1. Take A Few Minutes to C.A.L.M. Counsel on Access to Lethal Means Elaine Frank Elaine.frank@dartmouth.edu

2. Reducing Access to Lethal Means Make highly lethal means less accessible Attempt suicide with less lethal means or Delay suicide attempt

3. CALM Goals and Objectives Project Goal: Increase the number of mental health and, primary care professionals and other gatekeepers who counsel those at risk for suicide about reducing access to lethal means Learning Objectives: 1. Understand what "lethal means" are 2. Recognize the contribution reducing access to lethal means has for preventing suicide 3. Develop skills and confidence to counsel on reducing access to lethal means 4. Identify how you can use this information in your professional and personal lives

4. Why do it? Proven to be an effective intervention – many people will not switch to another means (Means Substitution) Part of the National Strategy for Suicide Prevention and many state plans Most suicidal people are ambivalent about death as they are about life The actual act of suicide is often highly impulsive - particularly among young people WHY NOT?

5. A few facts before we go on ● 90% of those who die by suicide suffered from some form of mental illness and/or substance abuse – often undiagnosed but often treatable ●90% of those who survive a nearly lethal attempt do not go on to die by suicide ● 92% of those prevented from jumping off the Golden Gate Bridge did not die by suicide

6. What Means to Focus On? * Frequency * Lethality * Impulsivity * Availability * Feasibility

7. Suicide Methods by Age

8. The decline in the suicide rate has largely been due to a decline in firearm suicides, particularly in the 1990s. Total Firearm Poison Suffocation Other U.S. Suicides Deaths per 100,000 population

9. Total Firearm Suffocation Poison Other U.S. Youth Suicide, 15-24 year-olds

10. Relative Lethality of Means Ohio - 1999 - 2005

11. Self-Harm Case Fatality Rates Firearms Cutting & Poisoning 85-90% fatal 15% nonfatal, ED-treated 1-2% fatal 98% nonfatal, ED-treated Source: CDC WISQARS

12. Moving Attempters Down the Ladder Firearm Jump from great height Carbon monoxide Hanging/suffocation Overdose/poisoning Cutting High Case Fatality Rate Low Case Fatality Rate

13. Impulsivity Among survivors of near fatal suicides, when asked about time from their decision to complete suicide and the attempt: ● 24% said less than 5 minutes ● 47% more said an hour or less

14. Firearm Availability As A Suicide Promoter  Suicide rates vary with rates of firearm ownership  Case control studies show greater prevalence of guns and less securely stored guns in homes of those who suicide than in controls  85% of youths who die by suicide using a firearm obtained it from home  Parents underestimate the likelihood that their children have or could obtain their firearms.

15. Firearms – can limit access at home, some opportunity to impact purchase. Particularly feasible for those under 18 and those who are not primary owners Bridges/other high places – requires public policy and political will but highly effective Hanging – too many means, remove the obvious ones and focus on connectedness and supervision Medications – can limit quantity of prescription and OTC medications at home Cut/pierce – again, too many means but low lethality Feasibility ( in order of lethality)

16. “Natural (Gas) Case Study” Self-asphyxiation by domestic gas, Great Britain Pre-1957: Proportion of suicides = 40% 1957-1970: Transition from coal to natural gas: CO content went from 12% 2% 1971: Proportion of suicides = 10% Overall suicide rate: 26%

17. Steps to Take Express your concern directly to client/family and explain that you believe the individual is at risk for suicide Inquire about access to firearms and other lethal means Inform the client/family that restricting access reduces risk Discuss how to accomplish this as well as the need for ongoing supervision, treatment and follow up