physicians suicide awareness training

8/8/2019 Physicians Suicide Awareness Training

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Saving Lives:Saving Lives:Understanding Depression And PreventingUnderstanding Depression And PreventingSuicideSuicide Prevention Training For PhysiciansPrevention Training For Physicians

and Medical Personneland Medical Personnel

The Ohio Suicide Prevention FoundationThe Ohio Suicide Prevention Foundation

Developed by Ellen J. Anderson, Ph.D., LPCC, 2004Developed by Ellen J. Anderson, Ph.D., LPCC, 2004--20062006


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Physicians Awareness TrainingPhysicians Awareness Training 22

Still the effort seems unhurried. Every 17Still the effort seems unhurried. Every 17minutes in America, someone commitsminutes in America, someone commits

suicide. Where is the public concern andsuicide. Where is the public concern and

outrage?outrage?

Kay Redfield JamisonKay Redfield Jamison

Author ofAuthor ofNight Falls Fast: UnderstandingSuicideNight Falls Fast: UnderstandingSuicide


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Training GoalsTraining Goals

Learn about local suicide prevention efforts, how theseLearn about local suicide prevention efforts, how theseefforts connect with your practice and patientsefforts connect with your practice and patients

Understand the pivotal role of medical personnel in theUnderstand the pivotal role of medical personnel in thetreatment of depressed patients and in reducing suicidetreatment of depressed patients and in reducing suicideriskrisk

Increase awareness of suicide risk characteristics inIncrease awareness of suicide risk characteristics inpatients who may not present as depressed/suicidalpatients who may not present as depressed/suicidal

Learn a brief suicide risk assessment modelLearn a brief suicide risk assessment model

Learn to ask the S questionLearn to ask the S question


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Why Do We Need To Improve SuicideWhy Do We Need To Improve SuicidePrevention Efforts?Prevention Efforts?

Suicide is the last tabooSuicide is the last taboo

We can talk about sex, alcoholism, cancer, but not suicideWe can talk about sex, alcoholism, cancer, but not suicide

People need to understand the impact of depression andPeople need to understand the impact of depression and

other mental illnesses, and how they lead to suicideother mental illnesses, and how they lead to suicide Suicide is a preventable deathSuicide is a preventable death

Integrating medical staff into the efforts of suicide preventionIntegrating medical staff into the efforts of suicide preventioncoalitions to reduce deaths, increase awareness, and reducecoalitions to reduce deaths, increase awareness, and reduce

stigma seems critical to local, state, and national efforts tostigma seems critical to local, state, and national efforts tochange our approach to this agechange our approach to this age--old problemold problem


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Changing Our Approach:Changing Our Approach:

Depression Is AnDepression Is AnIllnessIllness

Suicide has been viewed for countless generationsSuicide has been viewed for countless generationsas:as:

A moral failing, a spiritual weaknessA moral failing, a spiritual weakness An inability to cope with lifeAn inability to cope with life

The cowards way outThe cowards way out

A character flawA character flaw

This cultural view of suicide is not validated by ourThis cultural view of suicide is not validated by ourcurrent understanding of brain chemistry and itscurrent understanding of brain chemistry and itsinteraction with stress, trauma and genetics on moodinteraction with stress, trauma and genetics on moodand behaviorand behavior


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The research evidence is overwhelmingThe research evidence is overwhelming-- what we think ofwhat we think of

as depression is far more than a sad mood. It includes:as depression is far more than a sad mood. It includes:

1. Weight gain/loss2. Sleep problems

3. Sense of tiredness, exhaustion

4. Sad mood

5. Loss of interest in pleasurable things, lack of motivation

6. Irritability

7. Confusion, loss of concentration, poor memory

8. Negative thinking

9. Withdrawal from friends and family

10. Sometimes, suicidal thoughts(DSMIVR, 2002)(DSMIVR, 2002)


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20 years of brain research teaches that what we20 years of brain research teaches that what weare seeing is theare seeing is the behavioralbehavioral result of:result of:

InternalInternal changes in the physical structure of thechanges in the physical structure of thebrainbrain

Destruction or shutting down ofbrain cells inDestruction or shutting down ofbrain cells inthe hippocampus and amygdalathe hippocampus and amygdala

Decrease in neurotransmittersDecrease in neurotransmittersincreased agitation in the limbic systemincreased agitation in the limbic system

Depressed people suffer from a physical illnessDepressed people suffer from a physical illnesswithin the brainwithin the brain what we might considerwhat we might consider

faulty wiringfaulty wiring(Braun, 2000; Surgeon Generals Call To Action, 1999,(Braun, 2000; Surgeon Generals Call To Action, 1999, Stoff & Mann,Stoff & Mann,

1997, The Neurobiology of Suicide)1997, The Neurobiology of Suicide)


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Faulty Wiring?Faulty Wiring?

Literally, damage to certain nerve cells in our brainsLiterally, damage to certain nerve cells in our brains The result of too many stress hormonesThe result of too many stress hormones cortisol, adrenaline andcortisol, adrenaline and

testosteronetestosterone

Hormones activated by ourHormones activated by our AAutonomicutonomic NNervouservous SSystem toystem to

protect us in times of dangerprotect us in times of danger Chronic stress causes changes in the functioning of theChronic stress causes changes in the functioning of the

ANS, so that a high level of activation occurs with littleANS, so that a high level of activation occurs with littlestimulusstimulus

C

auses changes in muscle tension, imbalances in bloodC

auses changes in muscle tension, imbalances in bloodflow patterns leading to illnesses such as asthma, IBS, backflow patterns leading to illnesses such as asthma, IBS, backpain and depressionpain and depression

(Goleman, 1997, Braun, 1999)(Goleman, 1997, Braun, 1999)


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Faulty Wiring?Faulty Wiring?

Without a way to return to rest, hormonesWithout a way to return to rest, hormonesaccumulate, doing damage to brain cellsaccumulate, doing damage to brain cells

Stress alone is not the problem, but how weStress alone is not the problem, but how weinterpret the event, thought or feelinginterpret the event, thought or feeling

People withPeople with genetic predispositionsgenetic predispositions, placed in a, placed in a

highlyhighlystressful environmentstressful environmentwill experiencewill experience

damage to brain cells from stress hormonesdamage to brain cells from stress hormones

This leads to the cluster ofThis leads to the cluster ofthinking andthinking andemotional changesemotional changeswe call depressionwe call depression(Goleman, 1997; Braun, 1999)(Goleman, 1997; Braun, 1999)


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Where It Hits UsWhere It Hits Us


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One of Many NeuronsOne of Many Neurons

Neurons make up the brain and

cause us to think, feel, and actNeurons must connect to one

another (through dendrites andaxons)

Stress hormones damage dendrites

and axons, causing them to

shrink away from otherconnectors

As fewer connections are made,

more and more symptoms of

depression appear


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As damage occurs, thinking changes in the predictableAs damage occurs, thinking changes in the predictable

ways identified in our 10 criteriaways identified in our 10 criteria

Thought constriction can lead to the idea thatThought constriction can lead to the idea that

suicide is the only optionsuicide is the only option

How do antidepressants affect this brain damage?How do antidepressants affect this brain damage?

May counter the effects of stress hormonesMay counter the effects of stress hormones

We know now that antidepressants stimulate genesWe know now that antidepressants stimulate geneswithin the neurons (turn on growth genes) whichwithin the neurons (turn on growth genes) which

encourage the growth of new dendritesencourage the growth of new dendrites

(Braun, 1999)(Braun, 1999)


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Renewed dendrites:Renewed dendrites:

increase the number of neuronal connectionsincrease the number of neuronal connections

allow our nerve cells to begin connecting againallow our nerve cells to begin connecting again

The more connections, the more informationThe more connections, the more information

flow, the more flexibility and resilience the brainflow, the more flexibility and resilience the brain

will havewill have

Why does increasing the amount of serotonin, asWhy does increasing the amount of serotonin, as

many antimany anti--depressants do, take so long to reducedepressants do, take so long to reduce

the symptoms of depression?the symptoms of depression? It takes 4It takes 4--6 weeks to re6 weeks to re--grow dendrites & axonsgrow dendrites & axons

(Braun, 1999)(Braun, 1999)


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Why Dont We Seek Treatment?Why Dont We Seek Treatment?

We dont know we are experiencing a brainWe dont know we are experiencing a braindisorderdisorder we dont recognize the symptomswe dont recognize the symptoms

When we talk to doctors, we are vague aboutWhen we talk to doctors, we are vague aboutsymptomssymptoms

We believe the things we are thinking andWe believe the things we are thinking andfeeling are our fault, our failure, our weakness,feeling are our fault, our failure, our weakness,

not an illnessnot an illnessWe fear being stigmatized at work, at church, atWe fear being stigmatized at work, at church, at

schoolschool


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No Happy Pills For MeNo Happy Pills For Me

The stigma around depression leads to refusal ofThe stigma around depression leads to refusal of

treatmenttreatment

Taking medication is viewed as a failure by theTaking medication is viewed as a failure by thesame people who cheerfully take their bloodsame people who cheerfully take their bloodpressure or cholesterol medspressure or cholesterol meds

Medication is seen as altering personality, takingMedication is seen as altering personality, takingsomething away, rather than as repairing damagesomething away, rather than as repairing damage

done to the brain by stress hormonesdone to the brain by stress hormones


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Therapy? Are You Kidding? I DontTherapy? Are You Kidding? I Dont

Need All That WooNeed All That Woo--Woo Stuff!Woo Stuff! How can patients seek treatment for somethingHow can patients seek treatment for something

they believe is a personal failure?they believe is a personal failure?

Acknowledging the need for help is not popularAcknowledging the need for help is not popularin our culture (Strong Silent type, Cowboy)in our culture (Strong Silent type, Cowboy)

People who seek therapy may be viewed as weakPeople who seek therapy may be viewed as weak

Therapists are viewed as crazyTherapists are viewed as crazyTheyll just blame it on my mother or someTheyll just blame it on my mother or some

other stupid thingother stupid thing


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How Does Psychotherapy Help?How Does Psychotherapy Help?

Medications may improve brain function, but do not change howMedications may improve brain function, but do not change howwewe interpretinterpret stressstress

Psychotherapy, especially cognitive or interpersonal therapy, helpsPsychotherapy, especially cognitive or interpersonal therapy, helpspeople change the (negative) patterns of thinking that lead topeople change the (negative) patterns of thinking that lead to

depressed and suicidal thoughtsdepressed and suicidal thoughts

Research shows that cognitive psychotherapy is as effective asResearch shows that cognitive psychotherapy is as effective asmedication in reducing depression and suicidal thinkingmedication in reducing depression and suicidal thinking

Changing our beliefs and thought patterns alters our response toChanging our beliefs and thought patterns alters our response tostressstress we are not as reactive or as affected by stress at thewe are not as reactive or as affected by stress at the

physical levelphysical level (Lester, 2004)(Lester, 2004)


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What Therapy?What Therapy?

The standard of care is medication andThe standard of care is medication and

psychotherapy combinedpsychotherapy combined

At this point, only cognitive behavioral andAt this point, only cognitive behavioral andinterpersonal psychotherapies are considered tointerpersonal psychotherapies are considered tobe effective with clinical depression (evidencebe effective with clinical depression (evidence--

based)based)

Doctors should make referrals to a cognitive orDoctors should make referrals to a cognitive or

interpersonal therapistsinterpersonal therapists


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Yet most people do not understand the physicalYet most people do not understand the physical

aspects of mental illness, as you have no doubtaspects of mental illness, as you have no doubtfound in talking with your patientsfound in talking with your patients

Suicide is strongly linked with certain mentalSuicide is strongly linked with certain mental

illnesses, and most people do not understand thisillnesses, and most people do not understand thisconnectionconnection

Your county Suicide Prevention Coalition isYour county Suicide Prevention Coalition isattempting toattempting to Reduce the stigmaReduce the stigma attached toattached tomental illness, increasemental illness, increase helphelp--seeking behaviorseeking behavior, and, andincrease awareness of the consequencesincrease awareness of the consequences ofof

untreated depressionuntreated depression


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Suicide Prevention EffortsSuicide Prevention Efforts

First national effort established at NIMH in 1969First national effort established at NIMH in 1969

Surgeon General issued a call to action to preventSurgeon General issued a call to action to preventsuicide in 1999suicide in 1999

In 2001, a National Strategy for Suicide PreventionIn 2001, a National Strategy for Suicide PreventionCommittee developed future goals and objectivesCommittee developed future goals and objectives

An Ohio Suicide Prevention Plan was developed inAn Ohio Suicide Prevention Plan was developed inMay, 2002, and grants for local coalitions were givenMay, 2002, and grants for local coalitions were givenout in November of 2002out in November of 2002


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Development OfDevelopment Of

Prevention EffortsPrevention Efforts Over the past 20 years, we have acquired valuableOver the past 20 years, we have acquired valuable

information on risk and protective factors, methods forinformation on risk and protective factors, methods for

preventing suicidal behavior, and improved researchpreventing suicidal behavior, and improved researchmethodsmethods

An increase in suicide prevention programs in schoolsAn increase in suicide prevention programs in schools

The rapid development of suicidology as aThe rapid development of suicidology as a

multidisciplinary submultidisciplinary sub--specialtyspecialty

Establishment of centers for the study and prevention ofEstablishment of centers for the study and prevention ofsuicidesuicide


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Framework For PreventionFramework For Prevention

Public health approach to prevention in contrast toPublic health approach to prevention in contrast toclinical approaches used in the pastclinical approaches used in the past

The prevailing model is the Universal, Selective, andThe prevailing model is the Universal, Selective, andIndicated model (WHO, 2002)Indicated model (WHO, 2002)

Focuses attention on defined populations, fromFocuses attention on defined populations, fromeveryone, to specific ateveryone, to specific at--risk groups, to specific highrisk groups, to specific high--riskriskindividualsindividuals


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8989 people complete suicide every daypeople complete suicide every day

32,43932,439 people in 2004 in the USpeople in 2004 in the US

OverOver 1,000,0001,000,000 suicides worldwide (reported)suicides worldwide (reported)This data refers to completed suicides that areThis data refers to completed suicides that are

documented by medical examinersdocumented by medical examiners it isit isestimated that 2estimated that 2--3 times as many actually3 times as many actuallycomplete suicidecomplete suicide

(Surgeon Generals Report on Suicide, 1999)(Surgeon Generals Report on Suicide, 1999)

Is Suicide Really a Problem?Is Suicide Really a Problem?


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The Unnoticed DeathThe Unnoticed Death

For every 2 homicides, 3 people completeFor every 2 homicides, 3 people completesuicide yearlysuicide yearly data that has been constantdata that has been constant

for 100 yearsfor 100 yearsDuring the Viet Nam War from 1964During the Viet Nam War from 1964--

1972, we lost 55,000 troops, and 220,0001972, we lost 55,000 troops, and 220,000

people to suicidepeople to suicide


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Who Is At Risk?Who Is At Risk?

Most people assume young peopleMost people assume young people

are more likely to complete suicide,are more likely to complete suicide,

It is the 3It is the 3rdrd largest killer of youth ages 15largest killer of youth ages 15--2424

Adult malesAdult males fromfrom 3535--5555 actually complete suicideactually complete suicideat a far greater rate than youthat a far greater rate than youth

The elderly are at significant risk; among thoseThe elderly are at significant risk; among those

over 75, 1 out of 4 attempts end in death becauseover 75, 1 out of 4 attempts end in death becausethe elderly tend to use more lethal meansthe elderly tend to use more lethal means(Surgeon Generals call to Action, 1999)(Surgeon Generals call to Action, 1999)


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Comparative Rates Of U.S. SuicidesComparative Rates Of U.S. Suicides--20042004

Rates per 100,000 populationRates per 100,000 population National averageNational average -- 11.1 per 100,000*11.1 per 100,000*

White malesWhite males - - 1818

Hispanic malesHispanic males -- 10.310.3

AfricanAfrican--American males American males -- 9.1 **9.1 **

Asians Asians -- 5.25.2

Caucasian femalesCaucasian females -- 4.84.8

African American females African American females -- 1.51.5

Males over 85Males over 85 -- 67.667.6

Annual AttemptsAnnual Attempts 811,000 (estimated)811,000 (estimated) 150150--1 completion for the young1 completion for the young -- 44--1 for the elderly1 for the elderly

(*AAS website),**(Significant increases have occurred among African Americans in the(*AAS website),**(Significant increases have occurred among African Americans in the

past 10 yearspast 10 years -- Toussaint, 2002)Toussaint, 2002)


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Suicide Rate By Age Per 100,000Suicide Rate By Age Per 100,000

0%

5%

10%

15%

20%

25%

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age

%S

uicideper100,0

00

Older people: 12.7% of 1999 population, but 18.8% of suicides.(Hovert, 1999)


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Suicide Rates Among The ElderlySuicide Rates Among The Elderly

The elderly have the highest suicide rate of any group.The elderly have the highest suicide rate of any group.

Depression in late life affects six million people, one out of six patientsDepression in late life affects six million people, one out of six patients

in a general medical practicein a general medical practice

However, only one of those six patients is diagnosed and treatedHowever, only one of those six patients is diagnosed and treatedappropriatelyappropriately

The majority of these people have seen their primary care physicianThe majority of these people have seen their primary care physician

within the last month of lifewithin the last month of life

There is evidence that the majority of elderly suicide victims die in theThere is evidence that the majority of elderly suicide victims die in the

midst of theirmidst of their first episodefirst episode of major depressionof major depression

Depression is not a normal consequence of aging and can alter theDepression is not a normal consequence of aging and can alter the

course of other medical conditionscourse of other medical conditions(Empfield, 2003)(Empfield, 2003)


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PCPs And Diagnosis Of DepressionPCPs And Diagnosis Of Depression

Seniors have often visited a healthSeniors have often visited a health--care provider beforecare provider beforecompleting suicidecompleting suicide

20% of elderly (over 65 years) who complete suicide visited a20% of elderly (over 65 years) who complete suicide visited aphysician within 24 hoursphysician within 24 hours

41% within a week41% within a week

75% within one month75% within one month

Patients may not use the words depression or sadnessPatients may not use the words depression or sadness

Because of the stigma that is still attached to this diagnosis,Because of the stigma that is still attached to this diagnosis,somatic symptoms may become the focus of complaintsomatic symptoms may become the focus of complaint

There may be much denial and minimizing of affectiveThere may be much denial and minimizing of affectivesymptomssymptoms

(Empfield, 2003)(Empfield, 2003)


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Poor Quality Of Mental Health CarePoor Quality Of Mental Health Care

For EldersFor Elders

Increased risk for inappropriate medicationIncreased risk for inappropriate medicationtreatmenttreatment (Bartels, et al., 1997, 2002)(Bartels, et al., 1997, 2002)

> 1 in 5 older persons given an inappropriate> 1 in 5 older persons given an inappropriateprescriptionprescription (Zhan, 2001)(Zhan, 2001)

The elderly are less likely to be treated withThe elderly are less likely to be treated withpsychotherapypsychotherapy(Bartels, et al., 1997)(Bartels, et al., 1997)

Lower quality of general health care is associatedLower quality of general health care is associatedwith increased mortalitywith increased mortality

(Druss, 2001)(Druss, 2001)


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Depression Associated With WorseDepression Associated With WorseHealth OutcomesHealth Outcomes

Depression is common among older patients with certainDepression is common among older patients with certainmedical disordersmedical disorders

Associated with worse health outcomesAssociated with worse health outcomes

Greater use and costs of medicationsGreater use and costs of medications Greater use of health servicesGreater use of health services

Medical illness greatly increasesMedical illness greatly increases the risk for depressionthe risk for depressionparticularly in:particularly in:

Ischemic heart disease (e.g. MI, CABG)Ischemic heart disease (e.g. MI, CABG)

Stroke Cancer Chronic lung disease AlzheimerStroke Cancer Chronic lung disease Alzheimers diseases diseaseParkinsonParkinsons diseases disease

Rheumatoid ArthritisRheumatoid Arthritis (Empfield, 2003(Empfield, 2003))


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In Cancer, depression leads toIn Cancer, depression leads to

Increased HospitalizationIncreased HospitalizationPoorer physical functionPoorer physical function

Poorer quality of lifePoorer quality of life

Poorer pain controlPoorer pain control

Increased mortality rates forIncreased mortality rates for Hip fracturesHip fractures

Long Term Care ResidentsLong Term Care Residents

Myocardial InfarctionMyocardial Infarction

In heart attack patients, depression is a significantIn heart attack patients, depression is a significantpredictor of death at 6 monthspredictor of death at 6 months

( Frasure( Frasure--Smith 1993, 1995; Mossey 1990; Penninx et al. 2001; Katz 1989,Smith 1993, 1995; Mossey 1990; Penninx et al. 2001; Katz 1989,

Rovner 1991, Parmelee 1992;Ashby1991; Shah 1993, Samuels 1997)Rovner 1991, Parmelee 1992;Ashby1991; Shah 1993, Samuels 1997)


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Rates Of DepressionRates Of DepressionAmong Elders With IllnessAmong Elders With Illness

Cognitively intact nursing home patients shown toCognitively intact nursing home patients shown tohave symptoms consistent with depressivehave symptoms consistent with depressive

disordersdisorders 60%60%

Chronically ill outpatients in a primary careChronically ill outpatients in a primary carepracticepractice -- 25%25%

Hospitalized patientsHospitalized patients -- 20%20%

In nursing homes, regardless of physical health,In nursing homes, regardless of physical health,major depression increases the likelihood ofmajor depression increases the likelihood of

mortality bymortality by59%59% in one yearin one year(Empfield, 2003)(Empfield, 2003)


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Benefits Of Treatment For DepressionBenefits Of Treatment For DepressionIn The ElderlyIn The Elderly

Depression is one of the few medical conditions inDepression is one of the few medical conditions inwhich treatment can make a rapid and dramaticwhich treatment can make a rapid and dramaticdifference in an elderly persons level of function anddifference in an elderly persons level of function and

quality of lifequality of life Treatment may help patients accept medical treatmentTreatment may help patients accept medical treatment

that they otherwise might refuse because of feelings ofthat they otherwise might refuse because of feelings ofhopelessness or futilityhopelessness or futility

Treatment also helps enhance or recover coping skillsTreatment also helps enhance or recover coping skillsneeded to deal with the inevitable losses associated withneeded to deal with the inevitable losses associated withchronic medical illnesschronic medical illness

(Empfield, 2003)(Empfield, 2003)


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What Factors PutWhat Factors Put

Someone At Risk?Someone At Risk? Many things increase ones risk for suicideMany things increase ones risk for suicide-- biological,biological,

psychological, social factors all applypsychological, social factors all apply

The single greatest risk factor for suicide completionThe single greatest risk factor for suicide completion --having a depressive illness.having a depressive illness.

90% of reported US suicides are experiencing depression90% of reported US suicides are experiencing depression

The 2nd biggest factorThe 2nd biggest factor -- having anhaving an alcohol or drugalcohol or drug

problemproblem. However, many people with alcohol and drug. However, many people with alcohol and drugproblems are significantly depressed, and are selfproblems are significantly depressed, and are self--medicatingmedicating

(Lester, 1998)(Lester, 1998)


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Other risk factors includeOther risk factors include:: Previous suicide attemptsPrevious suicide attempts

A family history of suicideA family history of suicide -- increases our risk by 6 timesincreases our risk by 6 times

A significant loss by death, divorce, separation, moving, orA significant loss by death, divorce, separation, moving, orbreaking up with a loved one. Shock or pain, even long termbreaking up with a loved one. Shock or pain, even long termlower level stress, can affect the structure of the brain,lower level stress, can affect the structure of the brain,especially the limbic systemespecially the limbic system

30 years of research confirms the relationship between30 years of research confirms the relationship betweenhopelessnesshopelessness and suicide, across diagnosesand suicide, across diagnoses

Impulsivity, particularly among youth, is increasingly linkedImpulsivity, particularly among youth, is increasingly linkedto suicidal behaviorto suicidal behavior

Access to firearmsAccess to firearms 70% of completed suicides used70% of completed suicides usedfirearmsfirearms

(Surgeon Generals call to Action, 1999)(Surgeon Generals call to Action, 1999)


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Biological factors:Biological factors: Biological changes are associated withBiological changes are associated with

both completed and attempted suicideboth completed and attempted suicide Changes include abnormal functioning ofChanges include abnormal functioning of

the Hypothalamicthe Hypothalamic--PituitaryPituitary--Adrenal axis,Adrenal axis,

a major component of the way we adapt to stressa major component of the way we adapt to stress

Psychological factors:Psychological factors: Changes in thinking (constricted thought) leading to the beliefChanges in thinking (constricted thought) leading to the belief

that suicide is the only answer; negative automatic thoughts thatthat suicide is the only answer; negative automatic thoughts thatlead to sadness, hopelessness, loss of pleasure, inability to see alead to sadness, hopelessness, loss of pleasure, inability to see afuture, low selffuture, low self--esteemesteem

Suicidality, although clearly overlapping the symptoms ofSuicidality, although clearly overlapping the symptoms ofassociated MH disorders, does not appear to respond toassociated MH disorders, does not appear to respond totreatment in exactly the same waytreatment in exactly the same way

In some cases, depressive symptoms can be reduced byIn some cases, depressive symptoms can be reduced bymedication without a reduction in suicidal thinkingmedication without a reduction in suicidal thinking


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Protective FactorsProtective Factors

Stigma reduction programs, especiallyStigma reduction programs, especially

among youth, increase helpamong youth, increase help--seeking behaviorseeking behavior

Resiliency and coping skills to reduce risk can be taughtResiliency and coping skills to reduce risk can be taught

(Dialectical Behavioral Training)(Dialectical Behavioral Training) Spirituality improves defenses against suicidal thinkingSpirituality improves defenses against suicidal thinking

Social supportSocial support those with close relationships cope betterthose with close relationships cope betterwith various stresses, including bereavement, job loss, andwith various stresses, including bereavement, job loss, and

illnessillness Social disapproval of suicide reduces ratesSocial disapproval of suicide reduces rates

*(Berman & Jobes, 1996; Beck, 1985; Rush et al, 1992, Surgeon Generals Call To Action, 1999)*(Berman & Jobes, 1996; Beck, 1985; Rush et al, 1992, Surgeon Generals Call To Action, 1999)


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TreatmentTreatment

Treatment of suicidality has improved dramaticallyTreatment of suicidality has improved dramaticallyin the last 20 yearsin the last 20 years

Evidence is clear that lithium treatment of biEvidence is clear that lithium treatment of bi--polarpolardisorder significantly reduces suicide rates*disorder significantly reduces suicide rates*

A correlation has been noted between an increase inA correlation has been noted between an increase inprescription rates for SSRIs and a decline in suicideprescription rates for SSRIs and a decline in suicide

rates**rates** (*Baldessarini, et.al, 1999, **NIMH, 2002)(*Baldessarini, et.al, 1999, **NIMH, 2002)


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However, medication alone is insufficient to reduce suicidal ideationHowever, medication alone is insufficient to reduce suicidal ideation

Psychotherapy can reduce suicidality by helping people learn toPsychotherapy can reduce suicidality by helping people learn tointerpret the stresses in their lives more effectively, reducing the levelinterpret the stresses in their lives more effectively, reducing the levelof stress hormones in the bodyof stress hormones in the body

Psychotherapy provides a necessary therapeutic relationship thatPsychotherapy provides a necessary therapeutic relationship thatreduces risk through increased hope and supportreduces risk through increased hope and support

CognitiveCognitive--behavioral approaches that include problembehavioral approaches that include problem--solving trainingsolving trainingreduce suicidal ideation and attempts more effectively than otherreduce suicidal ideation and attempts more effectively than otherapproachesapproaches

Medication combined with psychotherapy is the current standard ofMedication combined with psychotherapy is the current standard of

care for clinical depressioncare for clinical depression

(Beck, 1996(Beck, 1996,, Quinnett, 2000, Macintosh, 1996)Quinnett, 2000, Macintosh, 1996)


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Barriers To TreatmentBarriers To Treatment

Fragmentation of services and cost of care are the mostFragmentation of services and cost of care are the mostfrequently cited barriers to treatmentfrequently cited barriers to treatment

About 67% of people withAbout 67% of people with significantsignificant mental disordersmental disorders do notdo notreceive treatmentreceive treatment

Psychological autopsy studies reveal that less than 14% ofPsychological autopsy studies reveal that less than 14% ofcompleters were receiving adequate treatment, and fewer thancompleters were receiving adequate treatment, and fewer than17% were being treated with psychiatric medications17% were being treated with psychiatric medications

However, 50However, 50--70% had contact with health services in the70% had contact with health services in theweeks before their deathweeks before their death

Surgeon Generals Call To Action, 1999; Empfield, 2003Surgeon Generals Call To Action, 1999; Empfield, 2003


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Currently, no psychological test, clinical technique or biologicalCurrently, no psychological test, clinical technique or biologicalmarker is sensitive enough to accurately and consistently predictmarker is sensitive enough to accurately and consistently predictsuicidesuicide

Primary care has become a critical setting for detection of the twoPrimary care has become a critical setting for detection of the twomost common factors: depression and alcoholism*most common factors: depression and alcoholism*

Depression is the second most common chronic disorder seen byDepression is the second most common chronic disorder seen byPCPsPCPs

According to the AMA, a diagnostic interview for depression isAccording to the AMA, a diagnostic interview for depression iscomparable in sensitivity to laboratory tests commonly used incomparable in sensitivity to laboratory tests commonly used indiagnosis, but currently, less than 50% of adults with diagnosablediagnosis, but currently, less than 50% of adults with diagnosabledepression are accurately diagnosed by PCPs*depression are accurately diagnosed by PCPs*

Physicians are often reticent to talk with patients about suicidePhysicians are often reticent to talk with patients about suicideintent or ideation, and patients seldom spontaneously report it**intent or ideation, and patients seldom spontaneously report it**

(*Surgeon Generals Call to Action, 1999; **Quinnett, 2000 )(*Surgeon Generals Call to Action, 1999; **Quinnett, 2000 )


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What Is Your County Doing?What Is Your County Doing?

Suicide prevention coalitions have been developed over theSuicide prevention coalitions have been developed over thepast 3 years across the state with grants from Ohio Dept. ofpast 3 years across the state with grants from Ohio Dept. ofMental HealthMental Health

In many counties, the Mental Health Board is spearheading thisIn many counties, the Mental Health Board is spearheading this

process, with helpprocess, with helpfrom all areas of the community,from all areas of the community,

including health care providers, mentalincluding health care providers, mental

health professionals, suicide survivors,health professionals, suicide survivors,

clergy, school personnel, human resourceclergy, school personnel, human resourcepersonnel, police/sheriff dept, healthpersonnel, police/sheriff dept, health

department, and many othersdepartment, and many others


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How Do We Know SuicideHow Do We Know Suicide

PreventionC

oalitions Work?PreventionC

oalitions Work? In 1996 the U.S. Air Force decided to mount an assaultIn 1996 the U.S. Air Force decided to mount an assault

on its high suicide rateon its high suicide rate

They targeted helpThey targeted help--seeking behavior, stigma, andseeking behavior, stigma, andawarenessawareness

After 5 years of a major collaborative effort within theAfter 5 years of a major collaborative effort within theservice, suicide rates dropped 78%service, suicide rates dropped 78%

Comparable rates in the other 4 armed servicesComparable rates in the other 4 armed servicesremained the sameremained the same


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HowCan You Help?HowCan You Help?

Medical personnel are the front line of defense againstMedical personnel are the front line of defense againstthis insidious killerthis insidious killer -- assess your patients for suicidalassess your patients for suicidalideation when depressive symptoms ariseideation when depressive symptoms arise

Specifically ask your patients if they are experiencingSpecifically ask your patients if they are experiencingsuicidal ideationsuicidal ideation They may not volunteer theThey may not volunteer theinformationinformation

Train staffTrain staff in depression awareness, and in asking the Sin depression awareness, and in asking the Squestionquestion

We must gain confidence in asking people if they areWe must gain confidence in asking people if they arethinking about dyingthinking about dying

(Surgeon Generals Call To Action, 1999)(Surgeon Generals Call To Action, 1999)


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Comfort And Competence Lead ToComfort And Competence Lead To

HopefulnessHopefulnessA study by Dr. Paul Quinett, a longA study by Dr. Paul Quinett, a long--timetime

researcher and clinician in suicide, indicates thatresearcher and clinician in suicide, indicates that

patients who felt their clinician was comfortablepatients who felt their clinician was comfortableasking questions about their suicidal thoughtsasking questions about their suicidal thoughts

and feelings reported much higher levels ofand feelings reported much higher levels ofhope about the futurehope about the future

The best outcome of asking theThe best outcome of asking the SS question isquestion isimmediate relief for the patientimmediate relief for the patient

(Quinnett, 2001)(Quinnett, 2001)


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Hopelessness is the most immediate risk factorHopelessness is the most immediate risk factor

for suicide, so instilling hope is essentialfor suicide, so instilling hope is essential If your patient is on antiIf your patient is on anti--depressant or antidepressant or anti--

anxiety medication, refer them to a psychologistanxiety medication, refer them to a psychologist

or counselor who can work with them on theor counselor who can work with them on themaintaining causesmaintaining causes of depressionof depression

Consider using aConsider using a risk assessment formatrisk assessment format totoensure you ask the right questionsensure you ask the right questions


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What To Ask?What To Ask?

Except for psychiatrists, routineExcept for psychiatrists, routine

questioning about suicidal ideationquestioning about suicidal ideation

isis notnot the current standard of carethe current standard of care

If you have a patient with depressive symptoms orIf you have a patient with depressive symptoms orother mental health disorders (especially anxiety)other mental health disorders (especially anxiety) Learn to Ask the S questionLearn to Ask the S question

NotNot you arent thinking of suicide are you?you arent thinking of suicide are you?

ButBut -- Some people who experience the amount of pain youreSome people who experience the amount of pain yourein think about killing themselves. Have you ever thoughtin think about killing themselves. Have you ever thoughtabout it?about it?

(Lester, 1998)(Lester, 1998)


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Use Of A Structured InterviewUse Of A Structured Interview

Many patients will not overtly acknowledge commonMany patients will not overtly acknowledge commonsymptoms of depression, focusing more on vague painsymptoms of depression, focusing more on vague pain

You may wish to develop or purchase a guided clinicalYou may wish to develop or purchase a guided clinical

interview for use with suicidal clientsinterview for use with suicidal clients A structured form assesses current risk, sets up aA structured form assesses current risk, sets up a

management plan, and ensures that all the rightmanagement plan, and ensures that all the rightquestions are askedquestions are asked

Most take just a few minutes to complete, and peopleMost take just a few minutes to complete, and peopleare surprisingly honestare surprisingly honest


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Screening RecommendationsScreening Recommendations The U.S. Preventive Services Task Force reviewed new evidence thatThe U.S. Preventive Services Task Force reviewed new evidence that

patients fare best when medical professionals recognize the symptoms ofpatients fare best when medical professionals recognize the symptoms ofdepression and make sure they receive appropriate treatmentdepression and make sure they receive appropriate treatment

The USPSTF issued new depression screening recommendations in May,The USPSTF issued new depression screening recommendations in May,

2002, asking PCPs to routinely screen adult patients for depression2002, asking PCPs to routinely screen adult patients for depression

Medical professionals should have systems in place to assure accurateMedical professionals should have systems in place to assure accurate

diagnosis, effective treatment, and followdiagnosis, effective treatment, and follow--up if patients are to benefitup if patients are to benefitfrom screeningfrom screening

The journal of AAFP offers the article Screening for Depression acrossThe journal of AAFP offers the article Screening for Depression across

theL

ifespan: A review of Measures of Use in PrimaryC

are settings totheL

ifespan: A review of Measures of Use in PrimaryC

are settings tohelp medical professionals make appropriate choices of screening toolhelp medical professionals make appropriate choices of screening tool(Sharp and Lipsky, 2002)(Sharp and Lipsky, 2002)


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Possible Depression ScalesPossible Depression Scales

Beck Depression InventoryBeck Depression Inventory Childrens Depression InventoryChildrens Depression Inventory CESCES--DC (Center for Epidemiological StudiesDC (Center for Epidemiological Studies

Depression Scale)Depression Scale) Edinburgh PostEdinburgh Post--Natal Depression ScaleNatal Depression Scale Geriatric Depression ScaleGeriatric Depression Scale QPRTQPRT -- Question, Persuade, Refer or TreatQuestion, Persuade, Refer or Treat --QPRQPR

InstituteInstitute -- www.qprinstitute.comwww.qprinstitute.com Zung Depression InventoryZung Depression Inventory


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LearningLearningQPRQPR Or, How To AskOr, How To AskThe S QuestionThe S Question

It is essential, if we are to reduce the number of suicideIt is essential, if we are to reduce the number of suicidedeaths in our country, that communitydeaths in our country, that communitymembers/gatekeepers learn members/gatekeepers learn QPRQPR

First identified by Dr. Paul Quinnett as an analogue toFirst identified by Dr. Paul Quinnett as an analogue toCPR, CPR, QPRQPR consists of consists of QQuestionuestion asking the S questionasking the S question

PPersuadeersuade Getting the person to talk, and to seek helpGetting the person to talk, and to seek help

RReferefer Getting the person to professional helpGetting the person to professional help

Medical staff can learn this method in a very short timeMedical staff can learn this method in a very short time(Quinnett, 2000)(Quinnett, 2000)


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InterventionIntervention

Once a patient has told someone they are thinking ofOnce a patient has told someone they are thinking ofsuicide, you need a thorough suicide assessmentsuicide, you need a thorough suicide assessment

In your area, what mental health facilities withIn your area, what mental health facilities withemergency services are available?emergency services are available?

Sending a suicidal patientSending a suicidal patient alonealone to the emergency roomto the emergency roomcould be a mistakecould be a mistake

Most mental health agencies have crisis workers whoMost mental health agencies have crisis workers who

can come to your office to interview your patientcan come to your office to interview your patient

suicidal people should never be left alone!suicidal people should never be left alone!


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Psychiatric HospitalizationPsychiatric Hospitalization

The actual prediction of suicide is, essentially,The actual prediction of suicide is, essentially,impossibleimpossible

The base rates are too low, and risk level changes fromThe base rates are too low, and risk level changes fromday to dayday to day

Statistically, you could almost always bet that no givenStatistically, you could almost always bet that no givenindividual will complete suicideindividual will complete suicide

Other risks are managed by understanding what riskOther risks are managed by understanding what riskfactors exist, and limiting as many of them as possible,factors exist, and limiting as many of them as possible,

like wearing sunscreenlike wearing sunscreen It is imperative that medical professionals know riskIt is imperative that medical professionals know risk

factors for suicidefactors for suicide(MacIntosh, 1993)(MacIntosh, 1993)


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The Top Ten Risk Factors WhenThe Top Ten Risk Factors WhenThinking Of HospitalizationThinking Of Hospitalization

Previous Suicide attempt(s)Previous Suicide attempt(s) Mental disorders (especially depression, bipolar)Mental disorders (especially depression, bipolar) CoCo--occurring mental and AL/SA disordersoccurring mental and AL/SA disorders Family history of suicideFamily history of suicide Hopelessness (should this be first?)Hopelessness (should this be first?) Impulsive/aggressive tendenciesImpulsive/aggressive tendencies Barriers to accessing mental health treatmentBarriers to accessing mental health treatment Relational, social, work or financial lossRelational, social, work or financial loss physical illness (esp. with chronic pain)physical illness (esp. with chronic pain) Easy access to lethal methods, especially gunsEasy access to lethal methods, especially guns

(Surgeon General(Surgeon Generals Call to Action to Prevent Suicide, 1999s Call to Action to Prevent Suicide, 1999))


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Voluntary HospitalizationVoluntary Hospitalization

Best choiceBest choice less hard on the patientless hard on the patients sense ofs sense ofselfself--worthworth a way to buy time (to think it over,a way to buy time (to think it over,get sleep, etc.)get sleep, etc.)

Safety is the main messageSafety is the main message

a good nighta good nightsssleep, a start on medications, talk with doctors,sleep, a start on medications, talk with doctors,put things on hold for awhileput things on hold for awhile

Allows them to save faceAllows them to save face

I didnI didnt want to, butt want to, butthey insistedthey insisted


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Sharing Knowledge Of HospitalsSharing Knowledge Of Hospitals

Ease the transition by addressing their fearsEase the transition by addressing their fears

Facts: hospital stays tend to be shortFacts: hospital stays tend to be short

Staff are wellStaff are well--trained and know about suicidaltrained and know about suicidalsufferingsuffering

ECT cannot be given without patient permissionECT cannot be given without patient permission

Patients rights are guaranteedPatients rights are guaranteed

Modern hospitals are not snake pitsModern hospitals are not snake pits


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Know Your Local Resources AndKnow Your Local Resources AndAgenciesAgencies

Where to hospitalizeWhere to hospitalize

Who do you callWho do you call

Have your risk assessment information readyHave your risk assessment information ready Help to overcome barriers to hospitalizationHelp to overcome barriers to hospitalization

such as child care, pets, transportation, calls tosuch as child care, pets, transportation, calls to

work, etc.work, etc.


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Local Professional ResourcesLocal Professional Resources

Your Local Mental HealthYour Local Mental HealthAgenciesAgencies

Your Local Mental HealthYour Local Mental Health

BoardBoardSchool GuidanceSchool GuidanceCounselorsCounselors

Your Hospital EmergencyYour Hospital EmergencyRoomRoom

Local Crisis HotlinesLocal Crisis Hotlines

National Crisis HotlinesNational Crisis Hotlines

School nursesSchool nurses

911911

Local Police/SheriffLocal Police/Sheriff

Local ClergyLocal Clergy


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Suicide is aSuicide is a

permanent solutionpermanent solution

to ato a

temporary problemtemporary problem

Edwin Schneidman, MD.Edwin Schneidman, MD.

Founder of SuicidologyFounder of Suicidology


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The Ohio Suicide Prevention FoundationThe Ohio Suicide Prevention Foundation

The Ohio State University, Center on EducationThe Ohio State University, Center on Education

and Training for Employmentand Training for Employment1900 Kenny Road, Room 20721900 Kenny Road, Room 2072

Columbus, OH 43210Columbus, OH 43210

614614--292292--85858585


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A Brief BibliographyA Brief Bibliography Anderson, E. The Personal and Professional Impact ofClientAnderson, E. The Personal and Professional Impact ofClient

Suicide on Mental Health Professionals. Unpublished DoctoralSuicide on Mental Health Professionals. Unpublished Doctoraldissertation, U. of Toledo, 1999dissertation, U. of Toledo, 1999

Berman, A. L. & Jobes, D. A. (1996)Berman, A. L. & Jobes, D. A. (1996) Adolescent Suicide: AssessmentAdolescent Suicide: Assessmentand Interventionand Intervention..

Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990).Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Over the LifeSuicide Over the Life

Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients.Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients.American Psychiatric Press.American Psychiatric Press.

Empfield, Maureen MD( 2002) PSYCHIATRY FOR THEEmpfield, Maureen MD( 2002) PSYCHIATRY FOR THEPRIMARYCARE PHYSICIANPRIMARYCARE PHYSICIAN Section 2. URLSection 2. URL

Goldberg, I. SSRIs and Suicide: Results of a MELINE Search. At:Goldberg, I. SSRIs and Suicide: Results of a MELINE Search. At:

ttp://www.psycom.net/depression.central.ssrittp://www.psycom.net/depression.central.ssri--suicide.htmlsuicide.html Jacobs, D., Ed. (1999).Jacobs, D., Ed. (1999). The Harvard Medical School Guide toThe Harvard Medical School Guide to

Suicide Assessment and Interventions.Suicide Assessment and Interventions. JosseyJossey--Bass.Bass.


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Jamison, K.R., (1999).Jamison, K.R., (1999). Night Falls Fast: Understanding Suicide.Night Falls Fast: Understanding Suicide.Alfred KnopfAlfred Knopf

Lester, D. (1998).Lester, D. (1998). Making Sense of Suicide: An InMaking Sense of Suicide: An In--Depth Look atDepth Look atWhy People Kill Themselves.Why People Kill Themselves. American Psychiatric PressAmerican Psychiatric Press

Oregon Health Department, Prevention. Notes on Depression andOregon Health Department, Prevention. Notes on Depression andSuicide:Suicide:ttp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cfttp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cf

mm Presidents New Freedom Council on Mental Health, 2003Presidents New Freedom Council on Mental Health, 2003

Quinnett,Quinnett, PP..GG.. ((20002000)).. CounselingCounseling SuicidalSuicidal PeoplePeople.. QPRQPR Institute,Institute,Spokane,Spokane, WAWA

Shea,Shea,CC

..,, 20002000.. AA PracticalPractical InterviewingInterviewing StrategyStrategy forfor thethe ElicitationElicitationofof SuicidalSuicidal IdeationIdeation.. JournalJournal ofofClinicalClinical PsychiatryPsychiatry (supplement(supplement 2020))5959:: 5858--7272,, 19981998


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Smith, Range & Ulner. Belief in Afterlife as a buffer in suicideSmith, Range & Ulner. Belief in Afterlife as a buffer in suicideand other bereavement. Omega Journal of Death and Dying,and other bereavement. Omega Journal of Death and Dying,

19911991--92, (24)3; 21792, (24)3; 217--225.225. Stoff, D.M. & Mann, J.J. (Eds.), (1997).Stoff, D.M. & Mann, J.J. (Eds.), (1997). The Neurobiology ofThe Neurobiology of

SuicideSuicide. American Academy of Science. American Academy of Science

Schneidman,Schneidman, EE..SS.. ((19961996)).. TheThe SuicidalSuicidal MindMind.. OxfordOxford UniversityUniversity

PressPress.. Styron,Styron, WW.. ((19921992)).. DarknessDarkness VisibleVisible.. VintageVintage BooksBooks

Surgeon Generals Call to Action (1999). Department of HealthSurgeon Generals Call to Action (1999). Department of Healthand Human Services, U.S. Public Health Service.and Human Services, U.S. Public Health Service.

Tang,Tang, TT..ZZ.. && DeDe Rubeis,Rubeis, RR..JJ.. ((((19991999))..SuddenSudden GainsGains andand criticalcriticalsessionssessions inin cognitivecognitive--behavioralbehavioral therapytherapy forfor depressiondepression.. JournalJournal

ofofConsultingConsulting andand ClinicalClinical PsychologyPsychology 6767:: 894894--904904..

physicians suicide awareness training

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