1 Welcome Stacey Chay, Graduate Director School of Social WorkEastern Washington University

2 Agenda Language Statistics Basic Concepts Screening and referralsBreak Basic Concepts Screening and referrals

3 Objectives: The epidemiology of suicide in AmericaUnderstand why someone may become suicidal Protective and risk factors Review of mental health diagnoses and their relation to suicide risk Review of suicide risk assessment and screening Hospital care and Civil Commitment

4 Why are we here…….. Professional Legal Moral perhapsTO HAVE THE CONVERSTATION

5 Suicide Policy ESHB 2366 passed in 2012, other wise know as the Matt Adler Suicide Assessment, Treatment and Management Act. Changed RCW chapter 43.70 House Bill 1336 which requires schools to have a plan to handle emotional and behavioral distress which includes suicide. House Bill 2315 amends ESHB 2366 to include all doctors and nurses practicing in Washington State.

6 Suicide Terminology

7 Language and stigma….. Note: The term “committed” suicide is discouraged because it connotes the equivalent of a crime or sin. The CDC has also deemed “completed suicide” and “successful suicide” as unacceptable. Preferred terms are “death by suicide” or "died by suicide."

8 Suicide: Death caused by self- directed injurious behavior with any intent to die as a result of the behavior.

9 A suicide attempt may or may not result in injury.A non-fatal self-directed potentially injurious behavior with any intent to die as result of the behavior. A suicide attempt may or may not result in injury.

10 Suicidal ideation: Thoughts of suicide. These thoughts can range in severity from a vague wish to be dead to active suicidal ideation with a specific plan and intent.

11 Unintentional injury:A fatal or nonfatal injury that was unplanned and not intended to happen. Causes include a motor vehicle crash, poisoning, fall, fire, and drowning. Unintentional injuries are sometimes referred to as “accidents,” but this term is discouraged since it implies the injury was not preventable.

12 Prevention: Interventions designed to stop suicidal behavior before it occurs. These interventions involve reducing the factors that put people at risk for suicide and suicidal behaviors. They also include increasing the factors that protect people or buffer them from being at risk.

13 Treatment: The care of suicidal people by licensed mental health caregivers, health care providers, and other caregivers with individually tailored strategies. These strategies are designed to change the self- injurious or self-directed violent thoughts, behaviors, mood, environment, or chemistry of individuals. These behaviors are assumed to increase the risk for engaging in suicidal behaviors, and help them identify and address their emotional, psychological, and physical needs without engaging in self-destructive behaviors.

14 Postvention: Actions taken after a suicide has occurred largely to help persons affected by the suicide loss, such as family, friends, and co-workers of the deceased.

15 How big is the problem? World Health OrganizationEvery year, more than 800,000 people world wide die from suicide; this roughly corresponds to one death every 40 seconds In the last 45 years suicide rates have increased by 60% worldwide. Suicide is among the three leading causes of death among those aged years in some countries, and the second leading cause of death in the years age group; These figures do not include suicide attempts which are up to 20 times more frequent than suicides. Review of stats help participants understand the depth of the problem Assist in the assessment process Many countries do not report Much of the suicide data is 5 to 10 years old The true scope of the problem is difficult to determine You may note that in China, or so die each year by suicide In China, suicide is the leading cause of death for year olds and more women kill themselves than men (25% more)

16 How big is the problem? In the top 10 causes of death in every countryMental disorders (particularly depression and alcohol use disorders) are a major risk factor for suicide in Europe and North America; however, in Asian countries impulsiveness plays an important role. Suicide is complex with psychological, social, biological, cultural and environmental factors involved.

17 U.S. numbers: 2014 Suicide was the 10th leading cause of death in the United States. Rate of 13 per 100,000 42,773 persons died as a result of suicide, an average of 117 each day. Death by suicide every 12.8 minutes. Number of emergency department visits for self-inflicted injury: 836,000 (2011) suggesting that approximately 12 people harm themselves (not necessarily intending to take their lives) for every reported death by suicide. Nonfatal self-inflicted injuries are most common among adolescents and young adults. CDC

18 Number of deaths for leading causes of death:2014Heart disease: 614,348 Cancer: 591,699 Chronic lower respiratory diseases: 147,101 Accidents (unintentional injuries): 136,053 Stroke (cerebrovascular diseases): 133,103 Alzheimer's disease: 93,541 Diabetes: 76,488 Influenza and Pneumonia: 55,227 Nephritis, nephrotic syndrome and nephrosis: 48,146 Intentional self-harm (suicide): 42,773 CDC

19 General suicide facts:Males die by suicide 4 times more than Females Females attempt suicide 3 times more than males Suicide is no respecter of age, race, religion, social or economic status; it’s an equal opportunity mode of death

20 United States Numbers Suicide has surpassed car accidents as the number 1 cause of injury related death in the U.S. Between 2000 – 2009 the death rate for suicide went up 15% while the death rate for car wrecks decrease 25%. Speaks to the culture suicidal people live in

21 U.S. Numbers Death by unintentional poisoning, which includes drug overdoes, came in third behind car wrecks and suicide after increasing 128% between data shows an increase of 136%. Review of easy of access to lethal means Discuss access to OTC and Rx meds and the role they play in a suicidal crisis

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23 Washington State: 2014 1,113 Washington State residents died by suicide. 90 of those were in Spokane County. On average 3 people per day Suicide is the eighth leading cause of death among all Washington residents The second leading cause among youth ages 15–24. The highest rates of suicide occur among men 75 years old or older, although the largest number of deaths occurs among men 45–64 years old. WA State Dept. of Health

24 Washington State: methodsThe leading suicide methods were: firearms (49 percent) Poisoning(22 percent) Suffocation (19 percent). In Washington State, firearms were the leading method of suicide for both males and females. Discussion on lethal means and restricting access

25 Washington State Suicide is consistently the second leading cause of death among kids in our state. Children as young as 5 have died by suicide

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28 Washington State Healthy Youth Survey18 percent of tenth graders (about 15,000 students) seriously thought about attempting suicide during the 12 months prior to the survey. 12% reported having a plan for their suicide attempt. Seven percent (about 6,000 students) reported making a suicide attempt. Responses by sixth-graders showed that 14 percent (about 11,000 students) seriously considered killing themselves and that 5 percent (almost 4,000 students) had tried to kill themselves.

29 WA youth facts: Suicide is the second leading cause of death in Washington for youth years old and caused 25% of the deaths in this age group in 2011 An average of 2 youth between the ages of 10 and 24 die by suicide each week in our state. There were nearly twice as many suicides as homicides of youth ages 10–24.

30 WA youth facts: Depression is associated with youth suicide.30% of 10th graders reported that at some point in the past year, they had been so sad or hopeless almost every day for two weeks or more in a row that they stopped doing their usual activities. About 39% of 10th graders reported having no adults to turn to when they were depressed. 38% of these youth reported they would be very unlikely to seek help if they were feeling depressed or suicidal. Tx considerations for this population

31 LGBTQ Rates Being LGTBQ alone is not a risk factor.People who identify as LGBTQ have greater risk factors due to their environment. Suicide rates are three times higher than the national average. More than 30% of LGBTQ youth report at least one suicide attempt within the last year. More than 50% of Transgender youth will have had at least one suicide attempt by their 20th birthday.

32 Suicide Epidemiology Most Common Suicide MethodsFIREARMS are the most common method for suicide completion 2010, Firearms used 52.1% (accounted for 62% of all gun deaths) Prevent Easy Access to Firearms and You Substantially Reduce Suicide Risk More discussion of restricting access to means

33 Method: 2010 Men Women Firearm 17,910 56.4% 2,756 31.2% Suffocation/hanging 8,016 25.2% 2,072 23.5% Poisoning* 3,538 11.1% 3,191 36.2% Fall 695 2.2% 256 2.9% Cut/pierce 594 1.9% 136 1.5% Other Spec., classifiable 394 1.2% 112 1.3% Drowning 271 0.9% 161 1.8% Transportation related 125 0.4% 42 0.5% Fire/burn 106 0.3% 54 0.6% Other Spec., NEC 94 30 Unspecified 37 0.1% 10 Total 31,780 8,820

34 Homicide VS. Suicide Handout

35 Suicide Prevention is Violence PreventionDV victims make more suicide attempts (20 to 26%). Violent families contribute to youth suicide. Violent people have a history of self- destructive behavior (30%). Abusive men who kill their wives and lovers usually do so in response to the woman’s attempt to leave. Overlap of violence to suicide The data here are also from the Washington State Consortium on Domestic violence. From other studies, about 1/3 of the males who kill their wives or lovers, then kill themselves. Point? We could stop some homicides by stopping the suicides planned as part of a murder-suicide dynamic.

36 Intimate Partner Violence in WA stateMales who threaten suicide in an intimate partner violence situation are at greater risk for murder-suicide. In 2014, 44 people died in Washington State as a result of domestic violence. These deaths include 17 women and 2 men killed by abusive partners or ex-partners; friends, family members and bystanders killed by abusers; abusers killed by victims, their friends or family, or law enforcement officers; and abuser’s suicide deaths following domestic violence homicide or attempted homicide. Thirty-one percent of abusers who committed murder since also killed themselves. WSCADV

37 DV Homicide/suicide deaths3/28/2014 Fay Marie Allen, 70, shot by her husband who then killed himself. 5/17/2014 Julie Johnson, 37, shot by her husband who then killed himself. 5/17/2014 Monique Williams, 29, shot by her ex-boyfriend who then killed himself. 6/9/2014 Sandra Luster, 49, shot by her husband who then killed himself. 7/8/2014 Sheena Henderson, 30, shot by her husband who then killed himself. 7/30/2014 Brenda Ray, 39, shot by her husband who then killed himself. 11/11/2014 Romeo Machuca, 41, shot by his girlfriend’s husband who then killed himself.

38 Suicide Attempts Most don’t die in their attemptYouth: attempts per 1 death Elder: 4 attempts per 1 death Average: 25 attempts per 1 death Reporting problem - under reporting - unknown (don’t ask, don’t tell) This scale pretty much speaks for itself. Note: a prior suicide attempt remains the most powerful predictor of later death by suicide. Too often, clinicians a) don’t ask about prior attempts, and b) don’t drill down for the details to determine the lethality of the attempt. I note the ratios of attempts to completion regarding the elderly, as this every attempt in this group has a high intention to die and if the person does not die it is not because they didn’t want to, but because their method failed.

39 Facts you need to know… Suicide risk rises with ageResponsibility for one or more children is a powerful protective factor against suicide in women (Swedish study) Contact with a healthcare provider does not confer protection…. and neither does recent psychiatric hospitalization The Swedish study compared # of live births with suicide completions; the more children a woman had the lower her risk for suicide (a perfect correlation). PMD. Point? Are these missed opportunities? Probably, as suicide ideation is infrequently queried for and is not the current standard of practice among PCPs. Discussion of treatment process and it’s impact on a suicidal crisis Psychosis impact on cognitive functioning over the life span.

40 Facts you need to know… Most suicides occur within weeks to months of last contact AND risk rises after discharge!

41 Survivors of Suicide There are currently over 41,100 suicides annually in the USA. It is estimated that for every suicide there are at least 6 survivors. Some suicidologists believe this to be a very conservative estimate. Based on this estimate, approximately 6 million Americans became survivors of suicide in the last 25 years. Suicide risk is greater in survivors (e.g., 4- fold increase in children when a parent dies by suicide) AAS 2014 This is American Association of Suicide data… There is a lot going on just now with building survivor support groups and beginning prevention with this high risk group./

42 Suicide: Myths & Facts Myth: Suicidal people keep their plans to themselves Fact: Most suicidal people communicate their intent to die during the week preceding an attempt

43 Always Take Suicide Talk SeriouslySuicide: Myths & Facts Myth: People who talk about suicide don’t do it Fact: People who talk about suicide may try, or even die by suicide Always Take Suicide Talk Seriously

44 Suicide: Myths & Facts Myth: Once a person decides to die by suicide, there is nothing anyone can do to stop them Fact: Suicide is the most preventable form of death and almost any positive action may save a life

45 Suicide: Myths & Facts Myth: Confronting a person about suicide will only make them angry and increase the risk of suicide Fact: Asking someone directly about suicidal intent lowers anxiety, opens-up communication, and lowers the risk of an impulsive act

46 Suicide: Myths & Facts Myth: Only experts can prevent suicideFact: Suicide prevention is everybody’s business and anyone can help prevent the tragedy of suicide

47 Good Friends Don’t Keep Deadly SecretsSuicide: Myths & Facts Myth: If a suicidal youth tells a friend, the friend will access help Fact: Many young people do not tell an adult Kids are a critical piece of a suicide prevention effort They need to know that--- Good Friends Don’t Keep Deadly Secrets