1. Basic Concepts about Suicide, Treatment and Prevention

2. “Suicide is the result of an untimely convergence of multiple psychiatric, psychological, social, environmental, occupational, cultural, medical, academic stressors that severely challenges an individual’s capacity to cope.” – Edwin Schneidman, 1954

3. The expression of suicidality is idiosyncratic for each individual
The expression of suicidality is idiosyncratic for each individual. It is the ultimate expression of an individual response to unbearable distress. There is no clear causality to suicide
Discussion about your “assessment” of the crisis.

4. Basic Concepts Suicide is almost always multi-determined.
Suicide prevention should involve multiple approaches.
Most suicidal people do not want to die, they want their pain to end.
Suicidal people want to find a way to live.
Start discussion of EBP

5. Basic Concepts
Suicide contagion: refers to the increase of suicides or suicidal behaviors upon a death by suicide
Suicide cluster: refers to a group of suicides that occur close together in time than would normally be expected.

6. Basic Concepts
A CDC study found that 24% of nearly lethal suicide attempts occurred less than five minutes after the person decided on suicide.
Only 13% said 24 hours or more went by.
At least 1 in 3 youth suicides followed within 24 hours of a crisis like an arrest, family argument or relationships break-up (Barber & Miller, 2010).
Timing of our assessment is crucial

7. Basic Concepts Ambivalence exists until the moment of death.
The final decision rests with the individual.
Reduce risk factors and you reduce risk.
Enhance protective factors and you reduce risk

8. Basic Concepts
There is a necessary condition plus a trigger (s) that push the suicide threshold.
Necessary condition = What?
Diagnosis……..
Triggers = What?
H.A.L.T. : hungry, angry, lonely, tired
Sudden loss, change (good or bad)
Intoxicated

9. Basic Concepts Mental illness and suicide connection (90%)
Absence of a psychiatric diagnosis does not equal mental health
Co-morbidity is one of the greatest risks

10. Basic Concepts The greater the number of losses, the greater the risk
Personally humiliating events
No good evidence for sexual orientation as an independent risk factor for suicide

11. Basic Concepts
60% of people who died by suicide had no previous attempt.
60% of people who died by suicide had no contact with a mental health professional.
60% to 90% of all people who died by suicide had communicated intent to a significant other during the period prior to death.
Clark and Fawcett 1991

12. Basic Concepts
75% to 80% had (non-psychiatrist) physician contact within six months of death
Only one-sixth of all people who died by suicide are in current treatment with a mental health provider
Treatment prevents suicide
Again, stressing the need for screening, assessment and referral in the medical setting
Reviewing that most people who are suicidal are never seen by a “mental health” provider

13. Neurobiology of Suicide
Familial patterns of suicide suggest biological (genetic) factors may influence risk.
Life history, culture, attitude and various forms of psychopathology, probably outweigh potential genetic determinants.
Current theory: DSM, APA

14. Neurobiology of Suicide
There is increasing evidence depletion of essential neurotransmitters, including dopamine and serotonin, may be the common clinical pathway for suicidal thinking, feeling and behaviors.
Low HIAA (metabolite of serotonin) has been found in severe suicidal depressions.
Research suggests reduced serotonin function in suicide, especially in suicides of high lethality or with considerable planning.

15. Neurobiology of Suicide
Lithium has pronounced anti-suicide effect.
Why?
No one's really sure how it works exactly. It was discovered to work for mania almost by accident:
1. alters sodium transport across nerve (brain) cells
2. alters metabolism of serotonin (brain chemical for mood)
Lithium appears to decrease aggression and impulsivity.
Lithium is used to treat bipolar so large segment of the suicidal population would not benefit from this treatment option
Therapy and mood stabilizers prevent suicide better than mood stabilizers alone.
Meds as an EBP, start with Lithium and discuss other SSRI’s, atypicals, etc.

16. Common Chemical Pathways for Suicidal Thoughts
Alcohol and to a lesser extent other substances, in the bloodstream
Low serotonin levels
Impaired dopamine function

17. Psychiatric Illness COMORBID TRANSIENT STATES
Schizophrenia Agitation
Depressive Disorders Mental Uneasiness
Bipolar Disorders Psych Ache
Suicidal Behavior
Anxiety Disorders Hopelessness
Substance Use Disorders Neurotransmitter Deficit
Personality Disorders H.A.L.T.
Co-morbid Physical Illness
Including chronic pain Alcohol Myopia

18. The Many Paths to Suicide Increasing Hopelessness = Contemplation
Cause of Death
Fundamental Risk Factors
Acute Risk Factors
Biological
Crisis in Relation
Poison
Genetic Load
Sex
GLTB
Loss of Freedom
Gun
Race
Age
Personal/Psychological
Increasing Hopelessness = Contemplation
of Suicide
as Solution
Fired/ Expelled
Hanging
Values
Religion
Beliefs
Drugs or
Alcohol
Child Abuse
Loss of Parent
Culture Shock/
Shift
WALL OF RESISTANCE
Illness
Autocide
This slide took years to develop and I cannot do it justice with a few bullet points.
Focus on risk as well as protective factors in your coverage.
GLTB literature for youth shows sexual orientation by itself is not a risk factor, what is a risk for this group is the social, psychological environment and the use of drugs and alcohol to combat stress, anxiety, depression that may develop (see M. Gould’s 10-year review article on youth suicide risk for citations).
Differentiate between fundamental or distal risk factors
Note: as crisis worsens, communications of suicidal planning increases
Wall of Resistance is one protective factor list
Model for Suicide
Environmental
Urban
vs.
Rural
Geo-graphy
Major Loss
Jumping
Season of year ?
All “Causes” are real.
Hopelessness is the common pathway.
Break the chain anywhere = prevention. ?

19. Counselor or therapist Medication Compliance Support of significant
Wall of Resistance to Suicide
Counselor or therapist
Duty to others
Sobriety
Good health
Medication Compliance
Fear
Job Security or
Job Skills
Responsibility
for children
Support of significant
other(s)
Difficult Access
to means
A sense of
HOPE
Positive
Self-esteem
Religious
Prohibition
Calm
Environment
AA or NA
Sponsor
Pet(s)
Sobriety is the foundation for safety, as everything rests on a non-intoxicated state of mind AND asking for abstinence can be the thing that creates the suicidal crisis
Read through these and add your own
Best
Friend(s)
Safety
Agreement
Treatment
Availability
-- SLEEP --
Protective Factors

20. THE LETHAL TRIAD UPSET PERSON ALCOHOL
Reduce or remove any of these risk factors quickly, and the risk of suicide drops dramatically.
Continuation of lethal means conversation (jumping, guns – can’t change your mind, other methods offer more opportunity for rescue)
FIREARM
ALCOHOL
When these three are present-the risk of violence is high. Reduce or remove any piece and risk drops significantly.

21. What can we do? Do we know how to help people get sober?
Do we know how to treat anxiety?
Do we know how reduce psychic pain?
Are there effective treatments for agitation?
Do we know what to do about neurotransmitter deficits?
CBT for depressive hopelessness?
DBT for individuals with personality disorders?
EBP discussion

22. Economic Impact of Suicides
The economic cost of suicide death in the U.S. was estimated in 2010 to be more than $44 billion annually. With the burden of suicide falling most heavily on adults of working age, the cost to the economy results almost entirely from lost wages and work productivity.
The average suicide costs $1,164,499.
Economic Impact of Suicide Attempts
Non-fatal injuries due to self-harm cost an estimated $2 billion annually for medical care. Another $4.3 billion is spent for indirect costs, such as lost wages and productivity.

23. Mental Disorders
An estimated 26.2 percent of Americans ages 18 and older — about one in four adults — suffer from a diagnosable mental disorder in a given year.
Even though mental disorders are widespread in the population, the main burden of illness is concentrated in a much smaller proportion — about 6 percent, or 1 in 17 — who suffer from a serious mental illness.

24. Schizophrenia Suicide Risk: 5% - 6% die by suicide 20% attempt
Risk remains high over lifespan for males and females
Risk higher for younger males with co-morbid substance use.
Depressive symptoms are often ignored and/or untreated leading to higher risk
Risk is higher right after a psychotic episode or hospital discharge

25. Schizoaffective Suicide risk Lifetime risk = 5%
Attempts = 42.8% found in a 1999 study
The presence of depressive symptoms is correlated with higher risk

26. Major Depression Suicide risk:
Major depression is the psychiatric diagnosis most commonly associated with suicide.
Lifetime risk of suicide among patients with untreated depressive disorder is nearly 20%
About 7 out of every hundred men and 1 out of every hundred women who have been diagnosed with depression in their lifetime will go on to die by suicide.
Most consistent risk factor is past attempts or threats

27. Major Depression
It should be remembered that most suicides are not preceded by an attempt.
About 2/3 of people who die by suicide are depressed at the time of their deaths.
The risk of suicide in people with major depression is about 20 times that of the general population.

28. Major Depression
Individuals who have had multiple episodes of depression are at greater risk for suicide than those who have had one episode.
People who have a dependence on alcohol or drugs in addition to being depressed are at greater risk for suicide.
Other risk factors: being male, single or living alone, and hopelessness.

29. Bipolar I
Suicide risk: estimated to be at least 15% higher than the general population.
32.4% make attempts
Bipolar may account for one –quarter of all suicides.
Past history of attempts and percent of days spent depressed in the last year are associated with greater risk for attempts or deaths.

30. Suicide risk: 36.3% make attempts
Bipolar II
Suicide risk:
36.3% make attempts
Approximately 1/3 of individuals report a lifetime history of suicide attempt
Lethality may be higher in individuals with bipolar II compared to bipolar I

31. Borderline Personality Disorder
Suicide Risk:
About 70% of people with BPD will make at least one suicide attempt in their lifetime.
8 to 10% die by suicide. This rate is more than 50 times the rate of suicide in the general population.
33% of youth who die by suicide have features, or traits, of BPD.
Young women with BPD have a suicide rate of 800 times higher than the general population.
Dr. Salters-Pedneault

32. Panic Disorder Suicide Risk:
Related to higher rates of attempts and ideation.
Specific Phobia:
60% more likely to make a suicide attempt than those without the diagnosis. May be correlated to comorbidity with personality disorders and other anxiety disorders.

33. Obsessive Compulsive Disorder
Suicide Risk:
About half of individuals with OCD will have suicidal thoughts.
One-quarter of individuals with OCD will make an attempt.

34. PTSD
Suicide Risk:
PTSD is associated with suicidal ideation and attempts, and the presence of the disorder may indicate which individuals with ideation eventually make a plan or actually attempt suicide.

35. Adverse Childhood Experiences
Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had:
4-to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt;

36. Intellectual Disability
This population is vulnerable to physiological, psychological, social, economic, and environmental correlates associated with suicide risk (Lunsky, 2004), and individuals with developmental disabilities die by suicide and manifest suicidal behaviors (Lunsky, 2004; Merrick et al., 2005). Developmental disability is not even mentioned in major documents promoting suicide prevention in the US. The National Strategy for Suicide Prevention: Goals and Objectives for Action and Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead (Litts, 2010) do not address suicide risk in those with developmental disabilities. “ They remain invisible in the suicide prevention agenda.