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4 links…
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Early recognition of warning signs
2.
Early application of QPR
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Early referral to professional care
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Early assessment and treatment
Knowledge + Practice = Action

Question: When to ask and what to say
Persuade: Influence another to seek help
Refer: Help another to get to a professional for assessment
Training: On-line or Face-toface

Gatekeeper – Foundational Training
Advanced – Suicide Risk Management and Triage
Available online or face-to-face
Tailored for populations – organizations
Primary Care
In Patient Hospital and ED
NGOs – Social Service Agencies
Adolescent MH – Youth Suicide Risk
Maori and Pacific – Whanau Ora
Schools – secondary and tertiary
Law Enforcement – NZ Police, Corrections, Probation
Professional Groups, e.g. Attorneys
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522 deaths (2010 – MOH Suicide Facts)
Rate: 11.5 per 100,000/year
10 New Zealanders each week (4 commercial jet crashes every year)
More than one New Zealander every day
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Of the 522 deaths
2.7 x male completions to female
2 x females to male attempts
Total Maori rate (13 per
100,000) 23 per cent higher than non-Maori
Among OECD NZ sits in the middle of the range
Rates are just ahead of the US and Canada
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Current youth suicide rate - at 18 per 100,000
More than a quarter of all youth deaths (15-24yo) are from suicide
Suicide is the second leading cause of death for youth
More teens and young adults die from suicide than from cancer, heart disease, AIDS, birth defects, stroke, pneumonia and influenza, and chronic lung disease,
COMBINED.
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Maori male youth suicide rate – highest in the OECD
28.7 per 100,000 population
80% higher than non-Maori youth
Female youth suicide is fifth highest in OECD – behind Korea,
Japan, Finland and Switzerland
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Those who die account for a small number of those affected by suicidal behavior…
Youth: 100 - 200 attempts per 1 completion
Females 15-19yo had highest rate of hospitalization for intentional self-harm
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Elder: 4 attempts per 1 completion
Adults over 60 after a non-fatal attempt at most risk that next attempt will be fatal

60 percent of all self-harm hospitalisation data has been excluded - due to inconsistencies in the way DHBs report data.
Data exclude patients who were only seen in an emergency department and those who were discharged within two days.
(???)
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People who knew someone who died of suicide in the past year:
1.6 x more likely to have suicidal ideation
2.9 x more likely to have made suicidal plans
3.7 x more likely to have made a suicide attempt
(Crosby and Sacks 2002)
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Six months after exposure to suicide youth are:
At increased psychiatric risk
4 x more likely to develop a psychiatric disorder
6 x more likely to develop a major depression
Youth who knew someone who died by suicide were 3 x more likely to
die by suicide than teenage peers who did not know someone who died by suicide
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Tetanus is rare, serious, preventable
Screen, tetanus shots
Suicidal ideation/behavior more common
3 – 8.4% of ED visitors for other reasons also report suicidal ideation

The Perfect Depression Care
Initiative
Dept of Psychiatry – Henry Ford
Health System
Goal: No suicides
Debate: If zero is not the right number of suicides, then what is? One? Four? Forty?

Programme resulted in 75% reduction in suicides
Results sustained over four years
Programme now prototype for redesign of outpatient mental health care

Medical illnesses contribute to suicidal behavior in several ways: by precipitating a severe depression making an existing psychiatric illness worse, impairing judgment.
Between 25% and 70% of completed suicides were physically ill at the time of death, with physical illness believed to be a major contributing factor in some 11% to 51% of the cases.
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High rates of depression are reported for patients with:
Diabetes
CVD
COPD
Chronic pain
Cancer,
Lupus,
Rheumatoid arthritis
Henk, Katzelnick, Kobak, Griest and
Jefferson, 1996
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80% of the time, people experiencing a first psychiatric illness see a general physician, not a mental health professional.
It has been estimated that between 25% and 30% of all ambulatory patients in general medicine have a diagnosable psychiatric condition.
Suicidal thoughts and feelings are one of the most common complications of untreated psychiatric illness. In general, psychiatric illness increases the risk of suicide 10 fold.
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Untreated depression has been found in 60% of suicides worldwide.
Suicide occurs only rarely in the physically ill where a psychiatric illness is not also present.
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Multiple studies reveal increased rates of depression in medical populations.
In patients with some chronic illnesses, prevalence rates are between 25% and 50%.
(Nesse and Finlayson, 1996)
Patients with chronic illnesses have been found to be at elevated risk for suicidal behaviours.
(Hughes & Kleepsies, 2001).
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Reduced serotonin function:
Particularly suicides of high lethality or with considerable planning
Common clinical pathway for suicidal thinking, feeling and behaviours:
Depletion essential neurotransmitters
Dopamine
Serotonin
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Not functioning within normal limits
Diminished capacity for complex decision-making
Seriously impaired
Strategic thinking
Problem-solving
General executive function
More workdays lost to depression than back pain
Leading cause of absenteeism, poor performance and decreased productivity
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Highest co-occurring diagnosis in completed suicides: Alcohol addiction and MDD
Suicide risk for alcoholics equal to risk of
MDD
Treatment significantly reduces suicide attempts
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Physicians detect only one in six patients who go on to kill themselves, yet warning signs of suicide crisis are known by others (family members, friends, co-workers, etc.).
One study of suicide risk detection found the odds of being asked if you were having thoughts of suicide by a GP was one in 20 (these were patients who made a suicide attempt within
60 days of their visit).
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No query - suicide ideation, current planning or history?
“There’s no help here, they can’t even talk about it.”
Or failure to reassess?
“They know I’m suicidal but don’t really care.”

Multiple surveys of practicing clinicians found most lacked comprehensive suicide assessment training in graduate and professional programmes
“On-the-job training” results in lack of coherence in approaches to assessment and risk management
Most lack training in a multi-factor ecological model of suicide risk
Risk assessment mistakenly believed to be achieved by a summation of risk factors!
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Time (lack of – real or perceived)
Attitude
Stigma
Privacy (lack of)
Discomfort
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Failure to screen amounts to risk denial or risk blindness.
Suicide screening questions are direct questions that, if asked correctly, should lead to disclosure of suicidal thoughts, feelings, intent, and desire.
Further questioning will establish capacity to inflict self injury.
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As people become suicidal they also may become less self-disclosing about their suicidal thoughts and feelings, and also become less able to ask for help.
Yakunina,et al, 2010
The idea that if a patient is suicidal,
"they will tell you" is no longer a safe clinical assumption.
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Fear that full disclosure will lead to voluntary or even involuntary hospitalization
Fear that full disclosure of suicidal desire and intent will lead to humiliation and/or rejection.
Fear that the interviewer is neither benevolent nor trustworthy
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Suicidal people send warning signs to people in their existing social network of relationships
Failure to respond to suicidal communications may accentuate a crisis

The need for indirect speech – the speaker says something he/she doesn’t mean literally knowing the hearer will interpret what was intended and correctly interpret what was meant.

All humans know how to “read between the lines” See,
Politeness Theory (Politeness: Some Universals in Language
Use – Brown & Levinson, 1987)
Context is everything….

Suicide warning signs require understanding the context in which they are observed
“I’m going to blow my brains out.”
“I just can’t stand it anymore.”
If either is a suicide warning sign, which statement requires immediate and urgent intervention?

“I’m going to blow my brains out!”
Is sitting in your office in a psychiatric hospital
“I just can’t stand it anymore.”
Is standing well out of arm’s reach on the edge of 10-story building
Now… which person needed immediate and aggressive intervention?

Problem gambler caller: “I know it’s too late for me, but can you recommend a counselor for my wife?”
Crisis line caller: “Is 24 aspirins and a bottle of vodka lethal?”
Older woman: “I can’t take care of my two cats anymore, and where I’m going they can’t come. Could you tell me where the nearest animal shelter is?”
Teenager: “Everyone would be better off if I wasn’t around.”

To make hearers of suicidal communications, polite requests for rescue or for help understood so that positive actions can follow.

Practice/rehearsal with means
(habituating to pain)
Verbal (written) threats & “dire warnings”
Non-fatal attempts/risky behavior/suspicions injuries
3 rd party fear-for-safety reports

What people say
Direct suicidal communications
Indirect suicidal communications
What people do
Behaviours indicating distress
Mood changes from baseline (increased anger, isolation, flat or depressed affect)
What people endure
Situational stressors
Significant loss
Unwanted change in circumstances
Loss of freedom or independence
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Consensus and literature based:
Suicide threats
Seeking access to means
Verbal or written statement revealing desire to die
Increased alcohol or drug use
No sense of purpose in life
Feeling trapped with no way out
Withdrawing from friends and family
Giving away prized possessions

No reason for living
No wish to carry on
Passive suicide attempts
Not eating
Not taking needed meds
Wishing to make a suicide attempt
Feeling trapped or hopeless
Feeling intolerably alone
- Beck et al., 1997; Joiner et al., 1997, 2003

Outward expression of suicidal desire includes:

Thinking about suicide

Experiencing serious psychological pain

Feeling hopelessness

Feeling helplessness

Feeling like a burden on others

Feeling trapped with no way out

Feeling intolerably alone

Capacity for self-injury
Preparing for attempt
Practicing behaviours at sub-lethal level
Via repeated exposure to self-inflicted injury or vicarious experience of painful injury, suicide capable people develop a kind fearlessness about dying by suicide.
- Tomas Joiner (2005)

Suicidal capability is characterized by the following factors:
History of suicide attempts
History of/current violence to others Exposure to/impacted by someone else’s death by suicide

Available means of killing self/others
Current intoxication and frequent intoxication
Acute symptoms of mental illness, e.g. dramatic mood change or psychotic symptoms
Extreme agitation/rage, e.g. increased anxiety and/or decreased sleep

Lethality of method and seriousness of intent increase with attempts.
Those with a history of suicide attempt have higher pain tolerance than others.

People who have experienced or witnessed violence or injury have higher rates of suicide – prostitutes, self-injecting drug abusers, people living in highcrime areas, veterans, physicians.

Doctors
Nurses
Addicts
Soldiers
Police
Males
Trauma exposed
Those with a history of suicide attempt have higher pain tolerance than others.

The most challenging aspect of assessing immediate suicide risk
Intent to act can vary according to a number of variables
The uncontrollable decisions of third parties, e.g., a man is left by a woman or is fired from his job

Suicide intent can best be determined by exploring the following:
Is there…
A suicide attempt in progress?
A plan to hurt/kill self/other
(method is known)?
Evidence of preparatory or practice behaviors?
Expressed intent to die by suicide?

Social supports
Planning for the future
Engagement with helper
Ambivalence for living/dying
Core values/beliefs
Sense of purpose (in life)

A suicide screen is indicated when there is:
A positive screen for depression or other psychiatric illness
A positive screen for substance abuse
Admitted or suspected deliberate selfharm such as cutting, self-poisoning, including alcohol poisoning and drug overdose
A known history of a previous suicide attempt or deliberate self-harm behavior
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A suicide screen is indicated when there is:
A recent suicide of a family member or significant other
A current or known history of trauma or abuse, including domestic violence
Recent diagnosis of major physical illness, especially if it is terminal or involves serious chronic pain
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Hopelessness about the consequences of a significant injury or traumatic loss, especially if patient is socially isolated.
The patient who has experienced recent relational or social loss such as the death of a loved one or unwanted or unexpected unemployment
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Because youth 15-25 years of age represent a high risk group, routine screens are indicated in any setting, but especially in ED and primary care.
Yakunina, E., Rogers,J., Waehler,C. &
Werth, J.L. (2010).
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Ambivalence exists until the moment of death
The final decision rests with the individual
Reduce risk factors and you reduce risk
Enhance protective factors and you reduce risk
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Crisis
Peaks
Crisis Begins
Risk
Imminent
Hazard
Encountered
Stable
Years
Days Hours
Plus or minus three weeks
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Crisis Diminishes
Stable
Years

Risk exists in multiple domains across the life-span
Fundamental risks :
Biological
Personal/Psychological
Environment
Acute or proximal risk factors
Biological
Triggers – the last straw!
We all have a baseline level of risk
Triggers tip one into suicidal crisis
Personal
Psychological
Environmental
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Risk changes from day to day, often moment to moment
Complex and changing
Defies the use of a check list approach re: determining risk and lethality
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Psychic suffering (Psychache)
Unbearable mental anguish
Psychic turmoil
Hopelessness
Most common psychological state for completed suicides
Cognitive constriction
Tunnel vision
Delusions of gloom and doom
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Mediate risk
Careful weighing of risk versus protections results in lethality profile
Protective factors can and should be enhanced!
This “Wall of Resistance” is essential to safety pla nning
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The absence of suicidal ideation does not equal no suicide risk
The denial of suicide ideation does not equal no suicide risk
Clinical care admission criteria often require specific suicide planning and/or a previous attempt – these requirements for admission are not based on scientific standards
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Given extensive research evidence we now know more about who is at especially high risk for attempting or completing suicide.
It is high time we apply what we know by routinely screening patients for suicide risk.
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Interview format
Gets beyond standard check list approach
Uncovers full picture of risk and protection
Covers information other assessment systems miss
Builds in safety planning
Far more accurate assessment of lethality
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