Suicide Prevention
Saving Lives
One Community at a Time
America Foundation for Suicide Prevention
Dr. Paula J. Clayton, AFSP Medical Director
120 Wall Street, 22nd Floor
New York, NY 10005
1-888-333-AFSP
www.afsp.org
Facing the Facts
An Overview of Suicide
Facing the Facts
In 2007, 34,598 people in the United States died by suicide. About
every 15.2 minutes someone in this country intentionally ends his/her
life.
Although the suicide rate fell from 1992 (12 per 100,000) to 2000 (10.4
per 100,000), it has been fluctuating slightly since 2000 –
despite all of our new treatments.
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Facing the Facts
Suicide is considered to be the second leading cause of death among
college students.
Suicide is the second leading cause of death for people aged 24-34.
Suicide is the third leading cause of death for people aged 10-24.
Suicide is the fourth leading cause of death for adults between the
ages of 18 and 65.
Suicide is highest in white males over 85.
(45.4/100,000, 2007)
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Facing the Facts
The suicide rate was 11.5/100,000 in 2007.
It greatly exceeds the rate of homicide. (6.1/100,000)
From 1979-2007, 881,443 people died by suicide, whereas 550,304
died from AIDS and HIV-related diseases.
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Facing the Facts
Death by Suicide and Psychiatric Diagnosis
Psychological autopsy studies done in various countries over almost
50 years report the same outcomes:
90% of people who die by suicide are suffering from one or more
psychiatric disorders:
Major Depressive Disorder
Bipolar Disorder, Depressive phase
Alcohol or Substance Abuse*
Schizophrenia
Personality Disorders such as Borderline PD
*Primary diagnoses in youth suicides.
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Facing the Facts
Suicide Is Not Predictable in Individuals
In a study of 4,800 hospitalized vets, it was not possible to identify
who would die by suicide — too many false-negatives, false-positives.
Individuals of all races, creeds, incomes and educational levels die by
suicide. There is no typical suicide victim.
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Facing the Facts
Suicide Communications Are Often Not Made to Professionals
In one psychological autopsy study, only 18% told professionals of
intentions*
In a study of suicidal deaths in hospitals:
77% denied intent on last communication
28% had “no suicide” contracts with their caregivers” **
Research does not support the use of no-harm contracts (NHC) as a
method of preventing suicide, nor from protecting clinicians from
malpractice litigation in the event of a client suicide***
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Facing the Facts
Suicide Communications ARE Made to Others
In adolescents, 50% communicated their intent to family members*
In elderly, 58% communicated their intent to the primary care
doctor**
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Facing the Facts
Research shows that during our lifetime:
20% of us will have a suicide within our immediate family.
60% of us will personally know someone who dies by suicide.
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Facing the Facts
Prevention may be a matter of a caring person with
the right knowledge being available in the right
place at the right time.
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Myths Versus Facts
About Suicide
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Myths versus Facts
MYTH:
People who talk about suicide don't complete suicide.
FACT:
Many people who die by suicide have given definite warnings to
family and friends of their intentions. Always take any comment
about suicide seriously.
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Myths versus Facts
MYTH:
Suicide happens without warning.
FACT:
Most suicidal people give clues and signs regarding their suicidal
intentions.
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Myths versus Facts
MYTH:
Suicidal people are fully intent on dying.
FACT:
Most suicidal people are undecided about living or dying, which is
called “suicidal ambivalence.” A part of them wants to live; however,
death seems like the only way out of their pain and suffering. They
may allow themselves to "gamble with death," leaving it up to others
to save them.
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Myths versus Facts
MYTH:
Men are more likely to be suicidal.
FACT:
Men are four times more likely to kill themselves than women.
Women attempt suicide three times more often than men do.
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Myths versus Facts
MYTH:
Asking a depressed person about suicide will push him/her to
complete suicide.
FACT:
Studies have shown that patients with depression have these ideas
and talking about them does not increase the risk of them taking
their own life.
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Myths versus Facts
MYTH:
Improvement following a suicide attempt or crisis means that the risk
is over.
FACT:
Most suicides occur within days or weeks of "improvement," when
the individual has the energy and motivation to actually follow
through with his/her suicidal thoughts. The highest suicide rates are
immediately after a hospitalization for a suicide attempt.
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Myths versus Facts
MYTH:
Once a person attempts suicide, the pain and shame they experience
afterward will keep them from trying again.
FACT:
The most common psychiatric illness that ends in suicide is Major
Depression, a recurring illness. Every time a patient gets depressed,
the risk of suicide returns.
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Myths versus Facts
MYTH:
Sometimes a bad event can push a person to complete suicide.
FACT:
Suicide results from having a serious psychiatric disorder. A single
event may just be “the last straw.”
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Myths versus Facts
MYTH:
Suicide occurs in great numbers around holidays in November and
December.
FACT:
Highest rates of suicide are in May or June, while the lowest rates are
in December.
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Risk Factors
For Suicide
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Risk Factors
Psychiatric disorders
Past suicide attempts
Symptom risk factors
Sociodemographic risk factors
Environmental risk factors
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Risk Factors
Psychiatric Disorders
Most common psychiatric risk factors resulting in suicide:
– Depression*
Major Depression
Bipolar Depression
– Alcohol abuse and dependence
– Drug abuse and dependence
– Schizophrenia
*Especially when combined with alcohol and drug abuse
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Risk Factors
Other psychiatric risk factors with potential to result in
suicide (account for significantly fewer suicides than
Depression):
Post Traumatic Stress Disorder (PTSD)
Eating disorders
Borderline personality disorder
Antisocial personality disorder
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Risk Factors
Past suicide attempt
(See diagram on right)
After a suicide attempt that is seen
in the ER about 1% per year take
their own life, up to approximately
10% within 10 years.
More recent research followed
attempters for 22 years and
saw 7% die by suicide.
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Risk Factors
Symptom Risk Factors During Depressive Episode:
Desperation
Hopelessness
Anxiety/psychic anxiety/panic attacks
Aggressive or impulsive personality
Has made preparations for a potentially serious suicide
attempt* or has rehearsed a plan during a previous episode
Recent hospitalization for depression
Psychotic symptoms (especially in hospitalized depression)
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Risk Factors
Major physical illness, especially recent
Chronic physical pain
History of childhood trauma or abuse, or of being bullied
Family history of death by suicide
Drinking/Drug use
Being a smoker
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Risk Factors
Sociodemographic Risk Factors
Male
Over age 65
White
Separated, widowed or divorced
Living alone
Being unemployed or retired
Occupation: health-related occupations higher (dentists,
doctors, nurses, social workers)
– especially high in women physicians
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Risk Factors
Environmental Risk Factors
Easy access to lethal means
Local clusters of suicide that have a "contagious influence"
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Preventing Suicide
One Community at a Time
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Preventing Suicide
Prevention within our community
Education
Screening
Treatment
Means Restriction
Media Guidelines
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Preventing Suicide
Education
Individual and Public Awareness
Professional Awareness
Educational Tools
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Preventing Suicide
Individual and Public Awareness
Primary risk factor for suicide is psychiatric illness
Depression is treatable
Destigmatize the illness
Destigmatize treatment
Encourage help-seeking behaviors and continuation of
treatment
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Preventing Suicide
Professional Awareness
Healthcare Professionals
– Physicians, pediatricians, nurse practitioners, physician assistants
Mental Health Professionals
– Psychologists, Social Workers
Primary and Secondary School Staff
– Principals, Teachers, Counselors, Nurses
College and University Resource Staff
– Counselors, Student Health Services, Student Residence Services, Resident Hall
Directors and Advisors
Gatekeepers
– Religious Leaders, Police, Fire Departments, Armed Services
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Preventing Suicide
Educational Tools
Depression and suicide among college students:
– The Truth About Suicide: Real Stories of Depression in College (2004)
Comes with accompanying facilitator’s guide
Depression and suicide among physicians and medical students:
– Struggling in Silence: Physician Depression and Suicide (54 minutes)*
– Struggling in Silence: Community Resource Version (16 minutes)
– Out of the Silence: Medical Student Depression and Suicide (15 minutes)
Both shorter films are packaged together and include PPT presentations on the
DVD’s
Depression and suicide among teenagers:
– More Than Sad: Teen Depression (2009)**
Comes with facilitator’s guide and additional resources
– Suicide Prevention Education for Teachers and Other School Personnel (2010)
Includes new film, More Than Sad: Preventing Teen Suicide, More Than Sad:
Teen Depression, facilitator’s guide, a curriculum manual and additional resources
*received 2008 International Health & Medical Media Award (FREDDIE) in Psychiatry category 36
**received 2010 Eli Lilly Welcome Back Award in Destigmatization category
Preventing Suicide
Screening
Identify At Risk Individuals:
Columbia Teen Screen and others
AFSP Interactive Screening Program (ISP):
The ISP is an anonymous, web-based, interactive screen for
individuals (students, faculty, employees) with depression and
other mental disorders that put them at risk for suicide. ISP
connects at-risk individuals to a counselor who provides
personalized online support to get them engaged to come in
for an evaluation. Based on evaluation findings, ISP was
included in the Suicide Prevention Resource Center’s Best
Practice Registry in 2009. It is currently in place in 16 colleges,
including four medical schools.
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Preventing Suicide
Treatment
Antidepressants
Psychotherapy
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Preventing Suicide
Antidepressants
Adequate prescription treatment and monitoring
Only 20% of medicated depressed patients are adequately
treated with antidepressants – possibly due to:
Side effects
Lack of improvement
High anxiety not treated
Fear of drug dependency
Concomitant substance use
Didn't combine with psychotherapy
Dose not high enough
Didn't add adjunct therapy such as lithium or other
medication(s)
Didn't explore all options including: ECT or other somatic
treatment
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Preventing Suicide
Psychotherapy
Research shows that when it comes to treating depression, all therapy
is NOT created equal.
Study shows applying correct techniques reduce suicide attempts by
50% over 18 month period
To be effective, psychotherapy must be:
Specifically designed to treat depression
Relatively short-term (10-16 weeks)
Structured (therapist should be able to give step-by-step treatment
instructions that any other therapist can easily follow)
Examples: Cognitive Behavior Therapy (CBT), Interpersonal Therapy (IPT),
Dialectical Behavior Therapy (DBT)
Implement teaching of these techniques 40
Preventing Suicide
Means Restrictions
Firearm safety
Construction of barriers at jumping sites
Detoxification of domestic gas
Improvements in the use of catalytic converters in motor vehicles
Restrictions on pesticides
Reduce lethality or toxicity of prescriptions
– Use of lower toxicity antidepressants
– Change packaging of medications to blister packs
– Restrict sales of lethal hypnotics (i.e. Barbiturates)
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Preventing Suicide
Media
Guidelines
Considerations
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Preventing Suicide
Media Guidelines
Encourage implementation of responsible media guidelines for reporting
on suicide, such as those developed by AFSP in partnership with
government agencies and private organizations.
Reporting on Suicide:
recommendations for the media
Can be found on AFSP website:
www.afsp.org/media
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Preventing Suicide
Media Considerations
Consider how suicide is portrayed in the media
TV
Movies
Advertisements
The Internet danger
Suicide chat rooms
Instructions on methods
Solicitations for suicide pacts.
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You Can Help!
Adapted with permission
from the Washington Youth Suicide Prevention Program
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You Can Help
Know warning signs
Intervention
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You Can Help
Most suicidal people don't really want to die – they just want their
pain to end
About 80% of the time people who kill themselves have given
definite signals or talked about suicide
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You Can Help
Warning Signs
Observable signs of serious depression
Unrelenting low mood
Pessimism
Hopelessness
Desperation
Anxiety, psychic pain, inner tension
Withdrawal
Sleep problems
Increased alcohol and/or other drug use
Recent impulsiveness and taking unnecessary risks
Threatening suicide or expressing strong wish to die
Making a plan
Giving away prized possessions
Purchasing a firearm
Obtaining other means of killing oneself
Unexpected rage or anger 48
Proposed DSM-V Suicide Assessment Dimension
Level of concern about Suicide risk factor groups:
potential suicidal behavior:
1. Any history of a suicide attempt
(sum of items coded as 2. Long-standing tendency to lose temper or
present) become aggressive with little provocation
3. Living alone, chronic severe pain, or recent
1. 0: Lowest concern (within 3 months) significant loss
4. Recent psychiatric admission/discharge or
2. 1-2: Some concern first diagnosis of MDD, bipolar disorder or
schizophrenia
3. 3-4: Increased concern 5. Recent increase in alcohol abuse or
worsening of depressive symptoms
4. 5-7: High concern 6. Current (within last week) preoccupation
with, or plans for, suicide
7. Current psychomotor agitation, marked
anxiety or prominent feelings of
hopelessness
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You Can Help
Intervention
Three Basic Steps:
1. Show you care
2. Ask about suicide
3. Get help
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You Can Help
Intervention: Step One
Show You Care
Be Genuine
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You Can Help
Show you care
Take ALL talk of suicide seriously
If you are concerned that someone may take their life, trust
your judgment!
Listen Carefully
Reflect what you hear
Use language appropriate for age of person involved
Do not worry about doing or saying exactly the "right" thing.
Your genuine interest is what is most important.
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You Can Help
Be Genuine
Let the person know you really care. Talk about your
feelings and ask about his or hers.
"I'm concerned about you… how do you feel?"
"Tell me about your pain."
"You mean a lot to me and I want to help."
"I care about you, about how you're holding up."
"I'm on your side…we'll get through this."
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You Can Help
Intervention: Step Two
Ask About Suicide
Be direct but non-confrontational
Talking with people about suicide won't put the idea in their
heads. Chances are, if you've observed any of the warning signs,
they're already thinking about it. Be direct in a caring, non-
confrontational way. Get the conversation started.
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You Can Help
You do not need to solve all of the person's problems – just engage
them. Questions to ask:
– Are you thinking about suicide?
– What thoughts or plans do you have?
– Are you thinking about harming yourself, ending your life?
– How long have you been thinking about suicide?
– Have you thought about how you would do it?
– Do you have __? (Insert the lethal means they have mentioned)
– Do you really want to die? Or do you want the pain to go away?
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You Can Help
Ask about treatment:
Do you have a therapist/doctor?
Are you seeing him/her?
Are you taking your medications?
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You Can Help
Intervention: Step Three
Get help, but do NOT leave the person alone
Know referral resources
Reassure the person
Encourage the person to participate in helping process
Outline safety plan
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You Can Help
Know Referral Resources
Resource sheet
Hotlines
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You Can Help
Resource Sheet
Create referral resource sheet from your local community
Psychiatrists
Psychologists
Other Therapists
Family doctor/pediatrician
Local medical centers/medical universities
Local mental health services
Local hospital emergency room
Local walk-in clinics
Local psychiatric hospitals
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You Can Help
Hotlines
National Suicide Prevention Lifeline
1-800-273-TALK
www.suicidepreventionlifeline.org
911
In an acute crisis, call 911
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You Can Help
Reassure the person that help is available and that you will
help them get help:
“Together I know we can figure something out to make you feel better.”
“I know where we can get some help.”
“I can go with you to where we can get help.”
“Let's talk to someone who can help . . . Let's call the crisis line now.”
Encourage the suicidal person to identify other people in their
life who can also help:
Parent/Family Members
Favorite Teacher
School Counselor
School Nurse
Religious Leader
Family doctor
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You Can Help
Outline a safety plan
Make arrangements for the helper(s) to come to you OR take the
person directly to the source of help - do NOT leave them alone!
Once therapy (or hospitalization) is initiated, be sure that the
suicidal person is following through with appointments and
medications.
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