1. SUICIDE PREVENTION SCREENING AND ASSESSMENT NANCY KIRKPATRICK, YOUTH SUICIDE PREVENTION PROGRAM COORDINATOR AND FRANCISCO CHAVEZ, BEHAVIORAL HEALTH CONSULTANT NM DEPARTMENT OF HEALTH OFFICE OF SCHOOL AND ADOLESCENT HEALTH

2. SUICIDE IS THE 10 TH LEADING CAUSE OF DEATH IN US SECOND LEADING CAUSE OF DEATH FOR 15-24 YEAR OLDS 18-24 Y/O NA MALES 2.5 - 3 TIMES HIGHER THAN NATIONAL AVERAGE 64-85 Y/O WHITE MALES FASTEST RISING RATE IN NM, 53% OF ALL SUICIDES WERE BY FIREARMS (2013)

3. DATA: THE SCOPE OF THE PROBLEM Top 5 states for Suicide rates in US Montana 24.5 Alaska 22.7 New Mexico 21.5 Wyoming 20.5 Colorado 20.2 (US RATE 13.4 2014 American Association of Suicidology)

4. RISK FACTORS FOR NEW MEXICO:  Rural – Frontier  Access to care  High gun ownership  Poverty  High rates of drug/alcohol use and abuse  High military population  High Veterans population PERSONAL RISK FACTORS:  Relationships  Alcohol/Drug use and abuse  Mental illness  Financial problems  Access to lethal means  Previous attempt  School Failure  Legal problems (JJ)/CYFD

6. WARNING SIGNS - FACTS  Feelings – helplessness, hopelessness, guilt, shame, self hate, worthlessness, sadness, anxiety  Actions – writing, drawing or talking about death, alcohol/drug use or abuse, aggression, recklessness  Changes – personality, behaviors, sleeping, eating, disinterest in friends, personal appearance, or activities  Threats – statements, making plans to die, self-injury, attempt  Situations – trouble at school, legal trouble, feeling overwhelmed, recent losses

7. PROTECTIVE FACTORS  Having an adult other than a parent in their life who cares about them  Responsibility to others  Supportive family – friends  Engaged in school/community  Someone who cares about their school work  Connectedness - Belonging

8. ORGANIZATIONAL POLICIES AND PROCEDURES Make sure your school has policies and guidelines around suicide ideation/attempts/completions and postvention Make sure everyone is trained: Everyone in your school needs to know the Who, What, When, Why, and How After everyone is trained, PRACTICE (just like a fire drill!) Document – everything!

9. ZERO SUICIDE INITIATIVE Explicit commitment to reduce suicide deaths Develop a confident, competent, and caring workforce Identify every person, every time, for suicide risk Engage clients in a Safety Management Plan Treat suicidal thought and behaviors directly Follow patients through every transition in care Apply data-driven quality improvement

10. ZERO SUICIDE INITIATIVE Explicit commitment to reduce suicide deaths Develop a confident, competent, and caring workforce Identify every person, every time, for suicide risk Engage clients in a Safety Management Plan Treat suicidal thought and behaviors directly Follow patients through every transition in care Apply data-driven quality improvement

11. PUBLIC-PRIVATE PARTNERSHIP: NATIONAL ACTION ALLIANCE – TOOLKIT FOR ZERO SUICIDE

12. C-SSRS COLUMBIA SUICIDE SEVERITY RATING SCALE Developed in the context of a national effort to meet the need for a scale to better identify people at risk Many schools, police departments and other first responders throughout the United States have implemented the C-SSRS as a tool for everyday use Recommended by: CDC, FDA, The Joint Commission, Action Alliance C-SSRS is one of 3 screening tools endorsed by SAMHSA-HRSA Using the same assessment instrument - the C-SSRS - across settings will allow for effective and efficient communication (Speak the Same Language)

13. C-SSRS HIGHLIGHTS Available on website at no cost Mental health training is not required to administer the scale. Includes clear definitions of suicidal ideation and behavior. Predicts risk of suicidal behavior in suicidal and non-suicidal individuals. Recent post-implementation evidence of reduction in suicide rates. Paper versions for a wide-range of clinical use (research trials, practice, screening, triage, pediatric, military, risk assessment). Translated into 116 country-specific languages. Comprehensive set of training materials is available (in-person, webinar, video, online, scoring/administration and data analytic manuals, triage guidelines).

14. 523 outpatient visits at the Cleveland Clinic 6.2% positive screen on self-report eCSSRS vs. 23.8% positive on PHQ-9. most, but not all, of the positive Columbia screen patients endorsed PHQ-9 item 9. Cases were over- and under-detected by the PHQ-9.

15. CONSEQUENCES OF INCONSISTENT ASSESSMENT ● If suicidal behavior and ideation cannot be properly identified, they cannot be properly understood, managed or treated in any population or diagnosis ● Misclassification leads to overestimation risk and more referrals to behavioral health (Jurek et al., 2005) ● In a clinical trial, the Columbia standardized assessment led to a 50% reduction in falsepositives (Posner et al., AJP, 2007)

16. C-SSRS USING THE SCALE There are several versions of the C-SSRS The “Full Version,” which still takes just a few minutes - assess severity of ideation as well as intensity of suicidal ideation. The “Screening Version” is an even shorter version that can be used by first responders Consisting of 3 to 6 questions assesses severity of the ideation and behaviors You don't have to ask any or all questions, just the amount that you need Integrate information given by collateral sources family, caregivers

17. C-SSRS SCREENER VERSION  Only 3 to 6 questions  If 2 is yes ask 3-4-5-6  If 2 is no go to 6  Question 6 is combined behaviors question

18. Suicidal Ideation – Children under 12 1. Wish to die Have you thought about being dead or what it would be like to be dead? Have you wished you were dead or wished you could go to sleep and never wake up? Do you ever wish you weren’t alive anymore? 2. Active Thoughts of Killing Oneself Have you thought about doing something to make yourself not alive anymore? Have you had any thoughts about killing yourself? 3. Associated Thoughts of Methods Have you thought about how you would do that or how you would make yourself not alive anymore (kill yourself)? 4. Some Intent When you thought about making yourself not alive anymore (or killing yourself), did you think that this was something you might actually do? 5. Plan and Intent Have you ever decided how or when you would make yourself not alive anymore/kill yourself? Have you ever planned out (worked out the details of) how you would do it? What was your plan? When you made this plan (or worked out these details), was any part of you thinking about actually doing it?

19. Low Risk # 1- Have you wished you were dead or wished you could go to sleep & not wake up? Low Risk Low Risk #2- Have you actually had any thoughts of killing yourself? Low Risk Moderate Risk #3- Have you been thinking of how you might kill yourself? Moderate Risk High Risk #4- Have you had these thoughts & had some intention of acting on them? High Risk High Risk #5- Have you started to work out the details of how to kill yourself? Do you intend to carry out this plan? High Risk High Risk #6- Have you ever done anything, started to do anything, or prepared to do anything to end your life? High Risk Positive Response to C-SSRS Questions

20. WHEN TO REFER FOR FURTHER PSYCHIATRIC EVALUATION OR MORE INTENSIVE TREATMENT? Ideation: 4 or 5 in the past month Behaviors: any behavior in the past 3 months Risk doubles from 3 to 4

21. Suicidal Ideation Intensity Suicidal Behavior Actual Attempt Interrupted Attempt Aborted Attempt Preparatory Behavior Lethality Assessment of Suicidal Risk Using C-SSRS This illustration gives an overview of the types of thoughts and behaviors you will assess with the C-SSRS.

22. OTHER SUICIDAL BEHAVIORS QUESTION 6: HAVE YOU EVER DONE ANYTHING, STARTED TO DO ANYTHING, OR PREPARED TO DO ANYTHING TO END YOUR LIFE? Interrupted suicide attempt: A person takes steps to injure self but is stopped by another person from starting the self-injurious act, before the potential for harm has begun. Aborted suicide attempt: A person takes steps to injure self but is stopped by self from starting the self-injurious act, before the potential for harm has begun. Suicide attempt: A potentially self-injurious act committed with at least some wish to die, as a result of act. Other preparatory suicidal behavior: Acts or preparation towards imminently making a suicide attempt, but before potential for harm has begun such as assembling a method (e.g., buying a gun, collecting pills) or preparing for one’s death by suicide (e.g., writing a suicide note, giving things away).

23. LET’S PRACTICE You have a C-SSRS Screening Version in your packet Turn to your neighbor and practice asking the questions Remember if 1 and 2 are NO you can move to question 6 http://www.cssrs.columbia.edu/

24. QUESTIONS RESOURCES ARE IN YOUR PACKET

25. Office of School and Adolescent Health 300 San Mateo Blvd NE Suite 902 Albuquerque, NM 87108 Nancy Kirkpatrick Francisco Chavez Nancy.Kirkpatrick@state.nm.usNancy.Kirkpatrick@state.nm.us Francisco.Chavez@state.nm.usFrancisco.Chavez@state.nm.us 505-222-8683 505-222-8677