Suicide Prevention,Warning Signs and the National Strategy Richard McKeon Ph.D., MPH Branch Chief,...
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Transcript of Suicide Prevention,Warning Signs and the National Strategy Richard McKeon Ph.D., MPH Branch Chief,...
Suicide Prevention ,Warning Signs and the National Strategy
Richard McKeon Ph.D., MPH Branch Chief, Suicide Prevention
SAMHSA
STAGGERING REALITY
~ 36,000 Americans die by suicide each year
Rank 10-14 years 15-19 years 20-29 years 30-39 years 40-49 years 50-59 years
1 UnintentionalInjuries
UnintentionalInjuries
UnintentionalInjuries
UnintentionalInjuries
MalignantNeoplasms
MalignantNeoplasms
2 MalignantNeoplasms
Homicide Homicide MalignantNeoplasms
Heart Disease
Heart Disease
3 Suicide Suicide Suicide Heart Disease
UnintentionalInjuries
UnintentionalInjuries
4 Homicide MalignantNeoplasms
MalignantNeoplasms
Suicide Suicide DiabetesMellitus
5 CongenitalMalformations
Heart Disease
Heart Disease
Homicide LiverDisease
Cerebro-vascular
6 Heart Disease
CongenitalMalformation
s
HIV HIV HIV LiverDisease
7 ChronicLower
Respiratory Ds
Cerebro-vascular
CongenitalMalformation
s
DiabetesMellitus
Cerebro-vascular
ChronicLower
Respiratory Ds
8 Influenza & pneumonia
Influenza and pneumonia
Diabetes mellitus
Cerebro-vascular
DiabetesMellitus
Suicide
Leading causes of death for selected age groups – United States, 2005
Source: CDC vital statistics
SUICIDE: DATA AND DISPARITIES
Suicides • 4 males : 1 female• Highest risk: elderly white males (85+)• Largest numbers: middle-aged (40-60) males at 2x’s
baseline rate of other Americans and working-aged males (20-64) = 60 percent of suicides
• Higher risk: young and middle-aged AI/ANSuicide attempts
• Female > male• Rates peak in adolescence and decline with age• Higher risk: LGBT youth and young Latinas
5
TOUGH REALITIES
• ~30 percent of deaths by suicide involved alcohol intoxication – BAC at or above legal limit
6
TOUGH REALITIES
2005-2009: 55%↑ in emergency department visits for drug related suicide attempts by men 21 to 34
2005-2009: 49% ↑ in emergency department visits for drug related suicide attempts by women 50+
Every year > 650,000 persons receive treatment in emergency rooms following suicide attempts
7
TOUGH REALITIES
50 percent of those who die by suicide were afflicted with major depression…the suicide rate of people with major
depression is 8 x’s that of the general population
90 percent of individuals who die by suicide had a mental disorder
8
2005 – 2009: More than 1,100 members of the Armed Forces took their own lives; an average of 1 suicide every 36 hours
Suicide among veterans accounts for as many as 1 in 5 suicides in the U.S.
TOUGH REALITIES9
MISSED OPPORTUNITIES = LIVES LOST
Individuals discharged from an inpatient unit continue to be at risk for suicide
• ~10% of individuals who died by suicide had been discharged from an ED within previous 60 days
• ~ 8.6 percent hospitalized for suicidality are predicted to eventually die by suicide
10
MISSED OPPORTUNITIES = LIVES LOST
77 percent of individuals who die by suicide had visited their primary care doctor within the year
45 percent had visited their primary care doctor within the month
THE QUESTION OF SUICIDE WAS SELDOM RAISED…
National Milestones in Suicide Prevention1996: World Health Organization and United Nations publish Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies1997: Congress passes S. Res. 84 and H. Res. 212 recognizing suicide as a national problem1998: SPAN USA and CDC partner to host the Reno Consensus Development Conference1999: HHS publishes the Surgeon General’s Call to Action to Prevent Suicide2001: HHS publishes National Strategy for Suicide Prevention2010: SPRC and SPAN USA/AFSP publish Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead. 2010: National Action Alliance for Suicide Prevention established 2012: National Strategy for Suicide Prevention revised
12
NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION
A public-private partnership established in 2010 to advance the National Strategy for Suicide Prevention (NSSP)
Vision: The National Action Alliance for Suicide Prevention envisions a nation free from the tragic experience of suicide
Mission: To advance the NSSP by:• Championing suicide prevention as a national priority• Catalyzing efforts to implement high priority objectives of the NSSP • Cultivating the resources needed to sustain progress
Leadership: • PUBLIC SECTOR CO-CHAIR, The Honorable John McHugh, Secretary of the
Army • PRIVATE SECTOR CO-CHAIR, The Honorable Gordon H. Smith, President and
CEO, National Association of Broadcasters
13
National Strategy for Suicide Prevention
Strategic Directions within the National Strategy for Suicide Prevention
15
Warning Signs
• Objective 2.4• Increase knowledge of the warning signs for
suicide and of how to connect individuals in crisis with assistance and care.
• Key issues are:• What to look for?• What to do?
Advances in Assessing Risk: From Risk Factors to Warning
Signs Problems with risk factors construct
– Limited clinical and practical relevance “acute risk” defined as 12 months time periods range from 1 to 20 years
– Fails to differentiate variable markers for near and long-term risk for suicide
– Can result in confusion in understanding and application and risk categories Perpetuating Predisposing Precipitating
Consensus Panel Recommendations
Warning Signs Expert Meeting 8/12
• What to look for?• Empirically supported warning signs can be
divided into:• Suicide specific warning signs such as ideation,
talking about or threatening suicide, preparatory behavior such as writing a note or attempting to access lethal means
• Making an attempt
Warning Signs Meeting 8/2012
• Other warning signs are not suicide specific and may be linked to shared risk for a variety of negative outcomes such as withdrawal, anxiety, mood changes, rage
• There may be differences in the recommended actions to take depending on whether these warning signs are suicide specific
Emergency Department
• Look for signs of acute suicide risk
• ED vs community context
Action Steps in Response to Warning Signs
• From NSSP• Do not leave the person alone• Remove any objects that could be used in a
suicide attempt• Call the National Suicide Prevention Lifeline at
800-273-TALK (8255)• Take to an emergency room or seek help from
a medical or mental health professional
Action Steps to take in Response to Warning signs
• Key questions• How hard is it for gatekeepers to recognize the
warning signs and to act on them?• What is the role of hotlines vs 911 (ideation vs
action?)• Do not leave alone for how long? Until
evaluated by someone experienced in suicide risk assessment.
ASIST workshops train Army leaders, chaplains and chaplain assistants, substance abuse counselors, family advocacy program workers, medical and dental-health professionals, and other care providers in a range of suicide-prevention and intervention skills
New Frontiers in Crisis Intervention
• Chat-Veterans chat initiated 2009• Texting-Crisis texting services in Lifeline• Social Networking Sites-relationship with
Lifeline• SAMHSA Summit and White Paper on suicide
prevention and the new technologies
COSTLY GAPS: CONTINUITY OF CARE
• U.S. E.D. visits, 1992-2001: More attempts (49% increase), fewer admissions for attempts (35% less) (Larkin et al, 2008).
• Fewer outpt. resources, longer waits: 76% of ED directors report lack of community referrals (Baraff et al, 2006).
• About 50% of suicide attempters fail to attend treatment post-discharge (Tondo et al, 2006).
• Over 1/3 re-attempt or die by suicide within 18 months post discharge (Beautrais, 2003).
• This is an intense challenge but also a real opportunity for us to do better.
Emergency Department
• Fleischmann et al (2008)– Randomized controlled trial; 1867 Suicide attempt survivors
from five countries (all outside US)– Brief (1 hour) intervention as close to attempt as possible– 9 F/u contacts (phone calls or visits) over 18 months
Died of Any Cause Died by Suicide0
0.5
1
1.5
2
2.5
3
Results at 18 Month F/U
Usual Care Brief Intervention
Pe
rce
nt
of
Pa
tie
nts
• Motto 1976: 389 pts. refusing outpt. assigned to “no “contact”
(up to 24 letters over 5 years)Contact group sig. fewer suicides than no-contact
group (particularly first 2 yrs)• Carter et al, 2005:
Postcards to 378 attempters, varying monthly intervals, 12 mos. after d/c
Approx 50% reduction in attempts
On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. “I still see my hands coming off the railing,” he said. As he crossed the chord in flight, Baldwin recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable—except for having just jumped.”
Tad Friend. Jumpers. The New Yorker (2003)
