1. Suicide and Mental Health in Virginia: 2003-2007 Marc Leslie Virginia Violent Death Reporting System Office of the Chief Medical Examiner Virginia Department of Health Presentation for Department of Mental Health, Mental Retardation and Substance Abuse Services Management Team June 22, 2009

2. 2 Outline of Presentation Overview of the National Violent Death Reporting System (NVDRS) and the Virginia Violent Death Reporting System (VVDRS) Overview of the National Violent Death Reporting System (NVDRS) and the Virginia Violent Death Reporting System (VVDRS) Suicide in Virginia: 2003-2007 Suicide in Virginia: 2003-2007 Suicide and mental health problems in Virginia: 2003-2007 Suicide and mental health problems in Virginia: 2003-2007 Additional detail on suicide victims with mental health problems: 2007 Additional detail on suicide victims with mental health problems: 2007

3. 3 Overview of NVDRS/VVDRS Surveillance project funded by the Centers for Disease Control and Prevention (CDC) in 17 states Surveillance project funded by the Centers for Disease Control and Prevention (CDC) in 17 states Collects data on all suicide, homicide, legal intervention, undetermined cause/manner, unintentional firearm injury, and terrorism deaths Collects data on all suicide, homicide, legal intervention, undetermined cause/manner, unintentional firearm injury, and terrorism deaths Abstracted into standardized database Abstracted into standardized database VVDRS began in late 2003 VVDRS began in late 2003 Located in the Office of the Chief Medical Examiner (OCME) which has legal authority over relevant cases Located in the Office of the Chief Medical Examiner (OCME) which has legal authority over relevant cases Information primarily from OCME, Vital Records, law enforcement, and Department of Forensic Sciences Information primarily from OCME, Vital Records, law enforcement, and Department of Forensic Sciences

4. 4 Overview of NVDRS/VVDRS Primary Data Elements Demographics (e.g., age, race, sex, education) Demographics (e.g., age, race, sex, education) Residential information of victim (e.g., address) Residential information of victim (e.g., address) Address of injury and type of location where injured Address of injury and type of location where injured Date and time of injury Date and time of injury Method of fatal injury (e.g., firearm) Method of fatal injury (e.g., firearm) Cause and manner of death Cause and manner of death Toxicological findings Toxicological findings Circumstances Circumstances

5. 5 Overview of NVDRS/VVDRS Circumstances Why victim committed suicide Why victim committed suicide Life stressors/events present at time of fatal injury Life stressors/events present at time of fatal injury Reported primarily from OCME and law enforcement investigations Reported primarily from OCME and law enforcement investigations Multiple criteria; different for each circumstance Multiple criteria; different for each circumstance

6. 6 Overview of NVDRS/VVDRS Collecting Data about Mental Health Problems Evidence in death investigation record that victim had a mental health problem Evidence in death investigation record that victim had a mental health problem Diagnosis is abstracted when death is investigated by a medical doctor, or when there is evidence that victim received treatment Diagnosis is abstracted when death is investigated by a medical doctor, or when there is evidence that victim received treatment Mental health treatment records are occasionally available, but not regularly Mental health treatment records are occasionally available, but not regularly Treatment labeled as “current” (within two months of injury) or “noncurrent” (over two months prior to injury) Treatment labeled as “current” (within two months of injury) or “noncurrent” (over two months prior to injury)

7. 7 Suicide in Virginia: 2003-2007 Overview of All Suicides: 2003-2007 4,216 suicides 4,216 suicides Rate of 11.2 (more than twice the homicide rate) Rate of 11.2 (more than twice the homicide rate) Most victims male (76.9%) and White (86.7%) Most victims male (76.9%) and White (86.7%) Median age of 46 Median age of 46 Firearm (57.0%), Hanging/Suffocation (18.9%), and Poison (18.1%) most common methods Firearm (57.0%), Hanging/Suffocation (18.9%), and Poison (18.1%) most common methods Rural areas have lower numbers, but higher rates Rural areas have lower numbers, but higher rates

8. 8 Suicide in Virginia: 2003-2007 Widowed males: 60.8 Widowed males: 60.8 LENOWISCO Planning District: 20.8 LENOWISCO Planning District: 20.8 Males: 17.5 Males: 17.5 State average: 11.2 State average: 11.2 Widowed females: 6.1 Widowed females: 6.1 Hispanics: 4.9 Hispanics: 4.9 Suicide risk (rate per 100,000) varies by race, sex, age, education, marital status, residence, and other factors:

9. 9 Suicide in Virginia: 2003-2007

10. 10 Suicide in Virginia: 2003-2007

11. 11 Suicide in Virginia: 2003-2007 Males and females differ notably on many features: Age influences risk, but in different ways for males (risk increases with age) and females (risk rises, then decreases with age) Age influences risk, but in different ways for males (risk increases with age) and females (risk rises, then decreases with age) Method of fatal injury different for males (1.8 times more frequent use of firearms than females) and females (3.4 times more frequent use of poison than males) Method of fatal injury different for males (1.8 times more frequent use of firearms than females) and females (3.4 times more frequent use of poison than males) Marital status has major impact on males, but not on females (except for divorced females) Marital status has major impact on males, but not on females (except for divorced females) Circumstances (46.5% of males have a mental health problem, compared to 70.9% of females) Circumstances (46.5% of males have a mental health problem, compared to 70.9% of females)

12. 12 Suicide and Mental Health Problems in Virginia: 2003-2007 This presentation focuses on persons who: Died between 2003 and 2007 Died between 2003 and 2007 Manner of death is suicide (completed suicides only) Manner of death is suicide (completed suicides only) Were residents of Virginia at time of injury or death Were residents of Virginia at time of injury or death Were noted as having a mental health problem (n = 2,128) Were noted as having a mental health problem (n = 2,128) Had at least one circumstance known, but were not noted as having a mental health problem (n = 1,948) Had at least one circumstance known, but were not noted as having a mental health problem (n = 1,948)

13. 13 Suicide and Mental Health Problems in Virginia: 2003-2007

14. 14 Suicide and Mental Health Problems in Virginia: 2003-2007

15. 15 Suicide and Mental Health Problems in Virginia: 2003-2007 Methods of fatal injury: Firearm (46.7%) Firearm (46.7%) Poison (25.8%) Poison (25.8%) Hanging/Suffocation (20.3%) Hanging/Suffocation (20.3%) Fall (2.2%) Fall (2.2%) Drowning (1.9%) Drowning (1.9%) Sharp Instrument (1.8%) Sharp Instrument (1.8%)

16. 16 Suicide and Mental Health Problems in Virginia: 2003-2007 Poisoning suicide (n = 548 victims) – use of at least one: Prescription medication (79.6%) Prescription medication (79.6%) Over-the-Counter medication (17.0%) Over-the-Counter medication (17.0%) Alcohol (13.5%) Alcohol (13.5%) Carbon Monoxide (10.6%) Carbon Monoxide (10.6%) Street drug (5.7%) Street drug (5.7%) Opiate (40.7%) Opiate (40.7%) Antidepressant (40.1%) Antidepressant (40.1%)

17. 17 Suicide and Mental Health Problems in Virginia: 2003-2007 Specific poisons (n = 548 victims) Amitriptyline/Nortriptyline (10.8%) Amitriptyline/Nortriptyline (10.8%) Citalopram (10.8%) Citalopram (10.8%) Oxycodone (10.6%) Oxycodone (10.6%) Methadone (10.2%) Methadone (10.2%) Quetiapine (9.5%) Quetiapine (9.5%) Hydrocodone (8.9%) Hydrocodone (8.9%) Diphenhydramine (8.8%) Diphenhydramine (8.8%) Acetaminophen (8.2%) Acetaminophen (8.2%) Alprazolam (6.9%) Alprazolam (6.9%) Morphine (6.8%) Morphine (6.8%) Propoxyphene (6.2%) Propoxyphene (6.2%) Fluoxetine (6.0%) Fluoxetine (6.0%) Bupropion (5.1%) Bupropion (5.1%) Cocaine (4.9%) Cocaine (4.9%)

18. 18 Suicide and Mental Health Problems in Virginia: 2003-2007 Diagnoses and treatment: Depression (74.6%) Depression (74.6%) Bipolar (13.7%) Bipolar (13.7%) Anxiety Disorder (8.8%) Anxiety Disorder (8.8%) Schizophrenia (4.7%) Schizophrenia (4.7%) Current mental health treatment (74.7%) Current mental health treatment (74.7%) Noncurrent mental health treatment (7.7%) Noncurrent mental health treatment (7.7%)

19. 19 Suicide and Mental Health Problems in Virginia: 2003-2007

20. 20 Suicide and Mental Health Problems in Virginia: 2003-2007

21. 21 Suicide and Mental Health Problems in Virginia: 2003-2007 Other Circumstances Warnings of suicide: Disclosed intent to commit suicide (31.9%) Disclosed intent to commit suicide (31.9%) History of suicide attempts (30.5%) History of suicide attempts (30.5%) Combined disclosed intent to commit suicide and/or history of suicide attempts (51.6%) Combined disclosed intent to commit suicide and/or history of suicide attempts (51.6%) This means that over half of suicide victims with a mental health problem were known to be or to have been suicidal.

22. 22 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Overview Variables created, defined, and collected by VVDRS Variables created, defined, and collected by VVDRS Standards may differ from the CDC Standards may differ from the CDC Arose from inability to capture details and nuances Arose from inability to capture details and nuances Over 90 new elements Over 90 new elements First year of completed data: calendar year 2007 First year of completed data: calendar year 2007 Currently working on calendar year 2008 Currently working on calendar year 2008 Additional information about 346 (71.6%) suicide victims with a mental health problem Additional information about 346 (71.6%) suicide victims with a mental health problem

23. 23 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 General Suicide Circumstances Crisis in past 24 hours (19.7%, or 61.0% of those with a crisis in past two weeks) Crisis in past 24 hours (19.7%, or 61.0% of those with a crisis in past two weeks) Took prescribed pain medication, past two months (16.4%) Took prescribed pain medication, past two months (16.4%) Sleeping too little (15.1%) or too much (0.4%) Sleeping too little (15.1%) or too much (0.4%) Unusual behavior, past two weeks (5.4%) Unusual behavior, past two weeks (5.4%) Family history of suicide (4.1%) Family history of suicide (4.1%) Loved ones not surprised by suicide (2.9%) Loved ones not surprised by suicide (2.9%)

24. 24 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Disclosed Intent to Commit Suicide Disclosed intent to: Family members (35.1%) Family members (35.1%) Intimate partners (current/former) (32.1%) Intimate partners (current/former) (32.1%) Friends/acquaintances (18.3%) Friends/acquaintances (18.3%) Mental health professionals (6.9%) Mental health professionals (6.9%) Medical personnel (4.6%) Medical personnel (4.6%) Corrections Officers/other corrections staff (2.3%) Corrections Officers/other corrections staff (2.3%)

25. 25 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Disclosed Intent to Commit Suicide Reactions to disclosed intent: Action taken to prevent suicide (34.4%) Action taken to prevent suicide (34.4%) Threats not taken seriously (11.5%) Threats not taken seriously (11.5%) Threats taken seriously, no action taken to prevent suicide (1.5%) Threats taken seriously, no action taken to prevent suicide (1.5%)

26. 26 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Disclosed Intent to Commit Suicide Actions taken by loved ones to prevent suicide (n = 45): Sought some form of mental health treatment (including hospitalization) (28.9%) Sought some form of mental health treatment (including hospitalization) (28.9%) Limited access to firearms (20.0%) or ammunition (2.2%) Limited access to firearms (20.0%) or ammunition (2.2%) Checked on victim (17.8%) Checked on victim (17.8%) Tried to persuade victim to not commit suicide(15.6%) Tried to persuade victim to not commit suicide(15.6%) Called 911/law enforcement (13.3%) Called 911/law enforcement (13.3%) Monitored victim (6.7%) Monitored victim (6.7%)

27. 27 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Past 24 hours (21.2%) Past 24 hours (21.2%) 25 hours – 7 days (27.3%) 25 hours – 7 days (27.3%) 8 – 14 days (9.1%) 8 – 14 days (9.1%) 15 – 31 days (6.1%) 15 – 31 days (6.1%) 32 days – 6 months (15.2%) 32 days – 6 months (15.2%) 7 – 12 months (6.1%) 7 – 12 months (6.1%) 1 year – 2 years (6.1%) 1 year – 2 years (6.1%) Over 2 years (9.1%) Over 2 years (9.1%) Disclosed Intent to Commit Suicide Time between first disclosure of intent and completed suicide (n = 33):

28. 28 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Mental Health Problems General issues: Ever given a TDO/ECO (5.2%) Ever given a TDO/ECO (5.2%) Mental health records classify victim as not a threat to self or others/not suicidal (2.5%) Mental health records classify victim as not a threat to self or others/not suicidal (2.5%) Hopeless about resolving/dealing with mental health problems (2.1%) Hopeless about resolving/dealing with mental health problems (2.1%)

29. 29 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Mental Health Problems Type of mental health professional seen, past two months: Psychiatrist (23.4%) Psychiatrist (23.4%) Primary care physician (7.0%) Primary care physician (7.0%) Medical doctor (type not specified) (2.7%) Medical doctor (type not specified) (2.7%) Psychologist (0.6%) Psychologist (0.6%)

30. 30 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Mental Health Problems Type of mental health professional seen ever: Psychiatrist (32.1%) Psychiatrist (32.1%) Primary care physician (5.4%) Primary care physician (5.4%) Medical doctor (type not specified) (3.3%) Medical doctor (type not specified) (3.3%) Psychologist (0.6%) Psychologist (0.6%)

31. 31 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 8 – 14 days (0.2%) 8 – 14 days (0.2%) 15 – 31 days (0.6%) 15 – 31 days (0.6%) 32 days – 6 months (0.4%) 32 days – 6 months (0.4%) 7 – 12 months (0.4%) 7 – 12 months (0.4%) 1 year – 2 years (0.4%) 1 year – 2 years (0.4%) Over 2 years (6.6%) Over 2 years (6.6%) Mental Health Problems Time between first visit to a mental health professional and completed suicide:

32. 32 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Past 24 hours (2.3%) Past 24 hours (2.3%) 25 hours – 7 days (5.4%) 25 hours – 7 days (5.4%) 8 – 14 days (2.5%) 8 – 14 days (2.5%) 15 – 31 days (3.9%) 15 – 31 days (3.9%) 32 days – 6 months (4.3%) 32 days – 6 months (4.3%) 7 – 12 months (0.8%) 7 – 12 months (0.8%) 1 year – 2 years (0.6%) 1 year – 2 years (0.6%) Over 2 years (1.0%) Over 2 years (1.0%) Mental Health Problems Time between last visit to a mental health professional and completed suicide

33. 33 Suicide and Mental Health Problems in Virginia: State-Added Data from 2007 Mental Health Problems

34. 34 Questions, Data Requests Marc Leslie VVDRS Coordinator Address: 737 N. 5 th Street Suite 301 Suite 301 Richmond, VA 23219 Richmond, VA 23219 Phone: 804-205-3855 E-mail: marc.leslie@vdh.virginia.gov