Suicide Prevention, Assessment, and Intervention The Role of a First Responder Lisa Schwartz, LSW and Kathleen Kowalski, LCSW Suicide Prevention Coordinators Erie VAMC

Objectives 1. Identify the mental health, medical, and psychosocial factors that place individuals, especially Veterans, at risk for suicidal ideation and behavior. 1. Identify the mental health, medical, and psychosocial factors that place individuals, especially Veterans, at risk for suicidal ideation and behavior. 2. Identify warning signs and appropriate responses to suicidal ideation to ensure safe intervention and treatment. 2. Identify warning signs and appropriate responses to suicidal ideation to ensure safe intervention and treatment. 3. Identify role of first responders in dealing with a suicidal individual 3. Identify role of first responders in dealing with a suicidal individual 4. Review 24/7 crisis resources available to Veterans 4. Review 24/7 crisis resources available to Veterans

Statistics Veterans have >2x greater risk & account for 1 in 5 suicides in the US. Veterans have >2x greater risk & account for 1 in 5 suicides in the US. Access to firearms- a major factor (guns are used in approximately 58% of completed suicides). Access to firearms- a major factor (guns are used in approximately 58% of completed suicides).

Current Suicide Rates Among Veterans (2011) 18 Veteran suicides a day 18 Veteran suicides a day 950 suicide attempts per month among Veterans receiving care at a VA 950 suicide attempts per month among Veterans receiving care at a VA 7% of suicide attempts resulted in death in FY % of suicide attempts resulted in death in FY % of those who attempted suicide in 11% of those who attempted suicide in FY 2009 (and did not die as a result of this attempt) made a repeat suicide attempt with an average of 9 months of follow-up FY 2009 (and did not die as a result of this attempt) made a repeat suicide attempt with an average of 9 months of follow-up

Total number of soldiers who have been deployed during OEF/OIF 1.6 million

Total number of soldiers who have been deployed to a war zone twice or more 700,000+

86% know someone who was seriously injured or killed.

77% have shot at or directed fire at the enemy.

68% have seen dead or seriously injured Americans.

“Never before have we asked so few citizen soldiers to do so much in war time, while knowing they and their families have great psychosocial needs.” Dr. Charles R. Figley

Nearly 1/3 of U.S. military personnel from the war in Iraq access mental health services after their return home…. –Col. Charles Hoge –March 1, JAMA

25% of individuals who die by suicide were intoxicated at the time of their death 25% of individuals who die by suicide were intoxicated at the time of their death Alcohol was involved in 64% of attempts Alcohol was involved in 64% of attempts Drug overdose deaths are typically ruled accidental in the absence of information confirming suicide Drug overdose deaths are typically ruled accidental in the absence of information confirming suicide 12 Suicide and Alcohol/Drugs

Newest Veterans Face TBI as a primary injury Patients with traumatic brain injuries may be at increased risk for suicide. TBI survivors are at increased risk for suicide ideation (Simpson and Tate, 2002), suicide attempts (Silver et al. 2001) and suicide completions (Teasdale and Engberg, 2001). Most concerning residual factor: Impulsivity

Risk Factors Among Veterans High gun ownership High gun ownership Debilitating injuries Debilitating injuries Mental health issues Mental health issues

Highest Risk Factors… Suicidal ideation reported Suicidal ideation reported Suicidal intention reported Suicidal intention reported Suicidal plan with means reported Suicidal plan with means reported

The ultimate aim of suicide prevention is to reduce deaths by suicide; however, it is equally important to reduce the frequency and severity of suicide attempts. The ultimate aim of suicide prevention is to reduce deaths by suicide; however, it is equally important to reduce the frequency and severity of suicide attempts.

First Responders Police officers, firefighters and other first line responders are increasingly called upon in situations involving mental health emergencies, such as suicidal crises. Police officers, firefighters and other first line responders are increasingly called upon in situations involving mental health emergencies, such as suicidal crises. First responders are in a unique position to determine the course and outcome of suicidal crises. First responders are in a unique position to determine the course and outcome of suicidal crises. They are often the first to be involved in situations where suicidal behaviors, such as a suicide threat, suicide attempt or completed suicide, have occurred. They are often the first to be involved in situations where suicidal behaviors, such as a suicide threat, suicide attempt or completed suicide, have occurred.

Awareness of risk When faced with a mentally ill person or offender, first interveners must be alert to the possibility of a suicidal act as well as the possibility of danger to others (including being personally attacked). When faced with a mentally ill person or offender, first interveners must be alert to the possibility of a suicidal act as well as the possibility of danger to others (including being personally attacked).

Involuntary admission Police can determine if an individual is in need of psychiatric care and they can transport to a local emergency room for medical /psychiatric assessment and treatment. Police can determine if an individual is in need of psychiatric care and they can transport to a local emergency room for medical /psychiatric assessment and treatment.

Suicide by deadly force One of the most difficult crisis situations for police to address occurs when an individual engages in life-threatening behavior to provoke officers to fire, either to protect themselves or a civilian bystander. This has been termed "police-assisted suicide" or "suicide by cop”. One of the most difficult crisis situations for police to address occurs when an individual engages in life-threatening behavior to provoke officers to fire, either to protect themselves or a civilian bystander. This has been termed "police-assisted suicide" or "suicide by cop”.

Recognizing this potential outcome, being able to identify the signs and symptoms of seriously mentally disordered behavior and following locally established inter-agency guidelines for the management and de-escalation of such crises will help to minimize lethal outcomes. Recognizing this potential outcome, being able to identify the signs and symptoms of seriously mentally disordered behavior and following locally established inter-agency guidelines for the management and de-escalation of such crises will help to minimize lethal outcomes.

First Responders HELPING SOMEONE WHO IS SUICIDAL People who feel suicidal often express hopelessness and depression. They see suicide as the only way to solve their problems and eliminate their suffering. People who feel suicidal often express hopelessness and depression. They see suicide as the only way to solve their problems and eliminate their suffering. Although suicide is difficult to predict, a large proportion of those who eventually kill themselves will give warning signs of their suicidal intentions in the weeks or months prior to their death. Although suicide is difficult to predict, a large proportion of those who eventually kill themselves will give warning signs of their suicidal intentions in the weeks or months prior to their death. These are not harmless bids for attention, but important cries for help that should be taken seriously. These are not harmless bids for attention, but important cries for help that should be taken seriously.

Warning signs include both behavioral and verbal clues: –Hopelessness/helplessness –Withdrawn from family/friends –Anger, rage –Giving away possessions –History of suicide attempts –Drug and/or alcohol abuse –A change in health

Warning signs continued….. –Constantly dwelling on problems for which there seem to be no solutions; –Expressing a lack of support or belief in the system; –Giving some other indication of a suicide plan.

Approach all situations involving someone who is suicidal as a psychiatric emergency and act accordingly. Never assume that suicidal ideas or gestures are harmless bids for attention or an attempt to manipulate others. Approach all situations involving someone who is suicidal as a psychiatric emergency and act accordingly. Never assume that suicidal ideas or gestures are harmless bids for attention or an attempt to manipulate others.

Assessing the risk Engage the individual. Engage the individual. Encourage the person to talk. Encourage the person to talk. Most suicidal people are ambivalent about dying. Most suicidal people are ambivalent about dying. Asking someone if they are suicidal will not “tip them over the edge”, but will provide a sense of relief and a starting point for a solution. Asking someone if they are suicidal will not “tip them over the edge”, but will provide a sense of relief and a starting point for a solution. To assess intent, ask if the individual has a plan, access to lethal means, or has decided when to act. To assess intent, ask if the individual has a plan, access to lethal means, or has decided when to act.

HELPING SOMEONE WHO IS SUICIDAL HELPING SOMEONE WHO IS SUICIDAL Never leave a potentially suicidal individual alone based on their promise to visit their mental health worker or the hospital. Never leave a potentially suicidal individual alone based on their promise to visit their mental health worker or the hospital. Ensure that family members or significant others are on the scene and accept responsibility for help seeking. Ensure that family members or significant others are on the scene and accept responsibility for help seeking.

Everyone’s role: Be available Be available Be aware Be aware Offer hope Offer hope

Veterans Crisis Line National Number: National Number: Press #1 for Veteran or family of Veteran Press #1 for Veteran or family of Veteran Crisis Line is available 24/7 and staffed by VA mental health professionals Crisis Line is available 24/7 and staffed by VA mental health professionals In an emergency, Crisis Line staff will assist with immediate referral to community resources including: In an emergency, Crisis Line staff will assist with immediate referral to community resources including: –Local Police Departments –County Crisis Services If non-emergent, the Veteran will be referred to the closest VA within 24hrs. If non-emergent, the Veteran will be referred to the closest VA within 24hrs.