatient intervention Score > 6 = moderate risk and need for psychiatric consultation Score < 6 = low (but not no) risk

V. Evaluate Effectiveness The global suicide rate may not be such a good indicator of effectiveness of interventions Breaking down populations Preventable versus non-preventable suicide Response may be seen in one year, may take decades Cohort effects

Sedgwick County 2012 Suicide Rates 83 Suicide deaths in Sedgwick County Rate of 16.5 deaths per 100,000 Highest rate seen in the 12 years that we’ve been tracking local data Suicide Prevention Hotline hours/ 7 Days per week

Methods Use of firearm is consistently most common method, followed by hanging and overdose Rate per 100,000 United States 2010 Sedgwick County 2010 Sedgwick County 2012 Firearm Hanging/Suffoc ation Overdose2.12.2

Sedgwick Co. Method of Suicide

Health History in Sedgwick County Suicides History of mental illness was noted in approximately 50% of suicides --Depression, bipolar disorder, substance abuse 27% have history of prior suicide thoughts or attempts Significant medical issues noted in 40% of suicides 72% suicides in Sedgwick County had alcohol or drugs in their system

Changing times/changing trends In the 1980s and 1990s most concerns were for young black males (injury) and older white males (suicide rate 90) Males ages were a high risk group, now down (element of hope?) The recent increase in the year old group is seen nationwide as well as locally This group of middle aged persons may reveal mixes of substance use, medical problems, relationship ills, and job losses as stressors. It may also reflect a lack of resilience in this cohort, and a cultural outlook that promotes suicidality or hopelessness. It may be the pain treatment culture promoted in the medical community

New Waves Pain control culture Narcotics What effect does cannabis have?

Our community is busy trying to help prevent suicide Via Christi Assessment Center Via Christi hospitals Other hospital ERs ComCare MHA Private practitioners Law enforcement EMS

Community Impact of Suicidal Ideation/ Attempts Sedgwick County 911 Dispatch calls  2,179 Suicide attempts  295 Suicide threats  816 Mental health emergencies COMCARE Crisis Intervention Services  5,586 Crisis Assessments  61,156 phone calls

Weakness in emergency management Involves the shortage of mental health specialists in general hospital ED Enhanced training of ED physicians may help Increasing patient access to mental healthcare Implementation of advances in clinical medicine is often a slow process Offson M, Marcus S, Bridge J, Viewpoint: Focusing Suicide Prevention on Periods of High Risk. JAMA. March 19, 2014, Volume 311, Number

The Risky Post-hospitalization Period  The period immediately following discharge from a psychiatric hospital poses an extraordinarily high risk of suicide--especially the first week. Qin P  Roughly 1/3 (39%) of all suicides in the first year after hospital discharge have been found to occur in the first 28 days. Goldacre M 1993  ¼ (24%) of all suicides occur among patients who are within 3 months of discharge from a psychiatric hospital. Appleby L, 1999

Interventions for the post-hospital discharge period Clinical interventions, programs, and policies targeting protecting patients from suicide during the period following discharge are needed. An observational study from the United Kingdom reported implementation of a 7-day follow-up after psychiatric hospital discharge was associated with a decline in suicide rates from 24.8 to 19.5 annually during the 3-month period following discharge. While D, 2012

U.S. and local clinical practice Improvement needed in patient transitions from inpatient to outpatient psychiatric care. Nationally only about ½ of psychiatric inpatients receive any outpatient mental healthcare during the first week following hospital discharge and only 2/3 receive care during the first month. NCQA DATA 2013 Problems with outpatient compliance (Lincoln et al, pending)

Addressing critical links in mental health care system will not replace other interventions Hotlines Screening programs Crisis counseling services Public education campaigns Offson 2014

WHERE DOES THAT LEAVE US NOW?

Organizational Restructuring Revision of the Strategy for Suicide Prevention A Prioritized Research Agenda for Suicide Prevention by NAASP

“A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives” tes/actionallianceforsuicideprevention.org/file s/Agenda.pdf tes/actionallianceforsuicideprevention.org/file s/Agenda.pdf 3 years in production, after observations that prioritizing research into other diseases helped to advance the science in those areas. Developed 6 key questions

Where we are at now: 6 Key Questions Why do people become suicidal? How can we better detect/predict risk? What interventions are useful? What services are most effective? What interventions outside healthcare settings reduce suicidality? What new research infrastructure is needed? Levin, A. “Clinical and Research News: Suicide Experts Identify Six Questions To Guide Research in Next Decade”. Psychiatric News, Vol 49, No 6, March 21, p 13.

Our little world; Sedgwick County Educate the public so that family and friends will pick up on the signs of risk and encourage treatment Educate gatekeepers, seminars Evaluate the programs already in use  Yellow Ribbon school program  Bookmark distribution  Annual run  Survivors of Suicide annual teleconference

Local prevention groups Sedgwick County Suicide Prevention Coalition American Foundation for Suicide Prevention National Association for the Mentally Ill Private foundations

Recommendations in SCSPC Continue efforts to collect data from a variety of sources to assess impact of Coalition activities Increase integration efforts with primary care, pastors and business Target high risk neighborhoods  Focus groups to identify neighborhood needs and targeted prevention efforts  Create Neighborhood Advisory Committees Community workshops to educate providers about local resources, promote dialogue among groups

Prevention measures; what you can do For information about suicide, a Survivors of Suicide Handbook, the Cluster Response Plan or upcoming events, go to (Living, Health and Welfare, Suicide Prevention) American Association of Suicidology - American Foundation for Suicide Prevention - Suicide Prevention Hotline Hours/7 Days a Week LISTEN, LISTEN, LISTEN Prevent access to firearms, monitor all medication use, and be aware of potential weapons Don't promise to keep their comments of suicide a secret Help them get help by talking to a family doctor, counselor, or clergy or by calling the Suicide Prevention Hotline. Go to an emergency room Do not leave the person alone

/suicide_prevention.asp SUICIDE PREVENTION If you or someone you know is talking about suicide, please call the suicide prevention hotline 24 hours a day/7 days a week. (316) Crisis Intervention Services (CIS) has been the suicide prevention service for many years in Sedgwick County. At CIS, priority is given to callers who are at risk for suicide. Crisis Intervention Services

Suicide can be prevented. Some occur without warning but most do give clues. Recognize the signs and know how to respond. Observable signs of serious depression:  Pessimism  Hopelessness  Desperation  Sleep problems  Anxiety, emotional pain and inner tension  Withdrawal from friends and/or family  Increased alcohol and/or other drug use Recent impulsiveness and taking unnecessary risks Threatening suicide or expressing a strong wish to die Making a plan Seeking access to pills, weapons or other means Unexpected rage or anger Stressful life events may precede suicide, such as intimate partner problems, other relationship problems, loss of employment, housing insecurity, financial difficulties, legal trouble and/or a history of medical illness. Although most depressed people are not suicidal, most suicidal people are depressed. One can help prevent suicide through early recognition and treatment of depression and other psychiatric illnesses. Be a link, save a life.SCSPC 2012 Annual Report

We always deceive ourselves twice about the people we love — first to their advantage, then to their disadvantage. ALBERT CAMUS, A Happy Death Read more at quotes.com/c/camus_albert.html#QlzA2Qwjy Ppv8crk.99http:// quotes.com/c/camus_albert.html#QlzA2Qwjy Ppv8crk.99

17 yo white female, distraught over the breakup with her boyfriend Secretly goes to her family’s medicine cabinet and downs a bottle of Tylenol and Benadryl, to “escape the pain.” Is ready to die if that’s what it takes. Gets sick to her stomach after several hours and now remorseful, discloses to her mother what she has done. Is rushed to the ER, stomach is pumped but to no avail; her liver fails from the toxin and doctors determine the chance of a transplant is unlikely to occur within the time period that she may still survive. The liver disease takes her life within the next few weeks.

Lock all medications up. Especially OTCs Any small deterrent in a suicide attempt may avert completion Impulsive patients are often too distraught to think of a plan of self harm, they simply reach for anything easy. Getting through this anxious distress will often be met with a return of more logical thinking.

18 yo white male recently hospitalized for depression and suicidal ideations A result of a break up with his girlfriend. The two reconciled while he was in hospital, his suicidal thinking remitted, he was treated with an antidepressant, and discharged improved to outpatient care after a safety plan was established with family Two weeks later, while doing well, he borrowed a gun to go hunting with friends. Three days later his girlfriend broke up with him over the phone. He used the rifle, still in his truck, to take his life. Alcohol may have been a factor.

Firearm Safety: Means Restriction Firearms in the home are a risk factor.  Never leave these at home unattended  Lock them away  Use the safety Pistols in the home raise the risk 10-fold Tell family and friends about the situation Alcohol and substances increase the risk of impulsivity of any type.

Build resilience in our children Problems come and go Relationships come and go Managing emotions can instill confidence and security There will be failures but it is not the end of the world

STIGMA Is a way of deceiving ourselves, a way to pretend that these things really do not exist in the “real” or “normal” world Denies the fact that we are all on the edge of our own insanity  Unforeseen tragedies  Unforeseen medical problems  Medications, supplements, substances  Unforeseen disasters

Bravery and Courage Required To address the addictions our loved ones face To address our loved ones that are “enablers” To be that freaky person that keeps the guns locked up and the safety on, keeps the medications locked up To acknowledge we are all one step away from the edge

Summary--Suicidality is a more complex process than other public health concerns Biological, clinical, subjective, and social factors—more complex than other “chronic disease” Prevention may be difficult to measure and the suicide rate may not be the best indicator of effectiveness Evaluate education, policy and/or technological changes and implement effective interventions

My Opinion Educate families and friends Reduce stigma for survivors Limit access to means (Firearm Safety!!!) Use caution with narcotics and substances Don’t ignore the influence of cannabis Monitor the suicide rate with an eye towards an understanding of our society’s ills Build resilience in our children

Stop the Silence Be a Voice for Life Man stands face to face with the irrational. He feels within him his longing for happiness and for reason. The absurd is born of this confrontation between the human need and the unreasonable silence of the world. ALBERT CAMUS, The Myth of Sisyphus Read more at quotes.com/c/camus_albert.html#QlzA2Qwjy Ppv8crk.99http:// quotes.com/c/camus_albert.html#QlzA2Qwjy Ppv8crk.99

References Baker SP, Hu G, Wilcox HC, Baker TD. Increase in suicide by hanging/suffocation in the US Am J Prev Med. 2013;44(2): Qin P, Nordentoft M. Suicide risk in relation to psychiatric hospitalization: evidence based on longitudinal registers. Arch Gen Psychiatry. 2005;62(4): Goldacre M, Seagroatt V. Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet. 1993;342(8866): Appleby L, Shaw J, Amos T, et al. Suicide within 12 months of contact with mental health services: national clinical survey. BMJ. 1999;318(7193):

References While D, Bickley H, Roscoe A, et al. Implementation of mental health service recommendations in England and Wales and suicide rates, : a cross-sectional and before-and-after observational study. Lancet. 2012;379(9820): National Committee on Quality Assurance. Improving quality and patient experience: the state of health care quality /SOHC-web%20version%20report.pdf.Accessed date

Offson M, Marcus S, Bridge J, Viewpoint: Focusing Suicide Prevention on Periods of High Risk. JAMA. March 19, 2014, Volume 311, Number Sedgwick County Suicide Prevention Coalition 2012 Annual Report (Nicole Klaus PhD) at h ttp:// ttp:// comcare/reports/Suicide_Prevention_AR.pdf. Accessed April 6, 2014 “A Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives” at rsuicideprevention.org/files/Agenda.pdf. rsuicideprevention.org/files/Agenda.pdf SAMSHA 2012 National Strategy Overview at suicide-prevention/overview.pdf. suicide-prevention/overview.pdf

Reducing Suicide; a National Imperative by the National Academy of Science, National Academies Press, 500 Fifth Street NW, Box 285, Washington DC, Others: al-strategy-suicide-prevention/index.html SSP

Offson M, Marcus S, Bridge J, Viewpoint: Focusing Suicide Prevention on Periods of High Risk. JAMA. March 19, 2014, Volume 311, Number