Physicians Awareness Training

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  • Talking about suicide is scary . It’s hard to get people, even physicians, to come to trainings about suicide. In fact, many people ask the question, “Aren’t you opening a can of worms?” By making people more aware of and less afraid of suicide, we hope to assist communities to be proactive in preventing suicide, rather than reactive to a suicide that has occurred. Suicide is something that many think about at some point in life but no one wants to talk about. Pretending it doesn’t exist won’t make it go away. Not learning about suicide means we are helpless to stop it. Talking about suicide, its causes and associated feelings provides us with our best opportunity for prevention.
  • Suicide’s direct link with depression is important to understand. No doubt you are already quite aware of what we have learned in the last 20 years - depression is a physical illness, one that can be cured with treatment. It is not a moral failing, any more than heart disease is a moral failing
  • The DSM–IV, the diagnostic and statistical manual of mental health disorders, is quite clear on the group of symptoms that can be diagnosed as a depressive disorder. Although we do not have blood tests for this problem, the listed criteria can be easily determined, as long as the patient is telling the truth about their symptoms. Many come in with vague somatic complaints because, for many, the body literally aches. The surgeon general’s report says that an assessment of depressive symptoms is as accurate and reliable as many blood tests currently the standard for assessment.
  • As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes. For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again.
  • As our brain cells become less able to connect with one another, our thinking changes in predictable ways. We find problem-solving more difficult, and get stuck on the idea that suicide is the only option. Most people tend to think of depression as affecting only the emotions, but it also hurts our thinking processes. For some time now we have wondered why increasing the amount of the neurotransmitter, serotonin, as most of the newer anti-depressants do, has slowly reduced the symptoms of depression. It seems clear now that increased serotonin blocks or reduces the effect of the stress hormones, allowing our nerve cells to begin functioning again.
  • As dendritic branches die back, the result of onslaught by stress hormones, fewer and fewer connections can be made in these brain areas
  • As you may be aware, Major Depression, Dysthymia, Schizophrenia and Bi-Polar disorder, as well as Borderline Personality Disorder all have an elevated risk of suicide. 15% of people with schizophrenia will complete suicide at some point in their lives.
  • Along with the brain research that is showing the physical nature of this disorder, we have made rapid improvement in our ability to work with those who are suicidal. Working with young people is critical to improving public understanding of the link between depression and suicide, and that depression is a treatable illness
  • Many people do not think of suicide as a significant health issue in this country, but as you can see, we are losing many people to a completely treatable illness. If you think it is not important, consider that we lose 3 people to suicide for every 2 we lose to homicide, a statistic that has been stable for the past 100 years.
  • While young people actually have a lower suicide rate than others, it should be remembered that depression tends to be a chronic illness, and those who begin to have suicidal feelings in their teens may attempt or complete suicide 20 years later.
  • These figures, unfortunately, are merely an estimate. Some experts fear the numbers are at least 2-3 higher, since many suicides are not identified as such. Because the stigma is so high, and because there are real financial consequences to a suicidal death as well as social, deaths that cannot be definitively called suicide are usually called an accident. Cars driven into trees on a clear night with no alcohol involvement, for example. We want to protect other family members. People wonder if life insurance must pay on suicide, because in the past it did not. In most states, if the death occurs more than 2 years after the policy is in effect. Just an aside - suicide is no longer a crime, which is why we talk about completed rather than “committed” suicide.
  • Note the rate at which suicide impacts people over 75.
  • Clearly this is a serious health risk for the elderly. The most important fact on this slide is that depression is not normal at any stage of life.
  • Primary Care physicians are those most likely to be treating depressed elderly patients. They may need additional training in how to look at their older patients.
  • Here are some examples of barriers to MH care. In general, elders with mental disorders are not getting good treatment.
  • We really need to understand depression better, since it is the single biggest factor in suicide. Additionally, depression is a misunderstood illness, and is not even considered an illness by most of the population. Resistance to taking medication for depression is very high, particularly among the elderly.
  • Although the first seems obvious, common opinion seems to be that is someone attempts suicide they are being manipulative or attention-seeking. Yet most who complete suicide have made one or more attempts in their past. We need to think of this as a first step that may lead to more attempts Since depression seems to have a genetic component, that may be why family survivors are more vulnerable to suicide themselves. However, it may also be that the “taboo” against suicide is broken, and survivors see suicide as an option.
  • Certain forms of psychotherapy, particularly Cognitive-Behavioral and Dialectical Behavioral Therapy, have strong research evidence to suggest they can reduce suicidal thinking.
  • SSRI stands for Selective Serotonin Reuptake Inhibitor, which refers to the action of the drug on the synapses in the brain – it stops Serotonin from being reabsorbed into the brain and makes it more available to the brain cells. This type of drug has been available about 20 years, and has the advantage of fewer side effects and more effectiveness than older style anti-depressants. It is difficult to understand how one SSRI could cause these problems and another be acceptable, since their actions are, to all intents and purposes, the same.
  • Prevention programs such as the one put in place by the US Air Force, have been proven to reduce suicidal deaths. From the top down, many organizations within the Air Force were drawn together to make changes in policy and procedure, and to make services more available to servicemen and women and their families. The Air Force reduced suicide rates by 76% over a 5 year period, while other armed services saw no change in their rates of suicide.
  • Dr. Paul Quinnett, who has written extensively in this area, conducted a study of patients who presented with thoughts of suicide at a mental health center. Those who saw their clinician as comfortable and competent with asking questions about their suicidal thoughts and feelings reported much higher levels of hope about their future. The best outcome of the S question is that the client experiences immediate relief. How many of you feel comfortable asking this question? Why or why not? What taught you to be more comfortable asking this question?
  • Watch for “frequent flyers” – patients who come in a lot with vague somatic symptoms, people who are difficult to diagnose. Routine questioning about depressive symptoms can help determine if this person needs a different kind of help.
  • Two examples of evidence-based methods of effective interviewing for suicidal ideation
  • 40 years ago someone thought it would be a good idea if the average American could learn some basics that would keep a person who was having a heart attack alive until the ambulance arrived. Millions of us have learned CPR, and many have been saved who might otherwise have died. Now we need to learn how to do it again, all of us, to stop the unnecessary deaths caused by depression and mental illness. Both on and off the job, if we all learned QPR, we could save a lot of lives. We would like the whole community to learn this model, but it needs to start with those who already have an investment in saving lives. Staff, nurses, EMT’s, PA’s and other hospital and clinic employees could easily learn this model and increase their awareness about potential risks to patients. The QPR Institute sells an inexpensive, 35 minute “gatekeeper” training to explain this model.
  • Clear up ideas set by One Flew Over the Cuckoo’s nest, etc.
  • Who can help do this? Get support from family and friends, co-workers, if needed
  • There are many resources available to assist people, their families and those working closely with them. Learn the ones in your community.
  • The father of suicidology, Edwin Schneidman, coined the phrase Permanent Solution to a Temporary Problem. It really is up to us to help physically ill people understand that another solution exists besides death.
  • Physicians Awareness Training

    1. 1. Saving Lives: Understanding Depression And Preventing Suicide – Prevention Training For Physicians and Medical Personnel The Ohio Suicide Prevention Foundation Developed by Ellen J. Anderson, Ph.D., SPCC, 2003-2008
    2. 2. <ul><li>“Still the effort seems unhurried. Every 17 minutes in America, someone commits suicide. Where is the public concern and outrage?” </li></ul><ul><li>Kay Redfield Jamison </li></ul><ul><li>Author of Night Falls Fast: Understanding Suicide </li></ul>
    3. 3. Training Goals <ul><li>Learn about local suicide prevention efforts, how these efforts connect with your practice and patients </li></ul><ul><li>Understand the pivotal role of medical personnel in the treatment of depressed patients and in reducing suicide risk </li></ul><ul><li>Increase awareness of suicide risk characteristics in patients who may not present as depressed/suicidal </li></ul><ul><li>Learn a brief suicide risk assessment model </li></ul><ul><li>Learn to ask the “S” question </li></ul>
    4. 4. Why Do We Need To Improve Suicide Prevention Efforts? <ul><li>Suicide is the last taboo </li></ul><ul><li>We can talk about sex, alcoholism, cancer, but not suicide </li></ul><ul><li>People need to understand the impact of depression and other mental illnesses, and how they lead to suicide </li></ul><ul><li>Suicide is a preventable death </li></ul><ul><li>Integrating medical staff into the efforts of suicide prevention coalitions to reduce deaths, increase awareness, and reduce stigma seems critical to local, state, and national efforts to change our approach to this age-old problem </li></ul>
    5. 5. Changing Our Approach: Depression Is An Illness <ul><li>Suicide has been viewed for countless generations as: </li></ul><ul><ul><li>A moral failing, a spiritual weakness </li></ul></ul><ul><ul><li>An inability to cope with life </li></ul></ul><ul><ul><li>“ The coward’s way out” </li></ul></ul><ul><ul><li>A character flaw </li></ul></ul><ul><li>This cultural view of suicide is not validated by our current understanding of brain chemistry and it’s interaction with stress, trauma and genetics on mood and behavior </li></ul>
    6. 6. The Feel of Depression <ul><li>“ I am 6 feet tall. The way I have felt these past few months, it is as though I am in a very small room, and the room is filled with water, up to about 5’ 10”, and my feet are glued to the floor, and its all I can do to breathe.” </li></ul>Gatekeeper Training- Dr. Ellen Anderson
    7. 7. <ul><li>The research evidence is overwhelming- what we think of as depression is far more than a sad mood. It includes: </li></ul><ul><ul><li>Weight gain/loss </li></ul></ul><ul><ul><li>Sleep problems </li></ul></ul><ul><ul><li>Sense of tiredness, exhaustion </li></ul></ul><ul><ul><li>Sad mood </li></ul></ul><ul><ul><li>Loss of interest in pleasurable things, lack of motivation </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Confusion, loss of concentration, poor memory </li></ul></ul><ul><ul><li>Negative thinking </li></ul></ul><ul><ul><li>Withdrawal from friends and family </li></ul></ul><ul><ul><li>Often, suicidal thoughts </li></ul></ul><ul><li>(DSMIVR, 2002) </li></ul>
    8. 8. <ul><li>20 years of brain research teaches that what we are seeing is the behavioral result of: </li></ul><ul><ul><li>Changes in the physical structure of the brain </li></ul></ul><ul><ul><li>Destruction or shutting down of brain cells in the hippocampus and amygdala (5HTP axis) </li></ul></ul><ul><ul><li>Decrease in neurotransmitters </li></ul></ul><ul><ul><li>increased agitation in the limbic system </li></ul></ul><ul><li>Depressed people suffer from a physical illness within the brain – what we might consider “faulty wiring” </li></ul><ul><li>(Braun, 2000; Surgeon General’s Call To Action, 1999, Stoff & Mann, 1997, The Neurobiology of Suicide) </li></ul>
    9. 9. Faulty Wiring? <ul><li>Literally, damage to certain nerve cells in our brains </li></ul><ul><ul><li>The result of too many stress hormones – cortisol, adrenaline and testosterone </li></ul></ul><ul><ul><li>Hormones activated by our A utonomic N ervous S ystem to protect us in times of danger </li></ul></ul><ul><li>Chronic stress causes changes in the functioning of the ANS, so that a high level of activation occurs with little stimulus </li></ul><ul><li>Causes changes in muscle tension, imbalances in blood flow patterns leading to illnesses such as asthma, IBS, back pain and depression </li></ul><ul><li>(Goleman, 1997, Braun, 1999) </li></ul>
    10. 10. Faulty Wiring? <ul><li>Without a way to return to rest, hormones accumulate, doing damage to brain cells </li></ul><ul><li>Stress alone is not the problem, but how we interpret the event, thought or feeling </li></ul><ul><li>People with genetic predispositions , placed in a highly stressful environment will experience damage to brain cells from stress hormones </li></ul><ul><li>This leads to the cluster of thinking and emotional changes we call depression (Goleman, 1997; Braun, 1999) </li></ul>
    11. 11. Where It Hits Us
    12. 12. One of Many Neurons <ul><li>Neurons make up the brain and cause us to think, feel, and act </li></ul><ul><li>Neurons must connect to one another (through dendrites and axons) </li></ul><ul><li>Stress hormones damage dendrites and axons, causing them to “shrink” away from other connectors </li></ul><ul><li>As fewer connections are made, more and more symptoms of depression appear </li></ul>
    13. 13. <ul><li>As damage occurs, thinking changes in the predictable ways identified in our 10 criteria </li></ul><ul><li>“ Thought constriction” can lead to the idea that suicide is the only option </li></ul><ul><li>How do antidepressants affect this “brain damage”? </li></ul><ul><li>May counter the effects of stress hormones </li></ul><ul><li>We know now that antidepressants stimulate genes within the neurons (turn on growth genes) which encourage the growth of new dendrites </li></ul><ul><li>(Braun, 1999) </li></ul>
    14. 14. <ul><li>Renewed dendrites increase the number of neuronal connections </li></ul><ul><li>The more connections, the more information flow, the more flexibility and resilience the brain will have </li></ul><ul><li>Why does increasing the amount of serotonin, as many anti-depressants do, take so long to reduce the symptoms of depression? </li></ul><ul><li>It takes 4-6 weeks to re-grow dendrites & axons </li></ul><ul><li>(Braun, 1999) </li></ul>
    15. 15. Why Don’t We Seek Treatment? <ul><li>We don’t know we are experiencing a brain disorder – we don’t recognize the symptoms </li></ul><ul><li>When we talk to doctors, we are vague about symptoms </li></ul><ul><li>We believe the things we are thinking and feeling are our fault, our failure, our weakness, not an illness </li></ul><ul><li>We fear being stigmatized at work, at church, at school </li></ul>
    16. 16. No Happy Pills For Me <ul><li>The stigma around depression leads to refusal of treatment </li></ul><ul><li>Taking medication is viewed as a failure by the same people who cheerfully take their blood pressure or cholesterol meds </li></ul><ul><li>Medication is seen as altering personality, taking something away, rather than as repairing damage done to the brain by stress hormones </li></ul>
    17. 17. Therapy? Are You Kidding? I Don’t Need All That Woo-Woo Stuff! <ul><li>How can patients seek treatment for something they believe is a personal failure? </li></ul><ul><li>Acknowledging the need for help is not popular in our culture (Strong Silent type, Cowboy) </li></ul><ul><li>People who seek therapy may be viewed as weak </li></ul><ul><li>Therapists are viewed as crazy </li></ul><ul><li>They’ll just blame it on my mother or some other stupid thing </li></ul>
    18. 18. How Does Psychotherapy Help? <ul><li>Medications may improve brain function, but do not change how we interpret stress </li></ul><ul><li>Psychotherapy, especially cognitive or interpersonal therapy, helps people change the (negative) patterns of thinking that lead to depressed and suicidal thoughts </li></ul><ul><li>Research shows that cognitive psychotherapy is as effective as medication in reducing depression and suicidal thinking </li></ul><ul><li>Changing our beliefs and thought patterns alters our response to stress – we are not as reactive or as affected by stress at the physical level (Lester, 2004) </li></ul>
    19. 19. What Therapy? <ul><li>The standard of care is medication and psychotherapy combined </li></ul><ul><li>At this point, only cognitive behavioral and interpersonal psychotherapies are considered to be effective with clinical depression (evidence-based) </li></ul><ul><li>Consider EMDR for patients with trauma experiences </li></ul><ul><li>Look for therapists with specific training – Ask! </li></ul>
    20. 20. <ul><li>Yet most people do not understand the physical aspects of mental illness, as you have no doubt found in talking with your patients </li></ul><ul><li>Suicide is strongly linked with certain mental illnesses, and most people do not understand this connection </li></ul><ul><li>Your county Suicide Prevention Coalition is attempting to Reduce the stigma attached to mental illness, increase help-seeking behavior , and increase awareness of the consequences of untreated depression </li></ul>
    21. 21. Suicide Prevention Efforts <ul><li>First national effort established at NIMH in 1969 </li></ul><ul><li>Surgeon General issued a call to action to prevent suicide in 1999 </li></ul><ul><li>In 2001, a National Strategy for Suicide Prevention Committee developed future goals and objectives </li></ul><ul><li>An Ohio Suicide Prevention Plan was developed in May, 2002, and grants for local coalitions were given out in November of 2002 </li></ul>
    22. 22. Development Of Prevention Efforts <ul><li>Over the past 20 years, we have acquired valuable information on risk and protective factors, methods for preventing suicidal behavior, and improved research methods </li></ul><ul><li>An increase in suicide prevention programs in schools </li></ul><ul><li>The rapid development of suicidology as a multidisciplinary sub-specialty </li></ul><ul><li>Establishment of centers for the study and prevention of suicide </li></ul>
    23. 23. Framework For Prevention <ul><li>Public health approach to prevention in contrast to clinical approaches used in the past </li></ul><ul><li>The prevailing model is the Universal, Selective, and Indicated model (WHO, 2002) </li></ul><ul><li>Focuses attention on defined populations, from everyone, to specific at-risk groups, to specific high-risk individuals </li></ul>
    24. 24. <ul><li>89 people complete suicide every day </li></ul><ul><li>32,637 people in 2005 in the US </li></ul><ul><li>Over 1,000,000 suicides worldwide (reported) </li></ul><ul><li>This data refers to completed suicides that are documented by medical examiners – it is estimated that 2-3 times as many actually complete suicide </li></ul><ul><li>(Surgeon General’s Report on Suicide, 1999) </li></ul>Is Suicide Really a Problem?
    25. 25. The Unnoticed Death <ul><li>For every 2 homicides, 3 people complete suicide yearly– data that has been constant for 100 years </li></ul><ul><li>During the Viet Nam War from 1964-1972, we lost 58,000 troops, and 220,000 people to suicide </li></ul>
    26. 26. Who Is At Risk? <ul><li>Most people assume young people </li></ul><ul><li>are more likely to complete suicide, </li></ul><ul><li>It is the 3 rd largest killer of youth ages 15-24 </li></ul><ul><li>In 2005, 267 children aged 10-14 completed </li></ul><ul><li>Adult males from 35-55 actually complete suicide at a far greater rate than youth </li></ul><ul><li>The elderly are at significant risk; among those over 75, 1 out of 4 attempts end in death because the elderly tend to use more lethal means </li></ul><ul><li>(Surgeon General’s call to Action, 1999) </li></ul>
    27. 27. <ul><li>Comparative Rates Of U.S. Suicides-2004 </li></ul><ul><li>Rates per 100,000 population </li></ul><ul><ul><li>National average - 11.1 per 100,000* </li></ul></ul><ul><ul><li>White males - 18 </li></ul></ul><ul><ul><li>Hispanic males - 10.3 </li></ul></ul><ul><ul><li>African-American males - 9.1 ** </li></ul></ul><ul><ul><li>Asians - 5.2 </li></ul></ul><ul><ul><li>Caucasian females - 4.8 </li></ul></ul><ul><ul><li>African American females - 1.5 </li></ul></ul><ul><ul><li>Males over 85 - 67.6 </li></ul></ul><ul><li>Annual Attempts – 811,000 (estimated) </li></ul><ul><ul><li>150-1 completion for the young - 4-1 for the elderly </li></ul></ul><ul><ul><li> (*AAS website),**(Significant increases have occurred among African Americans in the past 10 years - Toussaint, 2002) </li></ul></ul>
    28. 28. Suicide Rate By Age Per 100,000 Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hovert, 1999)
    29. 29. Suicide Rates Among The Elderly <ul><li>The elderly have the highest suicide rate of any group </li></ul><ul><li>Depression in late life affects six million people, one out of six patients in a general medical practice </li></ul><ul><li>However, only one of those six patients is diagnosed and treated appropriately </li></ul><ul><li>The majority of these people have seen their primary care physician within the last month of life </li></ul><ul><li>There is evidence that the majority of elderly suicide victims die in the midst of their first episode of major depression </li></ul><ul><li>Depression is not a normal consequence of aging and can significantly alter the course of other medical conditions </li></ul><ul><li>(Empfield, 2003) </li></ul>
    30. 30. PCP’s And Diagnosis Of Depression <ul><li>Seniors have often visited a health-care provider before completing suicide </li></ul><ul><ul><ul><li>20% of elderly (over 65 years) who complete suicide visited a physician within 24 hours </li></ul></ul></ul><ul><ul><ul><li>41% within a week </li></ul></ul></ul><ul><ul><ul><li>75% within one month </li></ul></ul></ul><ul><li>Patients may not use the words depression or sadness </li></ul><ul><li>Because of the stigma that is still attached to this diagnosis, somatic symptoms may become the focus of complaint </li></ul><ul><li>There may be much denial and minimizing of affective symptoms </li></ul><ul><li>(Empfield, 2003) </li></ul>
    31. 31. Poor Quality Of Mental Health Care For Elders <ul><li>Increased risk for inappropriate medication treatment (Bartels, et al., 1997, 2002) </li></ul><ul><ul><li>> 1 in 5 older persons given an inappropriate prescription (Zhan, 2001) </li></ul></ul><ul><li>The elderly are less likely to be treated with psychotherapy (Bartels, et al., 1997) </li></ul><ul><li>Lower quality of general health care is associated with increased mortality </li></ul><ul><li>(Druss, 2001) </li></ul>
    32. 32. Depression Associated With Worse Health Outcomes <ul><li>Depression is common among older patients with certain medical disorders </li></ul><ul><li>Associated with worse health outcomes </li></ul><ul><ul><li>Greater use and costs of medications </li></ul></ul><ul><ul><li>Greater use of health services </li></ul></ul><ul><li>Medical illness greatly increases the risk for depression particularly in: </li></ul><ul><ul><li>Ischemic heart disease (e.g. MI, CABG) </li></ul></ul><ul><ul><li>Stroke Cancer Chronic lung disease Alzheimer’s disease Parkinson’s disease </li></ul></ul><ul><ul><li>Rheumatoid Arthritis (Empfield, 2003 ) </li></ul></ul>
    33. 33. <ul><li>In Cancer, depression leads to </li></ul><ul><ul><ul><li>Increased Hospitalization </li></ul></ul></ul><ul><ul><ul><li>Poorer physical function </li></ul></ul></ul><ul><ul><ul><li>Poorer quality of life </li></ul></ul></ul><ul><ul><ul><li>Poorer pain control </li></ul></ul></ul><ul><li>Increased mortality rates for </li></ul><ul><ul><li>Hip fractures </li></ul></ul><ul><ul><li>Long Term Care Residents </li></ul></ul><ul><ul><li>Myocardial Infarction </li></ul></ul><ul><li>In heart attack patients, depression is a significant predictor of death at 6 months </li></ul><ul><ul><li>( Frasure-Smith 1993, 1995; Mossey 1990; Penninx et al. 2001; Katz 1989, </li></ul></ul><ul><ul><li>Rovner 1991, Parmelee 1992;Ashby1991; Shah 1993, Samuels 1997) </li></ul></ul>
    34. 34. Rates Of Depression Among Elders With Illness <ul><li>Cognitively intact nursing home patients shown to have symptoms consistent with depressive disorders – 60% </li></ul><ul><li>Chronically ill outpatients in a primary care practice - 25% </li></ul><ul><li>Hospitalized patients - 20% </li></ul><ul><li>In nursing homes, regardless of physical health, major depression increases the likelihood of mortality by 59% in one year </li></ul><ul><li>(Empfield, 2003) </li></ul>
    35. 35. Benefits Of Treatment For Depression In The Elderly <ul><li>Depression is one of the few medical conditions in which treatment can make a rapid and dramatic difference in an elderly person’s level of function and quality of life </li></ul><ul><li>Treatment may help patients accept medical treatment that they otherwise might refuse because of feelings of hopelessness or futility </li></ul><ul><li>Treatment also helps enhance or recover coping skills needed to deal with the inevitable losses associated with chronic medical illness </li></ul><ul><li>(Empfield, 2003) </li></ul>
    36. 36. What Factors Put Someone At Risk? <ul><li>Many things increase one’s risk for suicide- biological, psychological, social factors all apply </li></ul><ul><li>The single greatest risk factor for suicide completion - H aving a Depressive Disorder </li></ul><ul><li>90% of reported US suicides are experiencing depression </li></ul><ul><li>The 2nd biggest factor - having an alcohol or drug problem - However, many people with alcohol and drug problems are significantly depressed, and are self-medicating </li></ul><ul><li>(Lester, 1998) </li></ul>
    37. 37. <ul><li>Other risk factors include : </li></ul><ul><li>Previous suicide attempts </li></ul><ul><li>A family history of suicide - increases our risk by 6 times </li></ul><ul><li>A significant loss by death, divorce, separation, moving, or breaking up with a loved one. Shock or pain, even long term lower level stress, can affect the structure of the brain, especially the limbic system </li></ul><ul><li>30 years of research confirms the relationship between hopelessness and suicide, across diagnoses </li></ul><ul><li>Impulsivity, particularly among youth, is increasingly linked to suicidal behavior </li></ul><ul><li>Access to firearms – 60% of completed suicides used firearms </li></ul><ul><li>(Surgeon General’s call to Action, 1999) </li></ul>
    38. 38. <ul><li>Biological factors: </li></ul><ul><ul><li>Biological changes are associated with </li></ul></ul><ul><ul><li>both completed and attempted suicide </li></ul></ul><ul><ul><li>Changes include abnormal functioning of </li></ul></ul><ul><ul><li>the Hypothalamic-Pituitary-Adrenal axis, </li></ul></ul><ul><ul><li>a major component of the way we adapt to stress </li></ul></ul><ul><li>Psychological factors: </li></ul><ul><ul><li>Changes in thinking (constricted thought) leading to the belief that suicide is the only answer; negative automatic thoughts that lead to sadness, hopelessness, loss of pleasure, inability to see a future, low self-esteem </li></ul></ul><ul><ul><li>Suicidality, although clearly overlapping the symptoms of associated MH disorders, does not appear to respond to treatment in exactly the same way </li></ul></ul><ul><ul><li>In some cases, depressive symptoms can be reduced by medication without a reduction in suicidal thinking </li></ul></ul>
    39. 39. Protective Factors <ul><li>Stigma reduction programs, especially </li></ul><ul><li>among youth, increase help-seeking behavior </li></ul><ul><li>Resiliency and coping skills to reduce risk can be taught (Dialectical Behavioral Training) </li></ul><ul><li>Spirituality improves defenses against suicidal thinking </li></ul><ul><li>Social support – those with close relationships cope better with various stresses, including bereavement, job loss, and illness </li></ul><ul><li>Social disapproval of suicide reduces rates </li></ul><ul><li>*(Berman & Jobes, 1996; Beck, 1985; Rush et al, 1992, Surgeon General’s Call To Action, 1999) </li></ul>
    40. 40. Treatment <ul><li>Treatment of suicidality has improved dramatically in the last 20 years </li></ul><ul><li>Evidence is clear that lithium treatment of bi-polar disorder significantly reduces suicide rates* </li></ul><ul><li>A correlation has been noted between an increase in prescription rates for SSRI’s and a decline in suicide rates** </li></ul><ul><li>(*Baldessarini, et.al, 1999, **NIMH, 2002) </li></ul>
    41. 41. <ul><li>However, medication alone is insufficient to reduce suicidal ideation </li></ul><ul><li>Psychotherapy can reduce suicidality by helping people learn to interpret the stresses in their lives more effectively, reducing the level of stress hormones in the body </li></ul><ul><li>Psychotherapy provides a necessary therapeutic relationship that reduces risk through increased hope and support </li></ul><ul><li>Cognitive-behavioral approaches that include problem-solving training reduce suicidal ideation and attempts more effectively than other approaches </li></ul><ul><li>Medication combined with psychotherapy is the current standard of care for clinical depression </li></ul><ul><li>(Beck, 1996 , Quinnett, 2000, Macintosh, 1996) </li></ul>
    42. 42. SSRI’s And Suicide More Mythology? <ul><li>Media has sensationalized the idea that “Prozac” causes suicide in teens </li></ul><ul><li>There is a very low risk that SSRI’s can induce suicidal agitation in a very few individuals </li></ul><ul><li>Many teens on SSRI’s are, in fact already suicidal, and meds may not work well enough, or in time </li></ul><ul><li>The FDA has recently banned the use of Paxil for depression in adolescents, but Prozac has been approved for use in teens </li></ul>
    43. 43. <ul><li>The American College of Neuropsychopharmacology's Task Force report from January 21, 2004, which reviewed all clinical trials, epidemiological studies and toxicology studies in autopsies did not find evidence for a link between SSRI's and increased risk of suicide in children and adolescents </li></ul><ul><li>In a recent preliminary study of 49 adolescent suicides, researchers found that 24% had been prescribed antidepressants, but none had any trace of SSRI's in their system at the time of their death </li></ul><ul><li>There is an increased risk of suicide in depressed individuals who do not take their medication; which is a factor common to adolescents </li></ul><ul><li>A 2003 World Health Organization study in over fifteen countries found a significant reduction, averaging about 33%, in the youth suicide rate that coincided with the introduction of SSRI's </li></ul><ul><li>(Altesman, 2005) </li></ul>
    44. 44. <ul><li>A review of all the research on this topic was conducted recently </li></ul><ul><li>CONCLUSION : “No increased susceptibility to aggression or suicidality can be connected with fluoxetine or any other SSRI. In fact SSRI treatment may reduce aggression toward self or others” </li></ul><ul><li>“ In the absence of any convincing evidence to link SSRI’s causally to violence and suicide, the recent media reports are potentially dangerous, unnecessarily increasing the concerns of depressed patients who are prescribed antidepressants” (Goldberg, 2003) </li></ul><ul><li>In November, Newsweek reported that prescriptions for SSRI’s for teens have dropped by 50% in 03 and 04 – suicide rates have climbed 18% in 03 </li></ul>
    45. 45. High Risk Behaviors and Suicide <ul><li>Miller and Taylor (2000) analyzed high risk behaviors in 9 th -12 th graders and found a correlation with suicide ideation and attempts </li></ul><ul><li>High risk health behaviors included </li></ul><ul><ul><li>High Risk Sex (multiple partners, before age 14) </li></ul></ul><ul><ul><li>Binge Drinking (5 or more in several hours) </li></ul></ul><ul><ul><li>Drug Use </li></ul></ul><ul><ul><li>Disturbed eating patterns (boys do not get asked about this) </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Violence (girls do not get asked about this) </li></ul></ul>
    46. 46. <ul><li>The 17% of youth with more than three problem behaviors were the youth who acted </li></ul><ul><li>They accounted for 60% of medically treated suicidal acts </li></ul><ul><li>Compared to adolescents with zero problem behaviors, the odds of a medically treated suicide attempt were </li></ul><ul><ul><li>2.3 times greater among respondents with one </li></ul></ul><ul><ul><li>8.8 with two </li></ul></ul><ul><ul><li>18.3 with three </li></ul></ul><ul><ul><li>30.8 with four </li></ul></ul><ul><ul><li>50.0 with five </li></ul></ul><ul><ul><li>227.3 with six </li></ul></ul><ul><li>A count of problem behaviors may offer a reliable way to identify suicide risk </li></ul><ul><li>(Miller & Taylor, 2000) </li></ul>
    47. 47. Barriers To Treatment <ul><li>Fragmentation of services and cost of care are the most frequently cited barriers to treatment </li></ul><ul><li>About 67% of people with significant mental disorders do not receive treatment </li></ul><ul><li>Psychological autopsy studies reveal that less than 14% of completers were receiving adequate treatment, and fewer than 17% were being treated with psychiatric medications </li></ul><ul><li>However, 50-70% had contact with health services in the weeks before their death </li></ul><ul><li>Surgeon General’s Call To Action, 1999; Empfield, 2003 </li></ul>
    48. 48. <ul><li>Currently, no psychological test, clinical technique or biological marker is sensitive enough to accurately and consistently predict suicide </li></ul><ul><li>Primary care has become a critical setting for detection of the two most common factors: depression and alcoholism* </li></ul><ul><li>Depression is the second most common chronic disorder seen by PCP’s </li></ul><ul><li>According to the AMA, a diagnostic interview for depression is comparable in sensitivity to laboratory tests commonly used in diagnosis, but currently, less than 50% of adults with diagnosable depression are accurately diagnosed by PCP’s* </li></ul><ul><li>“ Physicians are often reticent to talk with patients about suicide intent or ideation, and patients seldom spontaneously report it”** </li></ul><ul><li>(*Surgeon General’s Call to Action, 1999; **Quinnett, 2000 ) </li></ul>
    49. 49. What Is Your County Doing? <ul><li>Suicide prevention coalitions have been developed over the past 3 years across the state with grants from Ohio Dept. of Mental Health </li></ul><ul><li>In many counties, the Mental Health Board is spearheading this process, with help </li></ul><ul><li>from all areas of the community, </li></ul><ul><li>including health care providers, mental </li></ul><ul><li>health professionals, suicide survivors, </li></ul><ul><li>clergy, school personnel, human resource </li></ul><ul><li>personnel, police/sheriff dept, health </li></ul><ul><li>department, and many others </li></ul>
    50. 50. How Do We Know Suicide Prevention Coalitions Work? <ul><li>In 1996 the U.S. Air Force decided to mount an assault on it’s high suicide rate </li></ul><ul><li>They targeted help-seeking behavior, stigma, and awareness </li></ul><ul><li>After 5 years of a major collaborative effort within the service, suicide rates dropped 78% </li></ul><ul><li>Comparable rates in the other 4 armed services remained the same </li></ul>
    51. 51. How Can You Help? <ul><li>Medical personnel are the front line of defense against this insidious killer - assess your patients for suicidal ideation when depressive symptoms arise </li></ul><ul><li>Specifically ask your patients if they are experiencing suicidal ideation – They may not volunteer the information </li></ul><ul><li>Train staff in depression awareness, and in asking the “S” question </li></ul><ul><li>We must gain confidence in asking people if they are thinking about dying </li></ul><ul><li>(Surgeon General’s Call To Action, 1999) </li></ul>
    52. 52. Comfort And Competence Lead To Hopefulness <ul><li>A study by Dr. Paul Quinett, a long-time researcher and clinician in suicide, indicates that patients who felt their clinician was comfortable asking questions about their suicidal thoughts and feelings reported much higher levels of hope about the future </li></ul><ul><li>The best outcome of asking the “S” question is immediate relief for the patient </li></ul><ul><li>(Quinnett, 2001) </li></ul>
    53. 53. <ul><li>Hopelessness is the most immediate risk factor for suicide, so instilling hope is essential </li></ul><ul><li>If your patient is on anti-depressant or anti-anxiety medication, refer them to a psychologist or counselor who can work with them on the maintaining causes of depression </li></ul><ul><li>Consider using a risk assessment format to ensure you ask the right questions </li></ul>
    54. 54. What To Ask? <ul><li>Except for psychiatrists, routine </li></ul><ul><li>questioning about suicidal ideation </li></ul><ul><li>is not the current standard of care </li></ul><ul><li>If you have a patient with depressive symptoms or other mental health disorders (especially anxiety) </li></ul><ul><ul><li>Learn to Ask the “S” question </li></ul></ul><ul><ul><li>Not – you aren’t thinking of suicide are you? </li></ul></ul><ul><ul><li>But - Some people who experience the amount of pain you’re in think about killing themselves. Have you ever thought about it? </li></ul></ul><ul><ul><li>(Lester, 1998) </li></ul></ul>
    55. 55. Use Of A Structured Interview <ul><li>Many patients will not overtly acknowledge common symptoms of depression, focusing more on vague pain </li></ul><ul><li>You may wish to develop or purchase a guided clinical interview for use with suicidal clients </li></ul><ul><li>A structured form assesses current risk, sets up a management plan, and ensures that all the right questions are asked </li></ul><ul><li>Most take just a few minutes to complete, and people are surprisingly honest </li></ul>
    56. 56. Screening Recommendations <ul><li>The U.S. Preventive Services Task Force reviewed new evidence that patients fare best when medical professionals recognize the symptoms of depression and make sure they receive appropriate treatment </li></ul><ul><li>The USPSTF issued new depression screening recommendations in May, 2002, asking PCP’s to routinely screen adult patients for depression </li></ul><ul><li>Medical professionals should have systems in place to assure accurate diagnosis, effective treatment, and follow-up if patients are to benefit from screening </li></ul><ul><li>The journal of AAFP offers the article “Screening for Depression across the Lifespan: A review of Measures of Use in Primary Care settings” to help medical professionals make appropriate choices of screening tool (Sharp and Lipsky, 2002) </li></ul>
    57. 57. Possible Depression Scales <ul><li>Beck Depression Inventory </li></ul><ul><li>Children’s Depression Inventory </li></ul><ul><li>CES-DC (Center for Epidemiological Studies Depression Scale) </li></ul><ul><li>Edinburgh Post-Natal Depression Scale </li></ul><ul><li>Geriatric Depression Scale </li></ul><ul><li>QPRT - Question, Persuade, Refer or Treat -QPR Institute - www.qprinstitute.com </li></ul><ul><li>Zung Depression Inventory </li></ul>
    58. 58. Learning “ QPR ” – Or, How To Ask The “S” Question <ul><li>It is essential, if we are to reduce the number of suicide deaths in our country, that community members/gatekeepers learn “ QPR ” </li></ul><ul><li>First identified by Dr. Paul Quinnett as an analogue to CPR, “ QPR ” consists of </li></ul><ul><ul><li>Q uestion – asking the “S” question </li></ul></ul><ul><ul><li>P ersuade– Getting the person to talk, and to seek help </li></ul></ul><ul><ul><li>R efer – Getting the person to professional help </li></ul></ul><ul><li>Medical staff can learn this method in a very short time </li></ul><ul><ul><li>(Quinnett, 2000) </li></ul></ul>
    59. 59. Intervention <ul><li>Once a patient has told someone they are thinking of suicide, you need a thorough suicide assessment </li></ul><ul><li>In your area, what mental health facilities with emergency services are available? </li></ul><ul><li>Sending a suicidal patient alone to the emergency room could be a mistake </li></ul><ul><li>Most mental health agencies have crisis workers who can come to your office to interview your patient – suicidal people should never be left alone! </li></ul>
    60. 60. Psychiatric Hospitalization <ul><li>The actual prediction of suicide is, essentially, impossible </li></ul><ul><li>The base rates are too low, and risk level changes from day to day </li></ul><ul><li>Statistically, you could almost always bet that no given individual will complete suicide </li></ul><ul><li>Other risks are managed by understanding what risk factors exist, and limiting as many of them as possible, like wearing sunscreen </li></ul><ul><li>It is imperative that medical professionals know risk factors for suicide </li></ul><ul><li>(MacIntosh, 1993) </li></ul>
    61. 61. The Top Ten Risk Factors When Thinking Of Hospitalization <ul><li>Previous Suicide attempt(s) </li></ul><ul><li>Mental disorders (especially depression, bipolar) </li></ul><ul><li>Co-occurring mental and AL/SA disorders </li></ul><ul><li>Family history of suicide </li></ul><ul><li>Hopelessness (should this be first?) </li></ul><ul><li>Impulsive/aggressive tendencies </li></ul><ul><li>Barriers to accessing mental health treatment </li></ul><ul><li>Relational, social, work or financial loss </li></ul><ul><li>physical illness (esp. with chronic pain) </li></ul><ul><li>Easy access to lethal methods, especially guns </li></ul><ul><li>(Surgeon General’s Call to Action to Prevent Suicide, 1999 ) </li></ul>
    62. 62. Voluntary Hospitalization <ul><li>Best choice – less hard on the patient’s sense of self-worth – a way to buy time (to think it over, get sleep, etc.) </li></ul><ul><li>Safety is the main message – a good night’s sleep, a start on medications, talk with doctors, put things on hold for awhile </li></ul><ul><li>Allows them to save face – I didn’t want to, but they insisted… </li></ul>
    63. 63. Sharing Knowledge Of Hospitals <ul><li>Ease the transition by addressing their fears </li></ul><ul><li>Facts: hospital stays tend to be short </li></ul><ul><ul><li>Staff are well-trained and know about suicidal suffering </li></ul></ul><ul><ul><li>ECT cannot be given without patient permission </li></ul></ul><ul><ul><li>Patients rights are guaranteed </li></ul></ul><ul><ul><li>Modern hospitals are not snake pits </li></ul></ul>
    64. 64. Know Your Local Resources And Agencies <ul><li>Where to hospitalize </li></ul><ul><li>Who do you call </li></ul><ul><li>Have your risk assessment information ready </li></ul><ul><li>Help to overcome barriers to hospitalization such as child care, pets, transportation, calls to work, etc. </li></ul>
    65. 65. Local Professional Resources <ul><li>Your Local Mental Health Agencies </li></ul><ul><li>Your Local Mental Health Board </li></ul><ul><li>School Guidance Counselors </li></ul><ul><li>Your Hospital Emergency Room </li></ul><ul><li>Local Crisis Hotlines </li></ul><ul><li>National Crisis Hotlines </li></ul><ul><li>School nurses </li></ul><ul><li>911 </li></ul><ul><li>Local Police/Sheriff </li></ul><ul><li>Local Clergy </li></ul>
    66. 66. <ul><li>“ Suicide is a </li></ul><ul><li>permanent solution </li></ul><ul><li>to a </li></ul><ul><li>temporary problem ” </li></ul><ul><li>Edwin Schneidman, MD. </li></ul><ul><li>Founder of Suicidology </li></ul>
    67. 67. <ul><li>The Ohio Suicide Prevention Foundation </li></ul><ul><li>The Ohio State University, Center on Education and Training for Employment </li></ul><ul><li>1900 Kenny Road, Room 2072 </li></ul><ul><li>Columbus, OH 43210 </li></ul><ul><li>614-292-8585 </li></ul>
    68. 68. A Brief Bibliography <ul><li>Anderson, E. “The Personal and Professional Impact of Client Suicide on Mental Health Professionals. Unpublished Doctoral dissertation, U. of Toledo, 1999 </li></ul><ul><li>Berman, A. L. & Jobes, D. A. (1996) Adolescent Suicide: Assessment and Intervention . </li></ul><ul><li>Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients. American Psychiatric Press. </li></ul><ul><li>Empfield, Maureen MD( 2002) PSYCHIATRY FOR THE PRIMARY CARE PHYSICIAN – Section 2. URL </li></ul><ul><li>Goldberg, I. SSRI’s and Suicide: Results of a MELINE Search. At: ttp://www.psycom.net/depression.central.ssri-suicide.html </li></ul><ul><li>Jacobs, D., Ed. (1999). The Harvard Medical School Guide to Suicide Assessment and Interventions. Jossey-Bass. </li></ul>
    69. 69. <ul><li>Jamison, K.R., (1999). Night Falls Fast: Understanding Suicide. Alfred Knopf  </li></ul><ul><li>Lester, D. (1998). Making Sense of Suicide: An In-Depth Look at Why People Kill Themselves. American Psychiatric Press </li></ul><ul><li>Oregon Health Department, Prevention. Notes on Depression and Suicide: ttp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cfm </li></ul><ul><li>President’s New Freedom Council on Mental Health, 2003 </li></ul><ul><li>Quinnett, P.G. (2000). Counseling Suicidal People. QPR Institute, Spokane, WA </li></ul><ul><li>Shea, C., 2000. A Practical Interviewing Strategy for the Elicitation of Suicidal Ideation. Journal of Clinical Psychiatry (supplement 20) 59: 58-72, 1998 </li></ul>
    70. 70. <ul><li>Smith, Range & Ulner. “Belief in Afterlife as a buffer in suicide and other bereavement.” Omega Journal of Death and Dying, 1991-92, (24)3; 217-225. </li></ul><ul><li>Stoff, D.M. & Mann, J.J. (Eds.), (1997). The Neurobiology of Suicide . American Academy of Science </li></ul><ul><li>Schneidman, E.S. (1996). The Suicidal Mind . Oxford University Press. </li></ul><ul><li>Styron, W. (1992). Darkness Visible. Vintage Books </li></ul><ul><li>  Surgeon General’s Call to Action (1999). Department of Health and Human Services, U.S. Public Health Service. </li></ul><ul><li>Tang, T.Z. & De Rubeis, R.J. ((1999). “Sudden Gains and critical sessions in cognitive-behavioral therapy for depression”. Journal of Consulting and Clinical Psychology 67: 894-904. </li></ul>

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