Preventing Suicide: The Challenges and the Opportunities

Today’s Presentation Scope of the problem The Zero Suicide movement Eileen Zeller, MPH The Zero Suicide movement Julie Goldstein Grumet, Ph.D. Clinical competencies for behavioral health providers Richard McKeon, Ph.D., MPH Q&A

True or False? Each year, there are about the same number of suicides as homicides in the United States.

Suicides and Homicides in the United States (2013) 41,140 suicides; 16,121 homicides. 10th leading cause of death vs. 16th leading cause of death.

Once someone is suicidal, he or she will always be suicidal. True or False? Once someone is suicidal, he or she will always be suicidal. 90% of people who attempt suicide do not die by suicide. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm. systematic review. Br J Psychiatry. 2002 Sep;181:193-9. However, a history of prior suicide attempts is one of the strongest predictors for death by suicide. Regarding attempts, the vast majority of suicide attempts are by women; their self-inflicted injuries tend to be less lethal, but should not be discounted. They contribute to significant health care costs and disability. Rates of attempts peak in adolescence and decline with age. Rates of attempts are disproportionately high among lesbian, gay, bisexual, or transgendered youth and among young Latinas.

Most people who die by suicide communicate their plans in advance. True or False? Most people who die by suicide communicate their plans in advance. 2/3 of people who die by suicide communicate their plans in advance. Sometimes directly, sometimes subtly. One of the things we do is to teach people--lay and clinical alike—about the warning signs of suicide. What they are, what to say to someone they are concerned about, and how to refer someone for help. For lay people, there are gatekeeper trainings; for providers, there are evidence-based clinical trainings.

Suicide is preventable. True or False? Suicide is preventable.

Pyramid of Suicidal Behaviors – U.S. Adults (2013) 41,149 Suicides* 572,000 Hospitalizations*** Pyramid: Top tier shows number of suicides in 2013; bottom tier shows number who seriously considered suicide in 2013. 494,169 Attempts/Self-harm Requiring Medical Attention**** 1,300,000 Suicide Attempts** A history of prior suicide attempts is one of the strongest predictors for death by suicide (Kessler, Berglund, Borges, Nock, & Wang, 2005; Suominen et al., 2004; U.S. Department of Health and Human Services, 2012). Thus, suicidal thoughts and behaviors are important public health concerns in the United States. From National Electronic Injury Surveillance System—All Injury Program (NEISS-AIP) (nationally representative data about types and causes of non-fatal injuries treated in US hospital EDs):   Self-harm, all causes, 20 and over, 2013: 494,169 injuries for an age-adjusted rate of 160.46 per 100,000. Please note that this isn’t necessary the # of adults but is the number of injuries (so does not take into account those people who are repeatedly in the ED for self-harm). CDC’s Facts at a Glance http://www.cdc.gov/ViolencePrevention/pdf/Suicide_DataSheet-a.pdf NSDUH 2012 data (released in 2013) hthttp://www.samhsa.gov/data/NSDUH/2k12MH_FindingsandDetTables/2K12MHF/NSDUHmhfr2012.pdf 9,300,000 Seriously Considered Suicide** (2,700,000 Made a Plan) Source: * Centers for Disease Control and Prevention, Understanding Suicide: Fact Sheet. Available from: http://www.cdc.gov/violenceprevention/pub/suicide_factsheet.html . **SAMHSA. Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings. Rockville, MD. 2014. ***SAMHSA. The NSDUH Report: Suicidal Thoughts and Behaviors among Adults. Rockville, MD. 2012. **** US Consumer Product Safety Commission. National Electronic Injury Surveillance System—All Injury Program, 2013.

Suicide: Data and Disparities Suicide rate in the United States in 2013 = 13 per 100,000. Rates differ by a many variables. Geography Gender Age Race/Ethnicity CDC collects this data; 2013 is the latest data available. Someone dies by suicide in this country every 12.8 minutes. Nationally, suicide impacts people regardless of gender, age, race, or ethnicity. Let’s break that down a bit.

Suicide: Regional Breakdown Numbers vs. rates. States with highest rates (above 20): Montana (243), Alaska (171), Wyoming (129), New Mexico (431), Utah (579) States with the lowest rates (below 9): DC (38), New Jersey (737), Massachusetts (572), New York (1,687), and Connecticut (330). Highest numbers all have rates below the national average: California (4.025; ranks 44th); Texas (3,059; ranks 43rd); Florida (2,928; ranks 21st) Reasons: Access to care; gun ownership; connectedness to others. Map of United States showing suicide rate by region.

10 Leading Causes of Death by Age, U.S. (2013, all races, both sexes) Green is suicide.

Suicide Rates per 100,000 by Age, United States, 2000–2013 Highest rates are among people ages 45 – 64 (19). From 1999 to 2010, the suicide rate among Americans in the middle years (ages 35 – 64) rose by 28.4 percent. Largest overall rates and numbers: people in the middle years (45 – 59). (22.73 per 100,000; 11,897) Then 85+ (18.56) 15-24 = 10.88 65 – 84 = 15.67

Suicide by Gender Suicides Suicide attempts Male > Female (~4:1) Elderly white men (85+): Highest rate Men ages 35–64 = Highest number Suicide attempts Female > Male (~3:1) Rates peak in adolescence and decline with age For every 100 people who die, 80 are men and 20 are women. Men: rate of 20.2 Women: rate of 5.5 MIMY die disproportionately of suicide. 25% of population; 41% of suicides Highest risk/rate: elderly white males (85+) (52.62 per 100,000; 963) Regarding attempts: the majority of suicide attempts are by women; their self-inflicted injuries tend to be less lethal, but should not be discounted. They contribute to significant health care costs and disability. Rates of attempts peak in adolescence and decline with age. Rates of attempts are disproportionately high among lesbian, gay, bisexual, or transgender youth and among young Latinas.

Suicide Rate by Race/Ethnicity, United States, 2000–2013 2013: Highest U.S. suicide rate (14.2) was among whites. 70% of all suicides in 2013 were among white males. Second highest (11.7) was among AI/AN. (In youth through middle age as the suicide rates are high and continuing to climb for this sub-population.) 15-19 57 15.21 20-24 93 23.55 25-29 64 18.20 30-34 68 20.37 35-39 43 14.45 40-44 45 15.58 45-49 54 19.52 Asians and Pacific Islanders: 5.8 Blacks: 5.4 Hispanics: 5.7 (CDC records Hispanic origin separately from racial groups, because of the overlap.) Attempts: High among young Latinas.

Suicide Deaths by Method, United States, 2013 Firearms were the most common method of death by suicide, accounting for more than half of all suicides. This was followed by suffocation (including hanging) and poisoning .

Thanks to the Suicide Prevention Resource Center for this slide.

National Action Alliance for Suicide Prevention Public-private partnership established in 2010 to advance the National Strategy for Suicide Prevention (NSSP) Current: Robert Turner, Senior Vice President – Corporate Relations, Union Pacific Corporation Jessica Garfola Wright, Under Secretary of Defense for Personnel and Readiness, DoD 200 organizations. Executive Committee, Task Forces, and Advisory Committees. Photo: Three smiling businessmen, two shaking hands.

National Strategy for Suicide Prevention On September 10, 2012 the Action Alliance, along with the U.S. Surgeon General, Dr. Regina Benjamin, released the revised National Strategy for Suicide Prevention (NSSP).  The revised strategy emphasizes the role every American can play in protecting their friends, family members, and colleagues from suicide.  It also provides guidance for schools, businesses, health systems, clinicians and many other sectors that takes into account nearly a decade of research and other advancements in the field since the last strategy was published.  The NSSP features 13 goals and 60 objectives.

Examples of Accomplishments and Progress Suicide Care in Systems Framework (basis of Zero Suicide model) Suicide Prevention and the Clinical Workforce: Guidelines for Training First-ever prioritized suicide prevention research agenda The Way Forward (Suicide Attempt Survivors Task Force) Responding to Grief, Trauma, and Distress After a Suicide (Loss Survivors Task Force) In addition to revising and releasing the National Strategy: Research agenda: A prioritized approach for allocating funds and monitoring future suicide research to ensure that available resources target research with the greatest likelihood of reducing suicide morbidity and mortality. Clinical Workforce Preparedness: Developing training guidelines to equip clinicians with knowledge and skills to effectively support suicidal individuals. Juvenile Justice: The Action Alliance is working with leaders in the juvenile justice system – in which suicide is the leading cause of death – to expand prevention research and programming. They have released a series of fact sheets for juvenile court judges and staff; juvenile detention and secure care staff; and juvenile probation staff. Attempt Survivor: Recommendations to infuse lived experience into all aspects of suicide prevention. We are witnessing—and SAMHSA and the Action Alliance are proud to have been a catalyst for and allies of—an historic movement of suicide attempt survivors championing their cause and finding their voices. You may have seen recent articles in the New York Times and Boston Globe. These emerging leaders are becoming catalysts for new and improved suicide prevention efforts. The Suicide Attempt Survivors Task Force of the Action Alliance is about to release a seminal report on attempt survivors with recommendations from the perspective of lived experience. articles Watch out for The Way Forward: Pathways to Hope, Recovery, and Wellness with Insights from Lived Experience. Information for all of this can be found on the Action Alliance web site: ActionAllianceForSuicidePrevention.org

Suicide Warning Signs

National Suicide Prevention Lifeline 1–800–273–TALK (8255) 24/7 Provides counseling and mental health referrals www.suicidepreventionlifeline.org Chat services available Cite research The National Suicide Prevention Lifeline is a network of 164 crisis centers—at least one in every state—that are connected by a single telephone number. You can call from anywhere in the country, 24/7, to be connected to the crisis center that is geographically closest to you. Trained counselors will listen, assess, and refer. These folks are busy: Last year they answered more than 1.3 million calls. You do not have to be suicidal, in crisis, or even in emotional distress to call the Lifeline. They will also help you if you are concerned about someone they care about.

Additional Resources SAMHSA programs http://www.samhsa.gov/suicide-prevention SAMHSA Publications (free) http://store.samhsa.gov/ Suicide Prevention Resource Center www.sprc.org National Action Alliance for Suicide Prevention http://actionallianceforsuicideprevention.org/

Eileen Zeller, MPH Lead Public Health Advisor Suicide Prevention Branch Eileen.Zeller@samhsa.hhs.gov 240–276–1863