1. Assessing Suicide Adapted from: National Institute of Mental Health ( http://www.nimh.nih.gov/health/publications/suicide-in- the-us-statistics-and-prevention/index.shtml). Guidelines for Identification, Assessment, and Treatment Planning for Suicidality Developed by the Suicide Risk Advisory Committee of the Risk Management Foundation of the Harvard Medical Institute in 1996. http://www.nimh.nih.gov/health/publications/suicide-in- the-us-statistics-and-prevention/index.shtml

2. Statistics Suicide is a major, preventable public health problem. In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths. The overall rate was 11.3 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death. Almost four times as many males as females die by suicide.

3. Statistics continued Older Americans are disproportionately likely to die by suicide. Of every 100,000 people ages 65 and older, 14.3 died by suicide in 2007. This figure is higher than the national average of 11.3 suicides per 100,000 people in the general population. Non-Hispanic white men age 85 or older had an even higher rate, with 47 suicide deaths per 100,000.

4. Risk Factors Men and the elderly are more likely to have fatal attempts than are women and youth. Depression and other mental disorders, alcohol and other substance abuse and separation or divorce. Depression and other mental disorders, or a substance-abuse disorder (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors. Family history of mental disorder, violence, abuse, or substance abuse Family history of suicide Firearms in the home, the method used in more than half of suicides Incarceration Exposure to the suicidal behavior of others, such as family members, peers, or media figures. A previous suicide attempt is among the strongest predictors of subsequent suicide. Most suicide attempts are expressions of extreme distress, not harmless bids for attention. A person who appears suicidal should not be left alone and needs immediate mental-health treatment.

5. Questions to Assess Suicide What form does the patient’s wish for suicide take? For example escape fantasy, ideation, or intent? What does suicide mean to the patient? Is the patient able to engage in a therapeutic alliance? Has the patient just lost or is anticipating losing an essential sustaining relationship? Has the patient lost or is anticipating losing his/her main reason for living? How far has the suicide planning process proceeded? Have suicidal behaviors occurred in the past?

6. Questions to Assess Suicide continued… Is there any family history of suicide? Does the patient’s mental status enhance potential for suicidality? Is the patient expressing despair, hopelessness? Does the patient’s physiologic state increase potential for suicide? (e.g. physical illness, delirium, intoxication, organicity) Are there recent stressors in patient’s life? Is patient vulnerable to painful affects such as loneliness, self-contempt, shame, despair? What are the patient’s capacities for self- regulation and coping? Is the patient able to participate in treatment?

7. Common Misperceptions about Suicide People who talk or joke about death or killing themselves are not the ones who actually commit suicide. At least 80% of people who commit suicide give definite warning signs through verbalizations or behavior. Only a small percentage of people commit suicide without any communication to others. Suicide happens without warning. Suicide is not a spontaneous activity. It is most often the result of long- term, gradual, decompensation and erosion of coping mechanisms. Most suicidal people are certain they want to die. Most suicidal people do NOT want to die, but rather they want an escape from what they experience as unbearable pain. People who consider suicide do not see any alternatives and suicide becomes for them the only conceivable solution.

8. Common Misperceptions about Suicide The suicide rate is highest during winter holidays. Suicide rates in the United are consistently higher in the late spring and fall. Sudden, unexplained recovery from a profound depression with suicidal ideation indicates that a suicidal crisis is over. Some people who have committed to killing themselves appear happy and at peace right beforehand, perhaps from the belief that their pain will be ending. Many people who make a failed suicide attempt make a subsequent attempt within 90 days after the diminution of a profound depression-apparent “recovery” could be the mobilization of resources to carry out a suicidal intent. Once a person has been suicidal, s/he will always consider suicide as an option when a crisis arises. Most suicidal people are suicidal only 1 time in their lives. Approximately 8% of people who attempt suicide are completers.

9. Common Misperceptions about Suicide Suicide is more prevalent among the wealthy. Suicide rates are higher among lower socioeconomic cohorts. However, by profession, groups at the highest socioeconomic levels (physicians, attorneys and business executives) also have high rates of suicide. Overall, suicide rates for whites exceeds those for persons of color, but among whiles living in ghettos, the rates are comparable. Most suicidal people leave notes. While almost all suicidal people communicate their ideation and/or intents directly or indirectly by verbalization or behaviors, most do not leave suicide “notes.” Suicide is the act of a psychotic, severely mentally ill individual. Data reveals that the majority of suicide completers are people who have suffered Major Depressive Disorder, but are not otherwise severely mentally ill and certainly not psychotic. If someone appears determined to kill themselves, there is nothing anyone can do about it. Self-destructive episodes are usually limited to approximately 24 hours, with some acute episodes lasting only moments. Most suicidal people are ambivalent about dying so accurate identification and active intervention focused on getting a person through the acute phase can save a life.

10. Interventions If you think someone is suicidal, do not leave him or her alone. Try to get the person to seek immediate help from his or her doctor or the nearest hospital emergency room, or call 911. Eliminate access to firearms or other potential tools for suicide, including unsupervised access to medications. Research shows that older adults and women who die by suicide are likely to have seen a primary care provider in the year before death, improving primary-care providers' ability to recognize and treat risk factors may help prevent suicide among these groups. Specific kinds of psychotherapy may be helpful for specific groups of people. When a patient is considered at risk for suicide they should be evaluated by a mental health professional. Medications can be helpful in improving symptoms of depression, pain, and anxiety that can lead to severe depression, hopelessness, and suicidal thinking. Comprehensive assessment and documentation of suicidal expression, thoughts, behaviors is a key component in providing ongoing care. Please see Suicide Assessment Form adapted for Harvest by Michelle Kieras, LCSW.