1. 1 On the Road to Zero Suicide On the Road to Zero Suicide Improving Identification, Triage, Care Delivery and Redirecting Scarce Resources with the Columbia Suicide Severity Rating Scale Kelly Posner, Ph.D. Principal Investigator Columbia/FDA Classification Project for Drug Safety Analyses Principal Investigator Center for Suicide Risk Assessment Columbia University 1

2. 2 Suicide is a Major Public Health Crisis Suicide is one of the world’s greatest public health crises – more deaths than war, homicide and natural disasters combined Suicide is one of the world’s greatest public health crises – more deaths than war, homicide and natural disasters combined Leading cause of death across the world and across ages Leading cause of death across the world and across ages Every 40 sec. worldwide and every 13 minutes in the US a person dies by suicide Every 40 sec. worldwide and every 13 minutes in the US a person dies by suicide #1 cause of injury mortality in U.S.; more people die by suicide than motor vehicle crashes #1 cause of injury mortality in U.S.; more people die by suicide than motor vehicle crashes “The under-recognized public health crisis of suicide” - Thomas Insel, Director of NIMH Suicide is a preventable cause of death 2

3. Need to Ask Like We Monitor for Blood Pressure Nearly 50% of people who die by suicide see their primary care doctor the month before they die (Luoma et al., 2002) Nearly 50% of people who die by suicide see their primary care doctor the month before they die (Luoma et al., 2002) 70% of older adults 70% of older adults 90% adolescents in the year prior 90% adolescents in the year prior 2/3 of adolescent attempters in the ER do not present for psychiatric reasons (King et al., 2015) 2/3 of adolescent attempters in the ER do not present for psychiatric reasons (King et al., 2015) 25% of all people who die by suicide are seen in ER in past 12 months for non-psychiatric reasons (Gairin et al., 2003) 25% of all people who die by suicide are seen in ER in past 12 months for non-psychiatric reasons (Gairin et al., 2003) A GREAT OPPORTUNITY FOR PRVENTION ! If we ask we can find them!!

4. … used to be 2 hours and 11 minutes Every 1 hour & 40 minutes, a person under the age of 25 dies by suicide … used to be 2 hours and 11 minutes 4 An Increasing Crisis in Youth and Young Adults

5. 2010-2013 suicide is the 2 nd leading cause of death in youth 10-24 passing homicide for the first time since 1999 Suicide by African American girls 10-18, increased 160% between 2006-2013 Suicide by African American girls 10-18, increased 160% between 2006-2013 8-14 year olds– has more than doubled from lowest point in 2007 8-14 year olds– has more than doubled from lowest point in 2007 CDC WISQARS 5

6. Suicide Ideation and Attempts Are Unbelievably Common… IN YOUR AVERAGE HIGH SCHOOLERS 8% attempted in the past year! 8% attempted in the past year! 20% of AI/AN girls – highest group 17% seriously considered it 17% seriously considered it 27% of AI/AN 27% of AI/AN IN DEPRESSED TEENS Attempt: 30% Attempt: 30% Ideation: 60% Ideation: 60% Within any typical classroom, it is likely that three students (one boy and two girls) have attempted suicide in the past year.

7. Relationship to Acts of Gun and School Violence (Safe Schools Initiative, 2002; Langman, 2009) 90% of attackers exhibited history of suicide attempts or suicidal thoughts at some point prior to their attack 90% of attackers exhibited history of suicide attempts or suicidal thoughts at some point prior to their attack 27% reported suicide as a motive in their attack - a suicide in disguise 27% reported suicide as a motive in their attack - a suicide in disguise 60% had a documented history of extreme depression or desperation 60% had a documented history of extreme depression or desperation and yet, only 34% of attackers had received a mental health evaluation and just 17% had been diagnosed 7 - Eric Harris (age 18) and Dylan Klebold (age 17) – 1999 - Jeffrey Weise (age 16) - 2005 - Seung Hui Cho (age 23) - 2007

8. Former Deputy Secretary US Dept. of Ed. - James Shelton “I often think of how many lives could have been saved literally and figuratively had C-SSRS been in the growing number of communities suffering from in school shootings. After the Navy Yard shootings, I wrote to Dr. Posner and her team, thanked her for her work to date and asked what it would take to make it ubiquitous so we could stem this unnecessary loss of life. If implemented to the extent of its capacity across the country, the C-SSRS has the potential to keep the 64 million children in our schools safe physically and mentally by helping prevent school violence.”

9. First Responders   A leading cause of death of law enforcement officers alongside car crashes   In 2012, almost as many died by suicide as were killed in the line of duty   The rate of police suicide is comparable to the US Army Rates   In 2014, 104 firefighters in the United States died by suicide, only 87 were killed in the line of duty Corrections  Leading cause of death in jails for past 15 years  1/3 of all jail deaths  Rate of suicide is close to three times that of general pop  Many within first 24 hours  Incarcerated youth: 37% report a suicide attempt  Recently released prisoners have rates similar to psychiatric hospital discharges A CRISIS Everywhere

10. Suicide Everywhere… Within corporate family consisting of 100,000 employees (average of 4 blood relatives per employee): Every 6 days, one employee or family member will die by suicide Every day, 3 attempts, some resulting in significant medical injury and disability, which directly impacts health care costs, particularly for self-insured companies. 10

11. Almost 20% of all U.S. suicides are active duty or veterans– many connected to systems of care ACTIVE DUTY1 suicide per dayAIR FORCE 9 suicides within ~first 15 days (2012) VETERANS 23 suicides per day 1000 attempts/month ARMY RESERVISTS AND NATIONAL GUARDSMEN Doubled in 2010 Crisis in the U.S. Military… Suicide has surpassed combat deaths

12. 12 Rural Areas: One of Our Greatest Challenges Highest rates of suicide Large populations, spread out across great distances Less consistent access to primary care Closest physicians may be several hours away and overburdened High rates of gun ownership (Miller et al., 2013)

13. Any Kind of Medical Illness… from Asthma to Cancer 25.5% have ideation 8.9% make an attempt Cancer patients - ideation 17.7% independent of depression If you have one of the following disorders (high blood pressure, heart attack/stroke, cancer, epilepsy, arthritis, chronic headache, chronic pain, respiratory conditions) you are: –30-160% more likely to have suicidal thoughts –40-90% more likely to have an attempt 13

14. Economic Burden: What Not Being Able to Identify High Risk Costs… Worldwide (2008): $141 billion— years of life disabled or lost US (2010): $45 billion— lost wages and work productivity –Tennessee: cost of $1.3 billion a year in 2012 Attempters constitute high proportion of all emergency referrals to child, adolescent, and adult psychiatric services Attempters constitute high proportion of all emergency referrals to child, adolescent, and adult psychiatric services –Subsequently, commands disproportionate level of resources Centers for Disease Control and Prevention 2011, Suicide Prevention Resource Center, 2012

15. Depression: Most Debilitating Disease in the World Depression will be the world’s most burdensome disease by the year 2030 (WHO, 2008) Depression will be the world’s most burdensome disease by the year 2030 (WHO, 2008) Depression is already the most burdensome disease in middle and high income countries (WHO, 2008) Depression is already the most burdensome disease in middle and high income countries (WHO, 2008) Depression is the #1 cause of work related absence Depression is the #1 cause of work related absence and costs US workplaces an estimated $23 billion annually in lost productivity from just those days missed

16. Unfortunately, People Who Need Treatment Do Not Get It! 90% of individuals who die by suicide have untreated mental illness (60% depression) Under-treatment of mental illness is pervasive – –50-75% of those in need receive no treatment or inadequate treatment (Alonso et al., 2007; Wang et al., 2005) – –70% of children and teens with depression go untreated – –> 80% of adolescents and college students who die by suicide never received any consistent treatment prior to their death

17. 1717 Suicide prevention efforts depend upon appropriate identification & screening

18. The Problem… …Consequences Field of medicine challenged by lack of conceptual clarity about suicidal behavior and absence of well-defined terminology (research and clinical) Variability of terms referring to same behaviors (threat, gesture) “Slap in the face” 16 different terms for the same behavior Negative implications on appropriate management of suicide and research - if suicidal behavior and ideation cannot be properly identified, it cannot be properly understood, managed or treated in any population or diagnosis Furthermore, comparison across epidemiological or drug safety data sets is compromised, decreasing confidence in data “ Research on suicide is plagued by many methodological problems… Definitions lack uniformity,…reporting of suicide is inaccurate…” Reducing Suicide Institute of Medicine 2002

19. How to Fix the Problem… Columbia - Suicide Severity Rating Scale Developed in NIMH attempter trial to uniquely address need for summary measures – 1 st scale to assess full range of ideation and behavior Developed in NIMH attempter trial to uniquely address need for summary measures – 1 st scale to assess full range of ideation and behavior Developed by many leading experts - collaboration with Beck’s group Developed by many leading experts - collaboration with Beck’s group Extensively international use across research, clinical and institutional settings Extensively international use across research, clinical and institutional settings Several million administrations Several million administrations Available in 116 languages Available in 116 languages Very brief administration time Very brief administration time Extremely sensitive and specific Extremely sensitive and specific Good acceptance in practice by patients and providers Good acceptance in practice by patients and providers Don’t have to rely only on individual report – can use multiple sources of information Don’t have to rely only on individual report – can use multiple sources of information Excellent feasibility – no mental health training required to administer Excellent feasibility – no mental health training required to administer 812 nurses, 99% reliability independent of MH training or education 812 nurses, 99% reliability independent of MH training or education excellent reliability in juvenile justice use by non-clinicians – Kerr, 2014 excellent reliability in juvenile justice use by non-clinicians – Kerr, 2014 Front line responders to clergy Front line responders to clergy Systematic use of C-SSRS shown to decrease burden compared to other methods or doing nothing Systematic use of C-SSRS shown to decrease burden compared to other methods or doing nothing Age: the C-SSRS is suitable across the lifespan for use with adults, adolescents, and young children. Special Populations: indicated for cognitively impaired (e.g. Alzheimer's, Autism) Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; Zelazny, J.; Fisher, P.; Burke, A.; Oquendo, M.; Mann, J.

20. Everyone, Everywhere Can Ask First Responders First Responders Juvenile Justice Juvenile Justice Corrections Corrections Parents Parents Youth Youth Crisis Response Teams Crisis Response Teams Hotlines Hotlines In schools: In schools: –Teachers –Safety Officers –Coaches –Road patrol –Bus drivers Pediatricians Pediatricians Clergy Clergy Child Protective Services Child Protective Services Gun shops/ranges Gun shops/ranges In behavioral healthcare settings: In behavioral healthcare settings: –Peer counselors –Paraprofessionals –Professionals –Nurses –Nurses’ aides –Custodial/Janitorial Staff 812 nurses trained - 99% reliability independent of mental health training and education Strong inter-rater reliability among non-clinicians in juvenile justice - (Kerr, et. al. 2014) One county’s story: Lapeer County, MI “Complete Blanket Coverage” from ER staff to bus drivers, cafeteria workers, clergy, and more!

21. Screener Demo http://youtu.be/fx3N3uDUQbo

22. 22 Hope Grows World Health Organization-Europe: 100 Best Practices for Adolescent Suicide Prevention World Health Organization-Europe: 100 Best Practices for Adolescent Suicide Prevention AMA Best Practices Adolescent Suicide AMA Best Practices Adolescent Suicide Health Canada Health Canada Japanese National Institute of Mental Health and Neurology Japanese National Institute of Mental Health and Neurology Israeli Defense Forces and Israeli National Suicide Prevention Program Israeli Defense Forces and Israeli National Suicide Prevention Program Korean Association for Suicide Prevention Korean Association for Suicide Prevention Managed Care Organizations/Mobile Crisis Teams Managed Care Organizations/Mobile Crisis Teams Tribal Nations Tribal Nations International Mission Organizations International Mission Organizations Drug and Alcohol Addiction Centers Drug and Alcohol Addiction Centers National Institute on Alcohol Abuse and Alcoholism National Institute on Alcohol Abuse and Alcoholism Fire and Police Departments Fire and Police Departments Worker’s Compensation Administration Worker’s Compensation Administration Crisis negotiation team Crisis negotiation team Homeless populations Homeless populations Needle Exchange Program Needle Exchange Program Claims/HMOs Claims/HMOs Clergy (ex: Hindu priests and priestesses) Clergy (ex: Hindu priests and priestesses) Judges/legal/police Judges/legal/police U.S. Army, Navy, Air Force, Marines, and National Guard U.S. Army, Navy, Air Force, Marines, and National Guard EAPs EAPs 22 Linking Systems Inpt  Bridge  Outpt Enables quicker response to those who need it due to precision of communication Counties…States…Countries

23. How the C-SSRS is Making an Impact… Linking Systems “The C-SSRS has made a big difference. Historically, the issue of lethality was “turfed out” to their psychologist. However, after the entire ACT team began using the C-SSRS, the discussions about suicide became more team wide and robust. Everyone was now providing observations and ideas about suicide risk management and wanting to take responsibility for client care. The greater clarity provided by the C-SSRS has been tremendously helpful” – OMH, NY 23

24. What A Medical Center Can Do: Organizational Vision/Top-Down Models 24 OncologistsResidentsPhysician Asst.GeriatricsCardiologyEmergency Orthopaedics PediatriciansNeurologyPTs/OTsPsychiatry NursesForensic Med. Administration Surgeons ObstetricsUrologistsInternal Medicine Policy: Nurse Screens, Worry of High Risk Among Patient, “Nurses Hotline”

25. Linking of Systems: Organizational Vision/Top-Down Models 25 Department Health & Mental Health First Responders and Crisis Lines Schools Hospitals Law Enforcement Justice Provider By Provider All ServicesBetween ServicesAll Systems of Care Policy at the state level, even legislation: ~30 States Linking Systems Inpt  Bridge  Outpt Precision of communication: enables quicker response to those who need it Rhode Island Senate Commission Hearing Report on ER Overuse: for State Wide Implementation “State wide coordination and implementation of an evidence-based tool and training for healthcare providers and first responders for determination of placement...critical in assisting those in the field with an additional tool for everyday use.” Primary Care

26. Endorsed by SAMHSA Center for Integrated Health Solutions The Joint Commission Leading Practice Library

27. 27 Also from CDC: “Unacceptable Terms” Completed suicide Failed attempt Parasuicide Successful suicide Suicidality Nonfatal suicide Suicide gesture Manipulative act Suicide threat CDC Self-Directed Violence: Uniform Definitions Adopted Columbia Definitions “The C-SSRS is changing the paradigm in suicide risk assessment in the US and worldwide” – Alex Crosby

28. 28 National Implementation Efforts in the Military/VA: The National Guard Psychological Health Program – CT PHA – all communications Air Force - Guide for the Management of Suicidal Behaviors Navy – Primary Care Marine Corps – “total force Rollout” use by all support workers (family advocacy workers, substance abuse specialists, victim advocates, attorneys, and chaplains ) Engaged in a collaborative empirical process while supporting simultaneous national implementation VA – Engaged in a collaborative empirical process while supporting simultaneous national implementation Already used or requested in 30-40 VA hospitals Army – Behavioral Health Data Platform Tri-Service – Inpatient/Outpatient 28

29. Military Medical Systems Medcom requires in ED Reccomendation to Tri-service Surgeon Generals for use in all treatment facilities 29 “There is literally no other suicide screening measure that has as much predictive capability of future suicidal behaviors, is feasible for executing in the real-world, and as immediately clinically useful in saving lives.” - Millard Brown

30. Intended use in all support workers: Intended use in all support workers: Family advocacy workers Family advocacy workers Substance Abuse Specialists Substance Abuse Specialists Victim Advocates Victim Advocates Attorneys Attorneys Chaplains Chaplains Mandated for use in Marine Corps Defense Services Mandated for use in Marine Corps Defense Services Force Preservation Force Preservation Train 16 installations including Okinawa Train 16 installations including Okinawa Suicides down 22% in 2014 and 64% in first quarter 2015. Suicides down 22% in 2014 and 64% in first quarter 2015. National Implementation Efforts in the Marines

31. 31 Top-Down Efforts Tennessee – “System-Wide Transformation” Policy of DOMH to use in all divisions and contract vendors  K-12 schools  Colleges, & Universities  Indian Health Services  Legal facilities  Hospitals  TN Suicide Prevention Network  Managed Care (statewide)  State Crisis Assessment Tool  Catholic Charities  Military facilities (The statewide adoption of the C-SSRS as the crisis assessment tool) “has catapulted a transformation of practices in TN by insuring professionals and family members who come in contact with an individual who may have thoughts of taking their own life receive the help they need before it is too late”

32. Centerstone TN reduces suicide rate by 65% 4 suicides in the past 10 months compared to 9 in the 10 months prior “as a multi-state behavioral health organization, we chose the C-SSRS as the tool used to screen and assess all individuals who enter our system. We have found it is the hinge pin of our Clinical Pathway for Suicide Prevention.” One of the Largest Providers of Behavioral Healthcare in the United States

33. 33 Recommendation: “Support the state wide coordination and implementation of an evidence based suicide/mental health assessment tool and training for Rhode Island healthcare providers and first responders for determination of placement in emergency department or alternative settings.” “…this recommendation would be critical in assisting those in the field with an additional tool for everyday use.”  Testimony by a Pawtucket police officer: “…the officer highlighted the important and timely decisions that law enforcement must make…the limited training that law enforcement often receives outside of the police academy was discussed and the importance of providing our first responders with the appropriate tools to assess an individual was identified as a necessary tool.” Rhode Island Senate Commission Hearing Report on ER Overuse: for State Wide Implementation

34. 34 State-Wide Dissemination Georgia Crisis and Access Line (GCAL) through Behavioral Health Link (BHL) Mobile Crisis Response Teams Community Hospitals providing designated beds Crisis Stabilization Units (CSU) provide walk-in psychiatric and counseling services in a center that is clinically staffed 24 hours per day, 7 days per week, to receive individuals in crisis. Crisis Apartments (in development) that provide an alternative to crisis stabilization units and hospitalization Assertive Community Treatment teams (ACT) that operate with fidelity to the Dartmouth ACT model. Intensive Case Management teams, comprising 10 full- time case managers per team, which coordinate treatment and support services and assist individuals with accessing community resources. Peer support Services Medicaid Projects for assistance in Transition from Homelessness (PATH) ***Anticipated large majority of hospitalizations can be avoided Forensic services Case Management service providers that coordinate treatment and support services and help maintain services and supports already in place. Supported housing services Supported employment services Core services provided through core providers Physician Assessment & Care Diagnostic Assessment Behavioral Health Assessment Group Counseling/Training Family Counseling/Training Community Support Service Plan Development Crisis Intervention Individual Counseling Psychological Testing Nursing Assessment & Care Medication Administration Prevention Services such as Suicide Prevention Policy

35. A COMPREHENSIVE SUICIDE PREVENTION INITIATIVE FOR GEORGIA’S MENTAL HEALTH PROVIDERS “AIM” Assessment, Intervention and Monitoring 1.Introduced Statewide 2.Overview by Region and regional support 3.Policy development at state level 4.Provider by Provider implementation 5.Providers implement in all services, between services, and in systems of care Georgia DBHDD Implementation Plan

36. Texas: Zero Suicide Implementation Recommended tool for ”suicide safer care” endorsement from state for local mental health authorities Recommended tool for ”suicide safer care” endorsement from state for local mental health authorities Universal assessment process for access to the public mental health system (embedding C-SSRS IN EXISTING TOOLS) - CANS for kids and the ANSA tool for adults. Universal assessment process for access to the public mental health system (embedding C-SSRS IN EXISTING TOOLS) - CANS for kids and the ANSA tool for adults. Mobile crisis units and hotlines Mobile crisis units and hotlines Psychiatric Emergency Walk in Centers Psychiatric Emergency Walk in Centers Mobile Crisis Teams Mobile Crisis Teams Physical Health/ Behavioral Health Integrations projects Physical Health/ Behavioral Health Integrations projects Suicide Safer Schools Model system Suicide Safer Schools Model system 36

37. Utah “All in” Effort – so far… Association for Utah Community Health - Federally Qualified Health Centers Association for Utah Community Health - Federally Qualified Health Centers –Front line personnel and support staff –Street medicine/homeless outreach providers –Street medicine/homeless outreach providers University of Utah Department of Emergency Medicine - crisis and social work teams using C-SSRS and S&B Safety Plans. University of Utah Department of Emergency Medicine - crisis and social work teams using C-SSRS and S&B Safety Plans. Utah Division of Child and Family Services - all new child welfare caseworkers trained in screening, referral and safety planning Utah Division of Child and Family Services - all new child welfare caseworkers trained in screening, referral and safety planning Utah Commission on Criminal and Juvenile Justice Utah Commission on Criminal and Juvenile Justice –Statewide domestic violence sentencing and treatment guidelines. –Law enforcement, judges, prosecutors and state-contracted DV treatment providers Utah Domestic Violence Coalition Utah Domestic Violence Coalition –Promoting the C-SSRS at annual DV conference –Staff at state-contracted domestic violence shelters Utah Department of Commerce/Utah Trafficking in Persons Committee Utah Department of Commerce/Utah Trafficking in Persons Committee Utah Association of Domestic Violence Treatment Providers - contracted treatment providers providing court ordered treatment to individuals adjudicated on charges of cohabitant abuse. Utah Association of Domestic Violence Treatment Providers - contracted treatment providers providing court ordered treatment to individuals adjudicated on charges of cohabitant abuse. Unified Fire Authority - EMT/Paramedic and Fire Fighters. Unified Fire Authority - EMT/Paramedic and Fire Fighters. Utah Safety Net - 2014 Safety Net Conference workshop. Utah Safety Net - 2014 Safety Net Conference workshop. 37

38. Revolutionizing Policy and Care 38 New York State Suicide Prevention Initiative Eval of recent suicides all same picture: No good risk assessment, no safety plan, no warm hand-off Comprehensive systems approach to suicide prevention Organizational vision of zero suicides All Adult and Youth Behavioral Health Care organizations statewide *All patients* screened using C-SSRS C-SSRS and Safety Planning online learning modules to be used in training all staff

39. Public-Private Partnership: National Action Alliance – Toolkit for Zero Suicide 39

40. Making Suicide a “Never Event” at the Buffalo Psychiatric Center Clinicians use the tool as part of a comprehensive suicide risk assessment “The C-SSRS…has been a cornerstone of our efforts and has had a tremendous impact on our ability to change our ‘corner of the world.’” “This protocol was fully implemented in January of 2014 and we are overwhelmed with the results we have seen thus far. Since full implementation at the beginning of 2014, the Buffalo Psychiatric Center has not seen a completed suicide in any of its inpatients or outpatients” 40

41. 41 County-Wide Dissemination One Example: Lapeer County, Michigan Court workers Mental health workers K-12 school staff: teachers, bus drivers, cafeteria workers, etc. Clergy Law enforcement ER staff Child welfare workers Police Officers, Sheriff, Road Patrol, Village & State Troopers * All first responders: EMT, Fire Department, Police Officers, etc. “CompleteBlanketCoverage” *Especially critical in rural areas

42. Breaking the Silence… Israel Israel removing barriers built up over thousands of years removing barriers built up over thousands of years 2 nd and 3 rd generation survivors of Holocaust 2 nd and 3 rd generation survivors of Holocaust Ethiopians Ethiopians Jewish providers assessing Arab children Jewish providers assessing Arab children Guyana Guyana Hindu Women Hindu Women 42 Silenced By Culture

43. “Suicide Screening Tool to be Rolled Out in Rhode Island”: Released: March 20, 2012 “The scale is an easy way to save lives…Our staff have been trained by Dr. Posner, the creator of the C-SSRS, and have found it easy to use and effective. By tying it to our electronic health records, it becomes that much more streamlined into every day care.” New York State, Office of Mental Health “…the feeling is that the C-SSRS has separated the wheat from the chaff; it focuses attention where it needs to be. This easy to use instrument allows our clinicians to move ahead with confidence and we are similarly confident that we are providing them with the best technology available.” – OMH, NY Why is it Helpful? From the Ground… 43

44. “It (the C-SSRS) was able to show, for the first time, that behaviors beyond previous suicide attempts—such as self-injury or making preparations for an attempt—may be used as predictors of subsequent suicide attempts…It also was able to determine clinically meaningful points at which a person may be at risk for an impending suicide attempt, something that other scales have been unable to consistently determine.” - NIMH Science Update, Nov. 28, 2011 “Having a proven method to assess suicide risk is a huge step forward in our efforts to save lives…have established the validity of the C-SSRS. This is a critical step in putting this tool in the hands of health care providers and others in a position to take steps for safety” -Michael Hogan, Former Commissioner, New York State Office of Mental Health Prediction Leads to Prevention

45. National Council Magazine “Ultimately, the C- SSRS serves as an effective mobile crisis tool which gets to the right people at the right time and right place and helps to save lives and save public dollars.”

46. 46 Hope at last to break suicide's silence March 25, 2012 Kelly Posner, Ph.D., principal investigator for Columbia’s Center for Suicide Risk Assessment, earlier this month brought this information to Middle Tennessee, in a meeting of health professionals at Nashville’s Oasis Center for troubled teens, and a separate briefing with authorities at Fort Campbell.” Other methods that use imprecise terminology and have variable concepts of what constitutes suicidal behavior… often hinder communication about an individual that could prevent suicide.” The new system is gradually being implemented by the Army, Navy, Air Force and National Guard; by police and fire departments; drug and alcohol addiction centers; and public schools and colleges. Commentary on Article: “A leading cause of death"? I have my doubts about that assertion.” “Maybe in some third- world, oppressed countries - or among some teenagers, but certainly not in the US.” “Hope at last to break suicide's silence. I was not aware there was any.” -Retired Mental Health Editor “Suicide is very much preventable. I applaud the development of an instrument to help identify those in need of help…”

47. Simply…. 1-5 rating for suicidal ideation, of increasing severity (from a wish to die to an active thought of killing oneself with plan and intent) 1-5 rating for suicidal ideation, of increasing severity (from a wish to die to an active thought of killing oneself with plan and intent) Have you wished you were dead or wished you could go to sleep and not wake up? Have you wished you were dead or wished you could go to sleep and not wake up? Have you actually had any thoughts of killing yourself? Have you actually had any thoughts of killing yourself? If answer is “No” to both, no more questions on ideation Relevant behaviors assessed Relevant behaviors assessed All items include definitions for each term and standardized questions for each category are included to guide the interviewer for facilitating improved identification All items include definitions for each term and standardized questions for each category are included to guide the interviewer for facilitating improved identification Two Screen Questions for Ideation 47

48. 48 This is the Full C-SSRS Typical Administration Time=Few Minutes Screening Questions *If #1 and #2 are no, ideation section is done

49. *Minimum of 3 Questions *Max of 6 Questions If 2 yes, ask 3-6 This is the C-SSRS Screener If 2 is no, go to 6

50. Crisis Assessment Tool Risk Assessment page and screener for all crisis evaluations Risk Assessment page and screener for all crisis evaluations 50

51. 51 Research Supported Items Preparatory Behavior Preparatory Behavior –Those with recent preparatory behavior (e.g., collecting pills, razors, or loaded weapon) 8-10x more likely to die by suicide (Brown & Beck, unpublished) Interrupted Suicide Attempts Interrupted Suicide Attempts –3x more likely to die by suicide (Steer, Beck & Lester, 1988) Aborted Suicide Attempts Aborted Suicide Attempts –Subjects who made aborted attempts 2x as likely to have made a suicide attempt (Barber et al., 1998)

52. eC-SSRS...Depressed Subjects… ALL Behaviors Are Prevalent and Predictive.6%.8%.2% 98.6% No Behavior: 28,303 Actual Attempt: 70 Interrupted Attempt: 178 Aborted Attempt: 223 Preparatory Behavior: 71.2% n = 28,699 administrations Mundt et al., 2011 472 Interrupted, Aborted and Preparatory (87%) vs. 70 Actual Attempts (13%) 52 *Only 1.7% had any worrisome answer *Only.9% with ~50,000 administrations Each behavior is EQUALLY PREDICTIVE to an attempt Multiple behaviors = greater risk

53. 53 Data Supports Importance of Full Range: All Lifetime Suicidal Behaviors Predict Suicidal Behavior Behavior reported at baseline Patients not prospectively reporting suicidal behavior Patients prospectively reporting suicidal behavior Odds ratio of prospective suicidal behavior report (95% CI; ***p-values <.001) Actual Attempt522 (85.6 %)88 (14.4 %)4.56 (3.40 – 6.11)*** Interupted Attempt 349 (82.7 %)73 (17.3 %)5.28 (3.88 – 7.18)*** Aborted Attempt 461 (84.7 %)83 (15.3 %)4.75 (3.53 – 6.40)*** Preparatory Behavior 177 (81.2 %)41 (18.8 %)4.92 (3.38 – 7.16)*** A person reporting any one of the lifetime behaviors at baseline is ~5X more likely to prospectively report a behavior during subsequent follow-up

54. 54 Number of Different Lifetime Suicidal Behaviors Predict Suicidal Behavior Patients not prospectively reporting suicidal behavior N =3577 Patients prospectively reporting suicidal behavior N =201 Odds ratio of prospective suicidal behavior report (95% CI; ***p-values <.001) No Behaviors Reported at BL 2791 (97.3%)76 (2.7%)4.56 (3.40 – 6.11)*** One Behavior 345 (91.5 %)32 (8.5%)3.41 (2.22 – 5.23)*** Two Behaviors214 (84.3 %)40 (15.7%)6.86 (4.57 – 10.32)*** Three Behaviors 172 (81.5 %)39 (18.5 %)8.33 (5.50 – 12.62)*** Four Behaviors55 (79.7 %)14 (20.3 %)9.35 (4.98 – 17.54)*** Any type of lifetime behavior increases likelihood of future behavior by ~ 3.4 times and increases proportionally with increased number of different behaviors reported

55. 55 Patients not prospectively reporting suicidal behavior N =8489 Patients prospectively reporting suicidal behavior N = 348 Odds ratio of prospective suicidal behavior report (95% CI) Common Odds Ratios for prospectively reporting a suicidal behavior as a function of the ideational intensity scores *** p.05

56. 56 Screening Vets with C-SSRS: Only.17% Required Referral to More Acute Care Negative Screens: n=2948 (99.53%) Positive Screen without Hospitalization: n=9 (0.30%) Positive Screen needing Hospitalization: n=5 (0.17%) Only 14 out of 2962 screened positive (.47%) Only 14 out of 2962 screened positive (.47%) Only 5 (.17%) required more acute care Only 5 (.17%) required more acute care

57. 57 … systematically assessing using the C-SSRS decreases burden while improving detection 57

58. 58 Improved Identification with Decreased False Positives PHQ-9 Suicide Item: Thoughts that you would be better off dead or of hurting yourself in some way Outpatient Psychiatry Pilot – Self Report Computer Version (523 Encounters)  6.2% positive screen on C-SSRS vs.  23.8% endorsed item #9 of PHQ-9 Most, but not all, of the positive Columbia screen patients endorsed #9 of PHQ9 e.g. Cases were missed

59. C-SSRS vs. Open Ended Leads to Improved Detection Detected 29.7% of patients with suicidal ideation and 18.7% of patients w/ history of suicide attempt undetected by clinician interview (Bongiovi-Garcia et al., 2009 ). Telephone assessment w/ C-SSRS detected (59%) of suicide attempts compared to chart reviews (18%) (ED-SAFE study, Arias et al, 2014). 59

60. 60 Impact on Care Delivery and Service Utilization…

61. 6161 The Key to Triage… Operationalized Criteria for Next Steps Allows for setting parameters for triggering next steps whatever they may be (e.g. referral to mental health, one-to-one, etc.) Allows for setting parameters for triggering next steps whatever they may be (e.g. referral to mental health, one-to-one, etc.) –4 or 5 on recent ideation item to indicate need for immediate action –Decreases unnecessary referrals, interventions, etc. Provides the best available information to inform your clinical judgment Provides the best available information to inform your clinical judgment *In the past, people didn’t know what to manage, so they would hear any wish to die and intervene…

62. 62 Indicates Need for Next Step Thresholds for Next Steps…

63. 63 New York State Electronic Medical Record 4/5 past month OR behavior past 3 months = highest level “SUICIDE WARNING” 4/5 OR behavior ever = “SUICIDE HISTORY” – suicidal risk elevated Risk Info Travels

64. Easily Integrated into Existing Tools i.e. Nursing Mental Status Checklists 64 California corrections department spent approx. $24 million in 2010 on a suicide-watch program, which they believe could be cut in half by these methods

65. 65 Centerstone Alert and Monitoring System **Largest Provider of Behavioral Healthcare in the United States

66. 66 Thresholds facilitate identification of those at highest, triage, and care delivery 4/5  Psych consult 3  Consult to Care team (Reading Hospital Policy) Example: Streamlining Care in Hospital Policies

67. 67 This is the C-SSRS Screener with Triage Points with Triage Points (Inpatient Med/Surg)

68. Harvard Partners in Care Safety Assessment Population Health Management68

69. 69 Fort Carson Streamlining Identification, Triage & Care Delivery in the Military

70. 70 Fort Carson Military Screener

71. MedCom Screener with Triage Points 71 Streamlining Identification, Triage & Care Delivery in the Military

72. 72 SSI Total Score by Highest Level of Ideation on the C-SSRS SSI Total F (5,185) = 14.35, p<0.001 Currier, Brown & Stanley (2009)

73. 73 Data Confirmation… 4 and 5 Predicts Attempts in National Attempter Study (Posner et al., AJP December 2011) C-SSRS Lifetime Ideation, types 4 and 5, predicted suicide attempts in adolescent suicide attempters, followed over a year C-SSRS Lifetime Ideation, types 4 and 5, predicted suicide attempts in adolescent suicide attempters, followed over a year Beck SSI NOT predictive Beck SSI NOT predictive C-SSRS Lifetime Ideation, types 4 and 5, predicted actual, interrupted or aborted attempts on CSHF C-SSRS Lifetime Ideation, types 4 and 5, predicted actual, interrupted or aborted attempts on CSHF

74. 74 Confirmed by eC-SSRS data: 35,007 (3776 subjects) across depression, epilepsy, insomnia, fibromyalgia (Mundt et. al., JCP 2013) Patients with baseline prior ideation of 4 or 5 or prior behavior are 4-5x more likely to report suicidal behavior at follow up Patients with both are 9x more likely to report suicidal behavior Prediction in adolescent emergency department follow- up study (King et al) Duration predictive Attempt and lifetime attempt not predictive, reinforcing ideation assessment NSSI not predictive Prediction in Non-Suicidal Adults and Adolescents

75. 75 Decreased Unnecessary Intervention & Getting Care to Those Who Need It 75

76. Psychiatric Consultations for Suicide Attempts July, 2009 to June, 2011 (Reading Hospital) Feb 2010 **Economic crises/increases in unemployment worse than national average in Reading and Berks county area Feb 2011 After C-SSRS, # of psychiatric consults always stayed below rates before implementation “[The C-SSRS] allowed us to identify those at risk and better direct limited resources in terms of psychiatric consultation services and patient monitoring and it has also given us the unexpected benefit of identification of mental illness in the general hospital population which allows us to better serve our patients and our community.”

77. 77 Recommendation: “Support the state wide coordination and implementation of an evidence based suicide/mental health assessment tool and training for Rhode Island healthcare providers and first responders for determination of placement in emergency department or alternative settings.” “…this recommendation would be critical in assisting those in the field with an additional tool for everyday use.”  Testimony by a Pawtucket police officer: “…the officer highlighted the important and timely decisions that law enforcement must make…the limited training that law enforcement often receives outside of the police academy was discussed and the importance of providing our first responders with the appropriate tools to assess an individual was identified as a necessary tool.” Rhode Island Senate Commission Hearing Report on ER Overuse: for State Wide Implementation

78. The Problem in Schools: Who Do We Refer? 78 –Four hospitals: 61-97% of referrals did not require hospitalization. –NYC DOE: “The great majority of children & teens referred by schools for psych ER evaluation are not hospitalized & do not require the level of containment, cost & care entailed in ER evaluation.” “The great majority of children & teens referred by schools for psych ER evaluation are not hospitalized & do not require the level of containment, cost & care entailed in ER evaluation.” “Evaluation in hospital-based psych ER’s is costly, traumatic to children & families, and may be less effective in routing children & families into ongoing care.” “Evaluation in hospital-based psych ER’s is costly, traumatic to children & families, and may be less effective in routing children & families into ongoing care.” One Student sat 9 hours in a principal’s office waiting for EMT! New York City

79. Screening in Schools – The Solution 79 “City schools expand suicide training” (C-SSRS): “This enhanced service has made more appropriate referrals for students to see support staff in the school and referrals to community agencies as needed…” – Crain’s, NY 7/20/12 -38 middle schools/nurse delivery: an estimated 100+ students were identified that would have otherwise been missed, while dramatically reducing unnecessary referrals. 640 middle schools this year –then on to the High Schools 2 weeks after training Tennessee schools, “may have already saved a life, 9 year old with aborted suicide attempt.” 25% of teachers report being approached by an at-risk child

80. 80 Asking These Questions Protects Against Risk Policies now place more burden on universities to implement interventions to protect students from self-harm (Franke, 2004; Lake et al., 2002) “If a practitioner asked the questions... It would provide some legal protection” – Bruce Hillowe, mental health attorney specializing in malpractice litigation (Crain’s NY, 11/8/11) Implemented by national risk managers of The Doctor’s Company, a medical malpractice insurance company to be used by physician members “I believe it sets the standard…we take a proactive position in patient safety” – Patient Safety Risk Manager

81. Multiple Sources : Don’t Have to Rely on Individual’s Report Most of time person will give you relevant info, but when indicated…. Most of time person will give you relevant info, but when indicated…. Allows for utilization of multiple sources of information Allows for utilization of multiple sources of information –Any source of information that gets you the most clinically meaningful response (subject, family members/caregivers, records) 81

82. Examples… –A friend of a student comes to your office and reports that the student posted on Facebook that he has been feeling like he wants to die. –A loved one brings a family member into the ER. The patient denies suicidal thoughts, but the family member shares with you that the he has been talking about suicide for the past two weeks and wrote a note yesterday and that is why he is here in the ER. 82

83. 83 Suicide Attempt Definition There does not have to be any injury or harm, just the potential for injury or harm (e.g., gun failing to fire) There does not have to be any injury or harm, just the potential for injury or harm (e.g., gun failing to fire) Any “non-zero” intent to die – does not have to be 100% Any “non-zero” intent to die – does not have to be 100% Intent and behavior must be linked Intent and behavior must be linked A self-injurious act with at least some intent to die, as a result of the act

84. Inferring Intent Intent can sometimes be inferred clinically from the behavior or circumstances Intent can sometimes be inferred clinically from the behavior or circumstances –e.g., if someone denies intent to die, but they thought that what they did could be lethal, intent can be inferred –“Clinically impressive” circumstances; highly lethal act where no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of a high floor/story, setting self on fire, or taking 200 pills) 84 Importance of Inference

85. 85 As Opposed To Non-suicidal Self-injurious Behavior Engaging in behavior PURELY (100%) for reasons other than to end one’s life: Engaging in behavior PURELY (100%) for reasons other than to end one’s life: –Either to affect: Internal state (feel better, relieve pain etc.) - “self-mutilation” Internal state (feel better, relieve pain etc.) - “self-mutilation” - and/or - External circumstances (get sympathy, attention, make angry, etc.) External circumstances (get sympathy, attention, make angry, etc.)

86. 86 Suicidal Behavior May help to infer intent Important: Shows you did the appropriate assessment and decided it should not be called suicidal Shows you did the appropriate assessment and decided it should not be called suicidal

87. 87 Suicide Attempt? Yes or No The patient wanted to escape from her mother’s home. She researched lethal doses of ibuprofen. She took 6 ibuprofen pills and said she felt certain from her research that this amount was not enough to kill her. She stated she did not want to die, only to escape from her mother’s home. She was taken to the emergency room where her stomach was pumped and she was admitted to a psychiatric ward. 1. Yes 2. No 3. Not enough information

88. C-SSRS Feasibility Good Acceptance in Practice Millions of administrations Many thousands of settings Available in 116 languages All Gatekeepers Developing an app for phones/ipads, etc.  Ease of training: very scalable; Online via website or DVD (45 minutes); 18 min training video for screener;  Free to train and use 1,000 sites across the country overwhelming majority said “easy to incorporate”, “has improved safety”, “is beneficial” Patient Satisfaction Study at Cleveland Clinic: 80% felt electronic tablet was easy to use 98% did not think suicide screening increased thoughts of suicide 45% found that using tablet made reporting sensitive topics easier Age: the C-SSRS is suitable across the lifespan for use with adults, adolescents, and young children. Special Populations: indicated for cognitively impaired (e.g. Alzheimer's, Autism) Who can we use the C-SSRS with?

89. Innovative Delivery: Implementation by All Gatekeepers Examples of utilization: - Laminated cards - Metal key chains - Apps on phone - Portable printers in EMT By healthcare professionals: - Electronic records - Piece of paper in a chart - Phone kiosks Electronic delivery, automatic risk notification

90. eC-SSRS A Critical Piece of an Optimal Prevention Plan Coordinated data – like pilot, surgeon and anesthesiologist checklists Coordinated data – like pilot, surgeon and anesthesiologist checklists Computers and clinicians are complementary Computers and clinicians are complementary Widely deployed and proven to be low burden to patients and providers Widely deployed and proven to be low burden to patients and providers Scalability Scalability **FDA Best Practices Meeting for Meta-analyses – optimal solution for minimizing bias NY – Post Discharge Most at-risk time Can call from home NJ – Youth in Schools Summertime vulnerability Reduced burden on school personnel Veteran’s Administration Hospital

92. C-SSRS: Lifetime / Recent

93. 93 Capture all events and types of thoughts since last assessment: “Since I last saw you have you done anything…….had thoughts of…” Like Blood Pressure… Monitoring is Critical Recommended EVERY visit Recommended EVERY visit –You don’t want the time you didn’t ask to be the time you needed to ask

94. C-SSRS is a Component of Many National, State and Agency Policies and Procedures…Examples 94

95. CORRECTIONS SYSTEM NSW GUIDELINES FOR USING THE C-SSRS SUICIDE SCREENING TOOL 95

96. CATHOLIC HEALTH PARTNERS POLICY 96

97. Safe-T/C-SSRS Triage Tool for NYOMH for Psychiatric Care/Behavioral Health

98. 98 The C-SSRS can be Tailored to Address Population Specific Risk

99. Pediatric C-SSRS / Cognitively Impaired

100. Suicide Cluster - Schenectady County

101. Military Version 101

102. 102 Screening Programs are Successful High-school screening programs associated with 2x in detection of at-risk individuals (Scott et al., 2009) High-school screening programs associated with 2x in detection of at-risk individuals (Scott et al., 2009) Meta-analysis concluded that screening results in lower suicide rates in adults (Mann et al., JAMA 2005) Meta-analysis concluded that screening results in lower suicide rates in adults (Mann et al., JAMA 2005) Columbia Teen-Screen demonstrated 88% sensitivity and 76% specificity Columbia Teen-Screen demonstrated 88% sensitivity and 76% specificity College Screening Project - data suggest that screening brings high-risk students into treatment College Screening Project - data suggest that screening brings high-risk students into treatment – Only 1 suicide in 4 years post-screening vs. 3 suicides in 4 years pre-screening program (Haas et al., 2008) years pre-screening program (Haas et al., 2008) Elderly primary care screenings - 118% increase in rates of detection and diagnosis of depression (Callahan et al., 1996) Elderly primary care screenings - 118% increase in rates of detection and diagnosis of depression (Callahan et al., 1996) 102

103. 103 Working with all aspects of hospitals, systems, states and programs to develop and consult on implementation policies and plans Facilitating Implementation with Innovative Resources Helping Develop Alert and Monitoring Systems Ensuring Fidelity Integrating into Electronic Medical Records Providing a Menu of Options

104. Why it’s good to do one thing… Science and the Public Health Demand Uniformity (Gibbons, NCDEU 2010) Moving away from a single instrument inherently degrades the precision of the signal The impact of imprecision grows when incidence rates are low Multiple measures increase noise, decrease precision and weaken rigor of epidemiological and research data “It should be noted that the use of different instruments is likely to increase measurement variability…decreasing the opportunity to identify potential signals in future meta-analyses…this type of imprecision is particularly problematic in dealing with events that have a low incidence, as is the case for suicidal ideation and behavior occurring in clinical trials.” –2012 FDA Guidance

105. For questions and other inquiries, email The Center at: posnerk@nyspi.columbia.edu posnerk@nyspi.columbia.edu Website address for more information on the C-SSRS: http://www.cssrs.columbia.edu/ 105

106. 106

107. Public- Private Partnership: National Action Alliance – Zero Suicide Toolkit

108. ESSENTRIS Military Electronic Health Records 108 Retrospective chart review: 1500 cases admitted for suicide-related events to Walter Reed, 2001- 2006 11% admitted for serious suicidal ideation 12% with suicide attempt had no documentation of past suicide behaviors No suicide screening and/or assessment measure administered in a single case Study PI “strongly recommends that military providers be trained in the usage of a screening and/or assessment tool such as the C-SSRS”

109. We Need Reliable Tools 109 “ Research on suicide is plagued by many methodological problems… Definitions lack uniformity,…reporting of suicide is inaccurate…” Reducing Suicide Institute of Medicine 2002 “reliable diagnostic tools to screen for behavioral health issues (are needed).” General Chiarelli (retired US Army general who served as the 32 nd Vice Chief of Staff of the U.S. Army, forefront of suicide prevention efforts)

110. 110 C-SSRS in the Military & VA Walter Reed National Military Medical Center: “This scale is so helpful, especially in the military, when providers have to make very quick judgments.” “Assessors find the tool easy to use…and helpful in treatment approach with the patient.” Navy Medical Center, San Diego: “I am very impressed with how comprehensive and how well- conceptualized the scale is designed.” Tennessee Valley VA Healthcare System: “Valuable tool to ensure that necessary steps were taken to safeguard an individual or return them back home with support. It can help avoid unnecessary hospitalization or save a life.” John D. Dingell VA Medical Center: “I am impressed with the increased quality of the C-SSRS in assessing this area in patients and feel it would serve our Veteran better in this area.” “to tease out those who have serious suicidal ideations from those who say they are suicidal…”

111. 111 Department of Defense and the Department of Veterans Affairs Require the CDC- adopted Columbia Definitions

112. Ft. Carson: Community Model On-Post BH Providers in Schools BH Providers in Schools Non-hospital Soldier assessment and care agencies Non-hospital Soldier assessment and care agencies Off-Post Outpatient BH Clinics Outpatient BH Clinics Hospital Screening Hospital Screening

113. 113 C-SSRS Uses in the Military/VA C-SSRS used among active military personnel and veterans for a myriad of populations and interventions: PTSD MDD Treatment Resistant MDD TBI Alcohol/Substance Abuse Bipolar disorder Schizophrenia Suicide Suicide risk tracking, prevention & treatment Group Intervention for OEF/OIF TBI Survivors & Families Over 40,000 active and veteran military personnel will be enrolled in studies using the C-SSRS for various indications Over 40,000 active and veteran military personnel will be enrolled in studies using the C-SSRS for various indications One Study – 7,000 Schizophrenia/Schizoaffective – VA clients One Study – 7,000 Schizophrenia/Schizoaffective – VA clients Self-Injury component of the Army Study to Assess Risk and Resilience in Service Members (Army STARRS) Self-Injury component of the Army Study to Assess Risk and Resilience in Service Members (Army STARRS) –Epidemiologic study of mental health, psychological resilience, suicide risk, suicide-related behaviors, and suicide deaths in the U.S. Army –Largest study of suicide and mental health among military personnel ever undertaken –One of a series of efforts by the Army aimed at reducing the rate of suicide among its soldiers –The Army STARRS study includes soldiers from all phases of Army service

114. 114 Scope of Suicide Among College Students Estimated to be the 2 nd leading cause of death Greater than all alcohol-related deaths 1100 suicides per year; 80% male 1-2% report suicide attempt in the past year 7-10% report serious suicidal ideation in the past year 55% of college students report having at least one suicidal thought in their life. Highest among seniors and graduate students ACHA- NCHA II, 2011; APHA, 2011; Centers for Disease Control and Prevents, 2009; National Survey of College Counseling, 2012, Drum et al., 2009

115. Step 1: Using the C-SSRS in their Mental Health Center Step 2: Training other important staff to use the screener –Student Life –Safety and Ambulance Corps –Coaches Step 3: Screening incoming freshmen 115

116. Complete Coverage for a School Community Marysville, Washington 116 Department of Education Community Providers Clinical Training Parent Meetings & Training School Staff Screening Training Student Health Assemblies and School-wide Screening Administration Training Nurses and Guidance Training Linking Systems Precision of communication enables quicker identification and response to those who need it Linking Systems Precision of communication enables quicker identification and response to those who need it

117. Pockets of Prevention: Isolated Systems 117 Prisons in New South Wales Australia DOC Wisconsin Community Colleges in California Primary Care in Maine Police in Rhode Island Juvenile Justice in New Jersey Hospitals in France

118. What Justice Can Do: Organizational Vision/Top-Down Models 118 Department of Corrections MH WorkersCrisis HotlinePrisonsWardenAdmin. Department of Corrections/Corrective Services, Community Health Association, Department of Emergency Medicine, Division of Child/Family Services, Commission on Criminal and Juvenile Justice, Domestic Violence Coalition, Association of Domestic Violence Treatment Providers Case Officer Immediate Response Settings, Intervention Settings, Community Settings Local Jails LawyersJudges Police Probation Off.Guards Parole OfficerForensics EMTs

119. Columbia-Suicide Severity Rating Scale (C-SSRS) Developed in NIMH attempter trial to uniquely address need for summary measures – 1 st scale to assess full range of ideation and behavior Developed in NIMH attempter trial to uniquely address need for summary measures – 1 st scale to assess full range of ideation and behavior Developed by many leading experts - collaboration with Beck’s group Developed by many leading experts - collaboration with Beck’s group Extensively international use across research, clinical and institutional settings Extensively international use across research, clinical and institutional settings Several million administrations Several million administrations Available in 116 languages Available in 116 languages Very brief administration time Very brief administration time Extremely sensitive and specific Extremely sensitive and specific Excellent feasibility – no mental health training required to administer Excellent feasibility – no mental health training required to administer 812 nurses, 99% reliability independent of MH training or education 812 nurses, 99% reliability independent of MH training or education excellent reliability in juvenile justice use by non-clinicians – Kerr, 2014 excellent reliability in juvenile justice use by non-clinicians – Kerr, 2014 Front line responders to clergy Front line responders to clergy Systematic use of C-SSRS shown to decrease burden compared to other methods or doing nothing Systematic use of C-SSRS shown to decrease burden compared to other methods or doing nothing Posner, K.; Brent, D.; Lucas, C.; Gould, M.; Stanley, B.; Brown, G.; Zelazny, J.; Fisher, P.; Burke, A.; Oquendo, M.; Mann, J.

120. Suicide: A Major Public Health Crisis Every 40 sec. worldwide and every 13 minutes in the US someone dies by suicide in the U.S. Every 40 sec. worldwide and every 13 minutes in the US someone dies by suicide in the U.S. 2 nd leading cause of death in youth 10-24 passing homicide for the first time in last decade 2 nd leading cause of death in youth 10-24 passing homicide for the first time in last decade 8-14 y.o. - from lowest point in 2007 more than doubled by 2013 8-14 y.o. - from lowest point in 2007 more than doubled by 2013 #1 cause of injury mortality in U.S.; more people die by suicide than motor vehicle crashes #1 cause of injury mortality in U.S.; more people die by suicide than motor vehicle crashes Within corporation of 100,000 employees (average of 4 blood relatives per employee) Every 7 days, one employee or family member will die by suicide 4 th leading cause of death: adults 4 th leading cause of death: adults 1 st or 2 nd leading cause of death in law enforcement officers 1 st or 2 nd leading cause of death in law enforcement officers –In 2011, nearly 3x as many policepersons died by suicide as were killed in the line of duty –Rate comparable to that in US Army Most common cause of death in incarcerated persons Most common cause of death in incarcerated persons –Suicide rates 3x general population –~60% of inmate suicides have no psychiatric illness & no clear warning signs 8% of average high schoolers attempt every year 8% of average high schoolers attempt every year “The under-recognized public health crisis of suicide”- Thomas Insel, Director of NIMH Suicide is a preventable public health problem – prevention efforts depend upon appropriate identification and screening..

121. 121 On the Road to Suicide Prevention- On the Road to Suicide Prevention- When a Community Comes Together There is Hope Looking Forward to a Zero Suicide Community Through Identification with the C-SSRS Kelly Posner, Ph.D. Principal Investigator Columbia/FDA Classification Project for Drug Safety Analyses Principal Investigator Center for Suicide Risk Assessment Columbia University 121

122. On the Road to Prevention: When a Community Comes Together There is Hope Increasing Detection, Improving Care Delivery and Redirecting Scarce Resources Kelly Posner, Ph.D. Principal Investigator Columbia/FDA Classification Project for Drug Safety Analyses Principal Investigator Center for Suicide Risk Assessment Columbia University

123. Former Deputy Secretary US Dept. of Ed. - James Shelton “I often think of how many lives could have been saved literally and figuratively (with these questions) If implemented to the extent of its capacity across the country, we have the potential to keep the 64 million children in our schools safe physically and mentally by helping prevent school violence.”

124. Former Deputy Secretary US Dept. of Ed. - James Shelton “We still lose too many young people each year to suicide; and the reports of suicidal students taking the lives of others as they seek escape have shaken the psyche of the nation. “I often think of how many lives could have been saved literally and figuratively had C-SSRS been in the growing number of communities suffering from in school shootings. After the Navy Yard shootings, I wrote to Dr. Posner and her team, thanked her for her work to date and asked what it would take to make it ubiquitous so we could stem this unnecessary loss of life. If implemented to the extent of its capacity across the country, the C-SSRS has the potential to keep the 64 million children in our schools safe physically and mentally by helping prevent school violence.”

125. Police Force 1 st or 2 nd leading cause of death of law enforcement officers alongside car accidents In 2012, almost as many died by suicide as were killed in the line of duty The rate of police suicide is comparable to the US Army Rates ) Corrections Most common cause of death in correctional facilities US prisons and jails, rate of suicide is close to three times that of general pop Many within first 24 hours Nearly 60% have no psychiatric illness & no clear warning signs Incarcerated youth: 37% report a suicide attempt A CRISIS Everywhere…from Police to Corporations

126. Sufficiency of Research Funding Given Disease Burden 126 Tuberculosis +89M$ Breast Cancer +258M$ Diabetes +390M$ AIDS $2474M In 2006, depression and injuries were the most underfunded health issues based on disease burden. (Gillum et al. 2011) Depression -719M$ Injuries -691M$

127. C-SSRS implemented in a “total force roll out” in the Marines C-SSRS implemented in a “total force roll out” in the Marines For all support workers: For all support workers: Victim Advocates Victim Advocates Attorneys Attorneys Chaplains Chaplains Installed at 16 installations, including Okinawa Installed at 16 installations, including Okinawa Marine suicides down 22% Marine suicides down 22% Active-duty Marines’ suicides during the first quarter of the year decreased 64% Marines “Total Force Roll Out” 127

128. 75 US Mass Shootings since Sandy Hook – Dec 2012 128