2. Suicide Prevention,Warning Signs and the National Strategy Richard McKeon Ph.D., MPH Branch Chief, Suicide Prevention SAMHSA

3. STAGGERING REALITY

4. Rank 10-14 years15-19 years20-29 years30-39 years40-49 years50-59 years 1 Unintentional Injuries Unintentional Injuries Unintentional Injuries Unintentional Injuries Malignant Neoplasms Malignant Neoplasms 2 Malignant Neoplasms Homicide Malignant Neoplasms Heart Disease Heart Disease 3Suicide Heart Disease Unintentional Injuries Unintentional Injuries 4 HomicideMalignant Neoplasms Malignant Neoplasms Suicide Diabetes Mellitus 5 Congenital Malformations Heart Disease Heart Disease HomicideLiver Disease Cerebro- vascular 6 Heart Disease Congenital Malformation s HIV Liver Disease 7 Chronic Lower Respiratory Ds Cerebro- vascular Congenital Malformation s Diabetes Mellitus Cerebro- vascular Chronic Lower Respiratory Ds 8 Influenza & pneumonia Influenza and pneumonia Diabetes mellitus Cerebro- vascular Diabetes Mellitus Suicide Leading causes of death for selected age groups – United States, 2005 Source: CDC vital statistics

5. SUICIDE: DATA AND DISPARITIES  Suicides 4 males : 1 female Highest risk: elderly white males (85+) Largest numbers: middle-aged (40-60) males at 2x’s baseline rate of other Americans and working-aged males (20-64) = 60 percent of suicides Higher risk: young and middle-aged AI/AN  Suicide attempts Female > male Rates peak in adolescence and decline with age Higher risk: LGBT youth and young Latinas 5

6. TOUGH REALITIES ~30 percent of deaths by suicide involved alcohol intoxication – BAC at or above legal limit ~30 percent of deaths by suicide involved alcohol intoxication – BAC at or above legal limit 6

7. TOUGH REALITIES 2005-2009: 55%↑ in emergency department visits for drug related suicide attempts by men 21 to 34 2005-2009: 49% ↑ in emergency department visits for drug related suicide attempts by women 50+ Every year > 650,000 persons receive treatment in emergency rooms following suicide attempts 7

8. TOUGH REALITIES 50 percent of those who die by suicide were afflicted with major depression…the suicide rate of people with major depression is 8 x’s that of the general population 90 percent of individuals who die by suicide had a mental disorder 8

9.  2005 – 2009: More than 1,100 members of the Armed Forces took their own lives; an average of 1 suicide every 36 hours  Suicide among veterans accounts for as many as 1 in 5 suicides in the U.S. TOUGH REALITIES 9

10. MISSED OPPORTUNITIES = LIVES LOST  Individuals discharged from an inpatient unit continue to be at risk for suicide ~10% of individuals who died by suicide had been discharged from an ED within previous 60 days ~ 8.6 percent hospitalized for suicidality are predicted to eventually die by suicide 10

11. MISSED OPPORTUNITIES = LIVES LOST 77 percent of individuals who die by suicide had visited their primary care doctor within the year 45 percent had visited their primary care doctor within the month THE QUESTION OF SUICIDE WAS SELDOM RAISED…

12. National Milestones in Suicide Prevention 1996: World Health Organization and United Nations publish Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies 1997: Congress passes S. Res. 84 and H. Res. 212 recognizing suicide as a national problem 1998: SPAN USA and CDC partner to host the Reno Consensus Development Conference 1999: HHS publishes the Surgeon General’s Call to Action to Prevent Suicide 2001: HHS publishes National Strategy for Suicide Prevention 2010: SPRC and SPAN USA/AFSP publish Charting the Future of Suicide Prevention: A 2010 Progress Review of the National Strategy and Recommendations for the Decade Ahead. 2010: National Action Alliance for Suicide Prevention established 2012: National Strategy for Suicide Prevention revised 12

13. NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION  A public-private partnership established in 2010 to advance the National Strategy for Suicide Prevention (NSSP)  Vision: The National Action Alliance for Suicide Prevention envisions a nation free from the tragic experience of suicide  Mission: To advance the NSSP by: Championing suicide prevention as a national priority Catalyzing efforts to implement high priority objectives of the NSSP Cultivating the resources needed to sustain progress  Leadership: PUBLIC SECTOR CO-CHAIR, The Honorable John McHugh, Secretary of the Army PRIVATE SECTOR CO-CHAIR, The Honorable Gordon H. Smith, President and CEO, National Association of Broadcasters 13

14. National Strategy for Suicide Prevention

15. Strategic Directions within the National Strategy for Suicide Prevention 15

16. Warning Signs Objective 2.4 Increase knowledge of the warning signs for suicide and of how to connect individuals in crisis with assistance and care. Key issues are: What to look for? What to do?

17. Advances in Assessing Risk: From Risk Factors to Warning Signs Problems with risk factors construct Problems with risk factors construct –Limited clinical and practical relevance  “acute risk” defined as 12 months  time periods range from 1 to 20 years –Fails to differentiate variable markers for near and long-term risk for suicide –Can result in confusion in understanding and application and risk categories  Perpetuating  Predisposing  Precipitating

18. Consensus Panel Recommendations

19. Warning Signs Expert Meeting 8/12 What to look for? Empirically supported warning signs can be divided into: Suicide specific warning signs such as ideation, talking about or threatening suicide, preparatory behavior such as writing a note or attempting to access lethal means Making an attempt

20. Warning Signs Meeting 8/2012 Other warning signs are not suicide specific and may be linked to shared risk for a variety of negative outcomes such as withdrawal, anxiety, mood changes, rage There may be differences in the recommended actions to take depending on whether these warning signs are suicide specific

21. Emergency Department Look for signs of acute suicide risk ED vs community context

22. Action Steps in Response to Warning Signs From NSSP Do not leave the person alone Remove any objects that could be used in a suicide attempt Call the National Suicide Prevention Lifeline at 800-273-TALK (8255) Take to an emergency room or seek help from a medical or mental health professional

23. Action Steps to take in Response to Warning signs Key questions How hard is it for gatekeepers to recognize the warning signs and to act on them? What is the role of hotlines vs 911 (ideation vs action?) Do not leave alone for how long? Until evaluated by someone experienced in suicide risk assessment.

27. ASIST workshops train Army leaders, chaplains and chaplain assistants, substance abuse counselors, family advocacy program workers, medical and dental-health professionals, and other care providers in a range of suicide- prevention and intervention skills

28. New Frontiers in Crisis Intervention Chat-Veterans chat initiated 2009 Texting-Crisis texting services in Lifeline Social Networking Sites-relationship with Lifeline SAMHSA Summit and White Paper on suicide prevention and the new technologies

30. COSTLY GAPS: CONTINUITY OF CARE U.S. E.D. visits, 1992-2001: More attempts (49% increase), fewer admissions for attempts (35% less) (Larkin et al, 2008). Fewer outpt. resources, longer waits: 76% of ED directors report lack of community referrals (Baraff et al, 2006). About 50% of suicide attempters fail to attend treatment post-discharge (Tondo et al, 2006). Over 1/3 re-attempt or die by suicide within 18 months post discharge (Beautrais, 2003). This is an intense challenge but also a real opportunity for us to do better.

31. Emergency Department Fleischmann et al (2008) – Randomized controlled trial; 1867 Suicide attempt survivors from five countries (all outside US) – Brief (1 hour) intervention as close to attempt as possible – 9 F/u contacts (phone calls or visits) over 18 months

32. Motto 1976:  389 pts. refusing outpt. assigned to “no “contact” (up to 24 letters over 5 years)  Contact group sig. fewer suicides than no-contact group (particularly first 2 yrs) Carter et al, 2005:  Postcards to 378 attempters, varying monthly intervals, 12 mos. after d/c  Approx 50% reduction in attempts

33. On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. “I still see my hands coming off the railing,” he said. As he crossed the chord in flight, Baldwin recalls, “I instantly realized that everything in my life that I’d thought was unfixable was totally fixable— except for having just jumped.” Tad Friend. Jumpers. The New Yorker (2003)

34. Contact information Richard McKeon Ph.D. Branch Chief, Suicide Prevention, SAMHSA 240-276-1873 Richard.mckeon@samhsa.hhs.gov