1. Suicide in the Northwest Health Planning Region, 2003-2008 Marc E. Leslie Coordinator, Virginia Violent Death Reporting System Office of the Chief Medical Examiner, Virginia Department of Health Presented by Stephanie Goodman Injury Data and Evaluation Coordinator Office of Family Health Services, Virginia Department of Health The Northwest Health Planning Region Suicide Prevention Summits May 24, 2011 Harrisonburg, VA May 25, 2011 Fredericksburg, VA

2. Map of the Northwest Health Planning Region (HPR) 2

3. 3 Pop Quiz In the Northwest Health Planning Region: 1.Average number of suicides per year? (Hint: average of 32 homicides per year). 2.Percentage of suicide victims who are White males? 3.Median age of a suicide victim? 4.Percentage of male and female suicides by firearm?

4. 4 Suicide in the Northwest HPR, 2003-2008 Overview of the Problem

5. 5 Suicide in the Northwest HPR, 2003-2008

6. 6

7. 7 Suicide vs. Homicide (2003-2008) 898 suicides; rate of 12.9 191 homicides; rate of 2.8 Suicide occurs 4.7 times more often than homicide

8. 8 Suicide in the Northwest HPR, 2003-2008

9. 9

10. 10 Suicide in the Northwest HPR, 2003-2008 Who is at Risk?

11. 11 Suicide in the Northwest HPR, 2003-2008 Selected Demographic Elements  Gender  Race  Age

12. 12 Suicide in the Northwest HPR, 2003-2008 Race and Gender Male (78%, rate of 20.5) White (93%, rate of 13.9) White male (73%, rate of 22.0) (remember, overall rate for Northwest HPR is 12.9)

13. 13 Suicide in the Northwest HPR, 2003-2008 Age Median age is 47 Ages 45-54 most common age group (25%) and highest rate (22.8) Next highest rates for those 75-84 (rate of 20.7) and 85 and older (rate of 21.0) In general, as age increases, so does suicide rate

14. 14 Suicide in the Northwest HPR, 2003-2008

15. 15 Suicide in the Northwest HPR, 2003-2008 Race and Gender: Non-Fatal Attempts Most commonly by females (62%, rate of 83.2) Whites still most common and highest risk; but Black risk level rises notably (from rate of 7.3 to 46.9)

16. 16 Suicide in the Northwest HPR, 2003-2008

17. 17 Suicide in the Northwest HPR, 2003-2008 Age: Non-Fatal Attempts Median age is 34 Risk shifts from middle-age and older adults to children and youth Rate for those 15-19 years old is 120.6 In general, non-fatal attempt rate decreases with age

18. 18 Suicide in the Northwest HPR, 2003-2008 At ages 65-74, the fatal rate surpasses the non-fatal rate

19. 19 Suicide in the Northwest HPR, 2003-2008 Veterans

20. 20 Suicide in the Northwest HPR, 2003-2008 Veterans 24% of all suicide victims (18 years and older) 29% of males; 4% of all females Unknown if veterans served in combat, but can generally tell if they are currently in the military

21. 21 Suicide in the Northwest HPR, 2003-2008 Veterans Male veterans older than male non-veterans (median ages of 61 and 44, respectively) Median age suggests that those who are combat veterans generally not in the most recent conflicts 63% of males ages 65 and over are veterans compared to 21% of males ages 18-64

22. 22 Suicide in the Northwest HPR, 2003-2008 Method of Fatal Injury

23. 23 Suicide in the Northwest HPR, 2003-2008 Method of Fatal Injury More than one method of fatal injury can be used per suicide (e.g., combining poison and drowning) Firearm, poison, and hanging/suffocation account for 95% of suicides Most poisons are prescribed medications, primarily mental health medications and pain medications

24. 24 Suicide in the Northwest HPR, 2003-2008

25. 25 Suicide in the Northwest HPR, 2003-2008 Method of Fatal Injury: Non-Fatal Attempts Most common method for non-fatal attempts is poison (82%) Poison use is defining method difference between fatal and non-fatal attempts

26. 26 Suicide in the Northwest HPR, 2003-2008 Geography

27. 27 Suicide in the Northwest HPR, 2003-2008 Geography Northwest HPR has 32 localities (24 counties and 8 cities) 23 of these localities (72%) have a suicide rate exceeding the rate for Virginia (11.3) In general smaller locality = lower number and higher rate

28. 28 Suicide in the Northwest HPR, 2003-2008 #Rate Five Highest Suicide Rates Rappahannock1227.8 Waynesboro2721.2 Warren4420.7 Page2819.5 Rockbridge2418.8 #Rate Five Lowest Suicide Rates Lexington00.0 Bath13.5 Harrisonburg166.4 King George129.5 Stafford689.6

29. 29 Suicide in the Northwest HPR, 2003-2008

30. 30 Suicide in the Northwest HPR, 2003-2008

31. 31 Suicide in the Northwest HPR, 2003-2008 Selected Circumstances

32. 32 Suicide in the Northwest HPR, 2003-2008 Most Common Circumstances Mental health problem (54%) Crisis in past two weeks (38%) Intimate partner problem (33%) Problem with alcohol and/or other substances (27%) Physical health problem (24%)

33. 33 Suicide in the Northwest HPR, 2003-2008 Circumstances: Mental Health Females (76%) more than males (47%) Most prevalent in ages 35-44 (69%); 30% or more of every age group 80% treated in past two months and/or prior 68% known to take mental health medications currently or in the past* *2007-2008 data

34. 34 Suicide in the Northwest HPR, 2003-2008 Circumstances: Crisis in Past 2 Weeks 38% of all persons; 40% of males, 32% of females Most crises (72%) occurred in the past 24 hours* Indicator of reactive suicides 50% or more for every age group through ages 25-34 *2007-2008 data

35. 35 Suicide in the Northwest HPR, 2003-2008 Circumstances: Intimate Partner Problems 33% having problems with current/former intimate partner at time of suicide Similar for males and females 68% also having a recent life crisis Shows volatility of intimate partner conflict

36. 36 Suicide in the Northwest HPR, 2003-2008

37. 37 Suicide in the Northwest HPR, 2003-2008 Circumstances: Alcohol and Other Substance Problems 27% of all persons Peaks at ages 35-44 (36%) 48% of those with alcohol problems had elevated levels of alcohol in their system (compared to 22% of those without alcohol problems)

38. 38 Suicide in the Northwest HPR, 2003-2008 Circumstances: Physical Health Problems 24% of all suicide victims; no gender differences Median age of 64 compared to 44 for those without a physical health problem 75% or more of those ages 75-84 and 85 and older

39. 39 Suicide in the Northwest HPR, 2003-2008 Circumstances: Physical Health Problems Explains majority of elder suicides Problems range from treatable (diabetes, mild pain) to severe (loss of vision, amputations) to terminal diseases and conditions

40. 40 Suicide in the Northwest HPR, 2003-2008 Circumstances: Warning Signs 47% disclosed intent and/or had prior attempts Most commonly disclosed to intimate partners (58%), family (28%), or friends/acquaintances (21%)* *2007-2008 data

41. 41 Suicide in the Northwest HPR, 2007-2008 Actions Taken to Prevent Suicide* Tried to persuade victim to not commit suicide (37%) Checked in on victim (27%) Called 911/law enforcement (20%) Sought/encouraged mental health treatment (17%) Limited access to firearms/ammunition (13%) *2007-2008 data (entire slide)

42. 42 Suicide in the Northwest HPR, 2007-2008 Efforts to Limit Access to Firearms and/or Ammunition* 10 persons had friends or family members who restricted access to firearms or ammunition Includes 6 persons not known to disclose intent, but loved ones acted out of concern Variety of techniques used to restrict (hiding, removing, disassembling) Of these persons, all (100%) used a firearm to commit suicide *2007-2008 data (entire slide)

43. 43 Suicide in the Northwest HPR, 2003-2008 In the fatal suicide, those with prior attempts used less lethal methods than those without prior attempts

44. 44 Suicide in the Northwest HPR, 2007-2008 Other Warning Signs of Suicide* Taking prescribed pain medication (15%) Sleeping too little (8%) Unusual behavior, past two weeks (6%) Family history of suicide (4%) Family/friends expected suicide (3%) *2007-2008 data (entire slide)

45. 45 Suicide in the Northwest HPR, 2003-2008 Conclusions Suicide rates are highest among Whites, males, and middle-aged and older adults Most suicides involve use of a firearm to inflict fatal injury Most suicide victims have a mental health problem, and most of these persons were being treated

46. 46 Suicide in the Northwest HPR, 2003-2008 Conclusions Nearly half of suicide victims talk about plans or desire to commit suicide and/or have a history of suicide attempt(s) Fatal suicide and non-fatal suicide attempts present radically different pictures of risk and methods of fatal injury

47. 47 Questions, Data Requests, Further Information Marc Leslie, VVDRS Coordinator 737 N. 5 th Street, Suite 301 Richmond, VA 23219 804-205-3855 marc.leslie@vdh.virginia.gov http://www.vdh.virginia.gov/medExam/NVDRS.htm Our goal is to provide data and information that can be used for prevention and education; please let me know how I can help

48. 48 Appendix: Additional Information and Complete Tables

49. 49 Suicide in the Northwest HPR, 2003-2008 InformationSlide Demographics Gender51 Race51 Ethnicity51 Race/Gender52 Age Group53 Veterans Male Age Group/Veteran56 Method of Fatal Injury Complete List of Methods57 Selected Methods by Age58 Categories of Poison59 Most Common Poisons60 InformationSlide Locality-Specific Number/Rate by Locality62-64 Circumstances Relationship Problems65 Life Stressors65 Alcohol/Other Substances66 Mental Health67-68 Warning Signs of Suicide69 Disclosed Intent70 Actions to Prevent Suicide71-72 Prior Suicide Attempts73 Other Warning Signs74 Index: Fatal Suicide

50. 50 Suicide in the Northwest HPR, 2003-2008 InformationSlide Non-Fatal Suicide Gender54 Race54 Ethnicity54 Age Group55 Method of Fatal Injury Complete List of Methods61 Index: Non-Fatal Suicide

51. 51 Suicide in the Northwest HPR, 2003-2008 #%Rate Gender Male70178.120.5 Female19721.95.6 Race White83593.013.9 Black576.37.3 Asian50.64.1 Native American00.0 Ethnicity Hispanic141.64.6 TOTAL898100.012.9

52. 52 Suicide in the Northwest HPR, 2003-2008 #%Rate Selected Race/Gender White male65272.622.0 White female18320.46.0 Black male465.112.0 Black female111.22.8 The White male suicide rate is almost 3.7 times the rate for White females, almost twice the rate for Black males, and almost eight times the rate for Black females.

53. 53 Suicide in the Northwest HPR, 2003-2008 #%Rate Age Group 10-1470.81.5 15-19444.98.6 20-24455.08.2 25-3412213.612.6 35-4417319.317.0 45-5422525.122.8 55-6412313.717.0 65-74778.616.9 75-84606.720.7 85 and older222.421.0 TOTAL898100.012.9 Next highest risk: 75 and older Largest percentage of victims and greatest risk: ages 45-54

54. 54 Non-Fatal Suicide Attempts in the Northwest HPR, 2003-2008 #%Rate Gender Male1,78237.852.2 Female2,93762.283.2 Race White4,14687.968.8 Black3657.746.9 Asian150.312.4 Native American00.0 Other1262.7- Unknown671.4- Ethnicity Hispanic641.421.1 TOTAL4,719100.068.0

55. 55 Non-Fatal Suicide Attempts in the Northwest HPR, 2003-2008 #%Rate Age Group 5-940.10.9 10-141032.222.3 15-1961513.0120.6 20-2463113.4114.3 25-341,01421.5104.6 35-441,21425.7119.2 45-5478316.679.3 55-642365.032.6 65-74731.516.0 75-84310.710.7 85 and older140.313.3 TOTAL4,719100.068.0 Greatest risk for attempts: ages 15-19 Largest percentage: ages 34-44

56. 56 Suicide in the Northwest HPR, 2003-2008

57. 57 Suicide in the Northwest HPR, 2003-2008 #% Method of Fatal Injury Firearm52558.5 Poison19721.9 Hanging/Suffocation13214.7 Drowning131.4 Fall121.3 Sharp Instrument111.2 Motor Vehicle70.8 Fire or Burn30.3 Non-Powder Gun20.2 Other Transport Vehicle10.1 Other20.2 95% of all suicides

58. 58 Suicide in the Northwest HPR, 2003-2008

59. 59 Suicide in the Northwest HPR, 2003-2008 #% General Category of Poison Prescription Medication13970.6 Carbon Monoxide4020.3 Over-the-Counter Medication2914.7 Alcohol2211.2 Street Drugs31.5 Other105.1 Percentages are based on the number of poisoning suicides (n = 197).

60. 60 Suicide in the Northwest HPR, 2003-2008 #% Most Common Poisons Amitriptyline*2512.7 Oxycodone**2110.7 Methadone**189.1 Diphenhydramine178.6 Quetiapine*157.6 Citalopram*147.1 Morphine**147.1 Acetaminophen136.6 Hydrocodone**136.6 Propoxyphene**126.1 Percentages are based on the number of poisoning suicides (n = 197). Poisons used by ten or more persons are listed. * Commonly prescribed for mental health treatment ** Commonly prescribed for pain management

61. 61 Non-Fatal Suicide Attempts in the Northwest HPR, 2003-2008 #% Method of Fatal Injury Poison3,84881.5 Sharp Instrument60912.9 Firearm791.7 Hanging/Suffocation230.5 Fall180.4 Fire or Burn170.4 Motor Vehicle80.2 Hot Object/Substance2<0.1 Environmental Exposure1<0.1 Other771.7 Unspecified370.8

62. 62 Suicide in the Northwest HPR, 2003-2008 #Rate Albemarle5910.8 Augusta7217.2 Bath13.5 Buena Vista513.0 Caroline1912.3 Charlottesville2510.5 Clarke1011.8 Culpeper3413.2 Fauquier4812.3 Fluvanna1610.9 Frederick5012.0 Fredericksburg1814.1 Number and Rate (per 100,000) of Suicides by Locality of Residence

63. 63 Suicide in the Northwest HPR, 2003-2008 #Rate Greene1413.4 Harrisonburg166.4 Highland213.5 King George129.5 Lexington00.0 Louisa2915.9 Madison1417.4 Nelson1314.3 Orange2815.2 Page2819.5 Rappahannock1227.8 Number and Rate (per 100,000) of Suicides by Locality of Residence (continued)

64. 64 Suicide in the Northwest HPR, 2003-2008 #Rate Rockbridge2418.8 Rockingham429.7 Shenandoah4017.0 Spotsylvania8211.8 Stafford689.6 Staunton2416.9 Warren4420.7 Waynesboro2721.2 Winchester2214.5 Northwest HPR89812.9 Virginia5,14611.3 Number and Rate (per 100,000) of Suicides by Locality of Residence (continued)

65. 65 Suicide in the Northwest HPR, 2003-2008 #% Relationship Characteristics Intimate Partner Problem29233.4 Non-intimate Relationship Problem809.2 Life Stressor Characteristics Crisis within Two Weeks of Suicide*33338.1 Physical Health Problem20523.5 Recent Criminal Legal Problem12314.1 Financial Problem11413.1 Job Problem10512.0 Death/Suicide of Family/Friend758.5 Perpetrator of Interpersonal Violence687.8 Percentages are based on the number of suicides with at least one known circumstance (n = 873). * Of these, 72% had a crisis in past 24 hours (2007-2008 data)

66. 66 Suicide in the Northwest HPR, 2003-2008 #% Substance Use Characteristics Problem with Alcohol/Other Substances23226.6 Problem with Alcohol11112.7 Problem with Other Substances677.7 Problem with Alcohol and Other Substances546.2 Percentages are based on the number of suicides with at least one known circumstance (n = 873).

67. 67 Suicide in the Northwest HPR, 2003-2008 #% Mental Health Problems Current Mental Health Problem46753.5 Diagnosis: Depression35941.1 Diagnosis: Bipolar748.5 Diagnosis: Anxiety Disorder526.0 Diagnosis: Schizophrenia232.6 Mental Health Treatment37543.0 Current Mental Health Treatment32837.6 Noncurrent Mental Health Treatment475.4 Percentages are based on the number of suicides with at least one known circumstance (n = 873). Diagnoses are not exclusive, but represent the most common diagnoses.

68. 68 Suicide in the Northwest HPR, 2007-2008 #% Use of Prescribed Mental Health Medications Used in Past 31 Days and/or Prior12767.6 Used in Past 31 Days10857.4 Used, But Not in Past 31 Days1910.1 Unknown/Never Used6132.4 Percentages are based on the number of victims with a mental health problem (n = 188). Data are from 2007-2008.

69. 69 Suicide in the Northwest HPR, 2003-2008 #% Warning Signs of Suicide Disclosed Intent/History of Attempts40746.6 Disclosed Intent to Commit Suicide31936.5 History of Suicide Attempts16719.1 Percentages are based on the number of suicides with at least one known circumstance (n = 873).

70. 70 Suicide in the Northwest HPR, 2007-2008 #% Person to Whom Victim Disclosed Intent Intimate Partner (Current/Former)4557.7 Family Members2228.2 Friends/Acquaintances1620.5 Mental Health Professional33.8 Medical Personnel33.8 Prison Guard/Other Prison Staff22.6 Percentages are based on the number of victims who disclosed intent and where this information is known (n = 78). Data are from 2007-2008.

71. 71 Suicide in the Northwest HPR, 2007-2008 #% Type of Action Taken to Prevent Suicide Tried to Persuade Victim1136.7 Checked on Victim826.7 Called 911/Law Enforcement620.0 Sought Mental Health Treatment516.7 Limited Access to Firearms and/or Ammunition413.3 Monitored Victim13.3 Percentages are based on the number of suicides where someone took action to prevent the suicide (n = 30). Data are from 2007-2008. Some victims had family, friends, or others who reacted to the disclosed intent and tried to prevent the suicide

72. 72 Suicide in the Northwest HPR, 2007-2008 #% How Firearm Access was Restricted Hidden (not locked)440.0 Removed; gave back later220.0 Monitored Victim110.0 Removed all but one firearm110.0 Removed all firearms110.0 Removed; Victim had hidden a firearm110.0 Percentages are based on the number of victims where it was known how firearm access was restricted (n = 10). Data are from 2007-2008.

73. 73 Suicide in the Northwest HPR, 2007-2008 #% Number of Prior Suicide Attempts One2847.5 Two813.6 Three23.4 Four or more58.5 Multiple, unspecified1627.1 Percentages are based on the number of victims with a known number of prior attempts (n = 59). Data are from 2007-2008.

74. 74 Suicide in the Northwest HPR, 2007-2008 #% Other Warning Signs Took Prescribed Pain Medication, Past Two Months4715.1 Sleep Problems258.0 Sleeping Too Little247.7 Sleeping Too Much10.3 Unusual Behavior, Past Two Weeks175.5 Family History of Suicide134.2 Family/Friends Expected Suicide103.2 Did Not Want to be a Burden92.9 Percentages are based on the number of suicides with at least one known circumstance (n = 311). Data are from 2007-2008.