Advances in Suicidology: What
We Know and Don’t Know
Michael F Myers, MD
Professor Clinical Psychiatry
SUNY Downstate Medical Center
Brooklyn, NY
Summary of Presentation
• Facts and stats
• Recent research initiatives and findings
• Special populations – youth, LGBT, military,
elderly, physicians, attempt survivors,
survivors of suicide loss
• Challenges and “good news”
• Resources
• Creative Q & A
2
Facts and stats (AAS)
•
•
•
•
•
40,600 Americans died by suicide (2012)
110.9 deaths daily
1 person dies by suicide every 13.0 minutes
1 person attempts suicide every 31 seconds
Suicide = 10th ranking cause of death (2nd for
age 15-24 and age 25-34)
• 3.6 male deaths by suicide for every female vs
3 female attempts for each male attempt
3
Facts and stats (AAS)
•
•
•
•
Elderly = 16 percent of suicides
Youth = 12.2 percent of suicides
Middle aged = 38.9 percent
Highest rates in whites
4
Wisconsin (AAS)
• # 36 = 723 deaths by suicide in 2012 (#30 in
2011)
• Rate = 12.6
• #1 = Wyoming at 29.7
• #51 = District of Columbia at 5.8
5
Suicide Methods (AAS)
•
•
•
•
•
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Firearms = 50.6% of total
Suffocation, hanging = 25.1%
Poisoning = 16.6%
Cut/pierce = 1.7%
Drowning = 0.9%
Other = remaining
6
Fact
• It is generally believed that approximately 8590 percent of people who kill themselves have
been living with some form of mental illness
• And these mental illnesses are often
unrecognized and undiagnosed
• Even if diagnosed, they may be untreated or
commonly undertreated
7
Health Factors (AFSP)
• Mental health conditions.
Depression.
Bipolar (manic-depressive) disorder.
Schizophrenia.
Borderline or antisocial personality disorder.
Conduct disorder.
Psychotic disorders, or psychotic symptoms in the
context of any disorder
Anxiety disorders.
Substance abuse disorders
• Serious or chronic health condition and/or pain.
8
Important research…..
• “The increasing domination of biological
approaches in suicide research and
prevention, at the expense of social and
cultural understanding, is severely harming
our ability to stop people dying…”
• From “Suicide and Culture: Understanding the Context”
Editors Erminia Colucci and David Lester. Hogrefe.
Cambridge, MA. 2013
9
Survivor statistics (AAS)
• Survivors are family members and friends of a
loved one who has died by suicide
• It is estimated that each suicide intimately
affects at least 6 other people
• It follows that with someone dying by suicide
every 13 minutes, six new people become
survivors every 13 minutes too
10
Suicidology “101”
• There is no one factor that causes someone to
kill herself/himself
• Most often there is a complicated – and
confusing mix – of current stressors and losses
+ old psychological wounds (which may be
hidden or unrecognized) + genetic or
biological factors + a psychiatric illness +
alcohol or other drugs + a readily available
way of dying
11
Suicide is an outcome that requires
several things to go wrong all at once.
-- There is no one cause of suicide and no single
type of suicidal person.
Biological
Factors
Familial
Risk
Predisposing
Factors
Major Psychiatric
Syndromes
Proximal
Factors
Immediate
Triggers
Hopelessness
Public Humiliation
Shame
Intoxication
AccessTo
Weapons
Serotonergic
Function
Substance
Use/Abuse
Neurochemical
Regulators
Personality
Profile
Impulsiveness
Aggressiveness
Severe
Defeat
Demographics
Abuse
Syndromes
Negative
Expectancy
Major
Loss
Pathophysiology
Severe Medical/
Neurological Illness
Severe
Chronic Pain
Worsening
Prognosis
12
What about depression and suicide
risk? (AAS)
• Depression is the psychiatric diagnosis most
commonly associated with suicide but most
patients with depression do not kill themselves
• Lifetime risk of suicide among patients with
untreated depression ranges from 2.2% to 15%
• Those suffering from depression are at 25 times
greater risk for suicide than the general
population
13
United States Preventive Services Task
Force (Psych News 6/20/2014)
• Recommends against suicide screening in
primary care (evidence is insufficient) BUT…..
• Strongly supports screening for major
depression in general medical patients,
especially the elderly, because of the burden
of distress
• And in adolescents, screen for anxiety +
depression (and alcohol abuse in boys)
14
Addressing suicide risk in emergency
department patients (JAMA 7/16/2014)
• Studies show that one in five ED patients may
be depressed but the Dx is often missed
• Why? Most patients don’t complain of
depression but have somatic depressive Sx
• Overt suicidal behavior = only 0.6% of ED visits
but suicidal thinking ranges from 3-11.6%
• Enhanced training of emergency MDs is
recommended
15
Baby boomers and suicide (SPRC
7/25/2014)
• Adults aged 45-64 have the highest suicide
rates (CDC) since 2008 when the recession
began
• Their mood states may be missed because
most are working and there is an erroneous
assumption that they have proven their
resilience
• Recommendation is for programs specific to
them
16
National Action Alliance for Suicide
Prevention (www.actionallianceforsuicideprevention.org)
• In Feb 2014, the NAASP Research Prioritization
Task Force released A Prioritized Research Agenda
for Suicide Prevention: An Action Plan to Save
Lives
• The themes are broad and intersect bench
research, community, justice, education,
technology and more
• This report outlines the research areas that show
the most promise in reducing the rates of suicide
attempts and deaths in the next 5-10 years, if
optimally implemented
17
Zero Suicide in Health and
Behavioral Healthcare
• http://zerosuicide.actionallianceforsuicideprev
ention.org/
• June 26-27, 2014 SPRC hosted the first
meeting of the academy
• 16 public and private health care organizations
came together to discuss innovative strategies
for suicide reduction
• See webinar slides on the website
18
“Preventing Suicide. A Global
Imperative” WHO September 2014
• http://apps.who.int/iris/bitstream/10665/131
056/1/9789241564779_eng.pdf?ua=1
• The 92 page report calls for national
prevention strategies, better surveillance, and
restricting access to lethal means
• Prevention demands “a comprehensive,
multisectorial” strategy because risk of suicide
is set in individual, social, community and
health system factors (Levin Psych News 10/17/2014)
19
AAS Childhood Sexual Abuse and
Suicide 2014
• “Sexual victimization creates an overwhelming
sense of powerlessness, worthlessness, and a
felt inability to change or control one’s
environment. It creates self-loathing… it
facilitates internalized feelings of shame, not
the guilt of feeling one has done something
bad, but a more pervasive sense of being bad.
It creates self-blame.”
20
AAS Childhood Sexual Abuse and
Suicide 2014
• “Sexual abuse is associated with changes in
the metabolism of serotonin: ‘the impact of
trauma on the brain’s stress response systems
can make children more vulnerable to later
stressful events and to the onset of
pathology… and suicidality’”
21
AAS Childhood Sexual Abuse and
Suicide 2014
• Among those sexually abused as children,
odds of suicide attempts were 2-4 times
higher among women and 4-11 times higher
in men compared to those not abused and
controlling for other adversities
22
“Peer Victimization, Cyberbullying and Suicide
Risk in Children and Adolescents” (Gina and Espelage JAMA 2014)
• A meta-analysis of 491 studies
• Peer victimization was found to be related to
both suicidal ideation and attempts
• Strong efforts to prevent or reduce these
behaviors are warranted
• AAP advises pediatricians to screen for
bullying experiences in/out home and online,
suicidal ideation and behaviors
23
“Peer Victimization, Cyberbullying and Suicide
Risk in Children and Adolescents” (Gina and Espelage JAMA 2014)
• Adults should recognize that stress-related
physical symptoms could be related to peer
conflict or bullying at school
• Should also talk to parents about gun safety if
there are guns in the home
• Sexual minority and disabled children are more at
risk for bullying
• Parents, teachers, mental and medical health
care practitioners and advocates all have a role
to play
24
The Jed Foundation
• The Jed Foundation was founded in 2000 by Donna
and Phil Satow after they lost their son Jed to suicide
• It is the leading nonprofit organization addressing
issues related to mental health and suicide in the
college population.
• Includes programming and resources that help
colleges, students and parents recognize and address
emotional health issues and prevent suicide
• www.jedfoundation.org
• Model for Comprehensive Mental Health Promotion
and Suicide Prevention for Colleges and Universities
25
What about LGBT youth? (AAS)
• NOTE: Being LGBT is not a risk factor in and of itself;
however many have one or more severe risk factors:
• more previous attempts at suicide
• minority stressors such as discrimination and harassment
• higher rates of major depression, anxiety disorder, conduct
disorder, and co-occurring psychiatric disorders than their
straight peers
• high rates of victimization (three quarters reported verbal
abuse and about one in seven reported physical attacks)
• severe family rejection (those who experience this are 8
times more likely to report having attempted suicide than
peers from supportive families)
26
What about LGBT youth? (AAS)
• We do not know whether more LGBT youth
than straight youth die by suicide because
sexual orientation/gender identity data aren’t
included on death certificates and often do
not show up in psychological autopsy
interviews
27
What about LGBT youth? (AAS)
• The Trevor Project is the leading national
organization providing crisis intervention and
suicide prevention services to lesbian, gay,
bisexual, transgender, and questioning youth
• http://www.thetrevorproject.org
28
What about the elderly? (AAS)
• There was one elderly (over the age of 65) suicide
every 96 minutes in 2011.
• There were about 15 suicides each day resulting
in 5,353 suicides in among those 65 and older.
• Elderly white men were at the highest risk with
those over age 85 (“old-old”) at most risk
• 83.5% of elderly suicides were male; the rate of
male suicides in late life was about 5.25 times
greater than female suicides
29
What about the elderly? (AAS)
•
•
•
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Common risk factors include:
The recent death of a loved one
Physical illness
Uncontrollable pain or the fear of a prolonged
illness
• Perceived poor health
• Social isolation and loneliness
• Major changes in social roles (e.g. retirement)
30
What about the elderly? (SPRC)
• Suicide attempts are rarely impulsive, usually
involve planning ahead and tend to be lethal
• Care transitions may be a time of increased
risk
• Good response to psychopharmacology +
psychotherapy, especially CBT
• Optimistic note is the implementation this
year of full parity for outpatient mental health
treatment in Medicare
31
What about the military?
32
A salute to……
Michael Orban – author of “Souled Out: A
Memoir of War and Inner Peace”
33
Some facts
• In 2005 the rate of suicide among soldiers in
the US army began increasing
• In 2010 and 2011 more soldiers died by their
own hands than in combat
• In 2010, 22 veterans died by suicide every day
• In 2013, 475 service members died by suicide
• Both male and female soldiers kill themselves
and all races/ethnicities too
34
What makes our soldiers vulnerable?
(Nock et al, 2013)
• Psychiatric illness – depression, anxiety, PTSD,
impulse control, alcohol/substance use,
personality disorders – especially if combined
• Family history of psychiatric illness and
suicidal behavior, childhood abuse
• Military related stressors – combat exposure,
injury, bereavement, negative unit climate,
demotion, sexual assault
35
What makes our soldiers vulnerable?
(Nock et al, 2013)
• Additional stresses – improvised explosive
devices, enemy fire, other dangers in civilian
areas, re-exposures to traumatic events, injuries
resulting in disfigurement and serious illnesses
• Acute stressful life events – separation from
family, romantic conflicts, family illness and
death, financial problems, unemployment
• Chronic stressful life events – pain, physical
illness, intimate partner violence (IPV)
• Firearm access
36
What makes our soldiers vulnerable?
(Nock et al, 2013)
• What about traumatic brain injury (TBI)?
• Due to exposure to explosive devices and blast
injuries – leads to impulsivity, aggression and
disinhibition
• This + more recent knowledge about
‘immature’ prefrontal cortex in adolescence
and young adults = emotional dysregulation
and impaired decision making
37
What are some protective factors?
(Nock et al 2013)
• Religious affiliation, a sense of responsibility
to one’s family, being pregnant, young
children in the home
• Unit cohesion, supportive leadership, strong
soldier-to-soldier relations
• Frequent contact with spouse and friends
• Psychological – resilience, positive adaptation
38
Understanding and preventing military
suicide (Bryan et al 2012)
• We must think about suicide from the service
member’s perspective
• Trained to be “warriors”
• The “warrior ethos” emphasizes honor,
integrity, selfless service, duty and courage in
the face of adversity
• Violation of these values leads to shaming by
peers and official disciplinary action
39
Understanding and preventing military
suicide (Bryan et al 2012)
• Mental toughness = “suck it up”
• Tolerate pain and discomfort
• Push away fear, anger, grief and self-doubt (all
of which are associated with anxiety and
depression!)
• The very skills that make a tough warrior can
inadvertently create a pathway to suicide
40
Understanding and preventing military
suicide (Bryan et al 2012)
• Collectivism = the cornerstone of military
culture = close, in-group bonds
• Vs individualism of civilian society
• Service members are 3x more likely to ask
another service member for help than seeking
professional services
• Seeking help from outsiders can be viewed
with suspicion and threatens group safety
41
Understanding and preventing military
suicide (Bryan et al 2012)
• The culture of self-sacrifice in defending one’s
country can distort thinking – suicide may
become an honorable ‘self-sacrifice’ for the
greater good of the group (which it never is)
• “Perceived burdensomeness” (Joiner)
becomes a dangerous line of thinking
• This plus a ‘fearlessness’ about death are two
linkages attributed to suicide (Joiner)
42
Understanding and preventing military
suicide (Bryan et al 2012)
• Approaching suicide prevention from the
military mindset
• Must adopt a strengths-based approach
emphasizing mental fitness, resilience
building, cognitive restructuring, finding
meaning in life, self-building
• Model = US Air Force 1997, public health
perspective improving the health of all =
reduced suicide deaths by 1/3
43
Understanding and preventing military
suicide (Bryan et al 2012)
• Prevention strategies must be specific,
concrete and action-oriented
• Mental health professionals must use
empirically supported treatments for anxiety,
depression, suicidality
• DBT (Dialectical Behavior Therapy), CT
(Cognitive Therapy), CAMS (Collaborative
Assessment and Management of Suicidality)
44
Army study to assess risk and resilience in
service members (Friedman MJ 2014)
• www.armystarrs.org
• A significant number of enlisted soldiers do not
disclose their pre-enlistment mental challenges
• Deployment is a factor, especially multiple and
extended tour of duty, with short length of ‘dwell
time’
• Never deployed soldiers also had an elevated risk
of suicide
• Married soldiers more at risk than never married
45
“Military Suicide Awareness or Healing
Awareness?” from Wounded Times
• Dedicated to defeating
combat PTSD
46
Jacob Sexton Military Suicide
Prevention Act
• Named after Indiana National Guardsman who
died by suicide in 2009 while home on a 15-day
leave from Afghanistan
• Passed the Senate Armed Services Committee in
May 2014 and will be considered by the full
Senate later this year
• This will ensure that every member of the
military – Active, Guard or Reserve – receives a
mental health assessment every year and has
better access to help
47
Blue Star Families
• “National, nonprofit network by and for
military families from all ranks and services,
including the National Guard and reserves”
• “Strengthens military families and our nation
by connecting communities and fostering
leadership”
• “Hosts a robust array of morale,
empowerment, education and employment
programs”
48
What about physicians?
49
Center C, Davis M, Detre T, et al. Confronting depression and suicide in
physicians. A consensus statement. JAMA 2003;289: 3161-3166.
• Suicide is a disproportionately high cause of
mortality in physicians, with depression as a
major risk factor
• Depression is more common in female
physicians than male physicians, including a
suicide rate that is much higher than other
females and approximates that of male
physicians
50
50
Struggling in Silence: Physician Depression and Suicide
(PBS Documentary 2008, DVD available www.afsp.org)
“Every year, three to four hundred physicians
take their own lives — the equivalent of two
to three medical school classes”
51
51
Most common illnesses in MDs
1.
2.
3.
4.
5.
6.
Depression and bipolar illness
Substance use disorder
Dual diagnosis of 1. and 2.
Severe and unrelenting burnout
Underlying personality disorder
Chronic, worsening, painful and debilitating
medical illness
52
52
Personality traits are significant
• Perfectionism – works for and against
physicians – may become severe and a
dangerous predisposing factor in suicidality –
i.e. unforgiving of self
• Need for autonomy – wants to set his/her
own agenda, eschews intrusion of others,
knows what is best for self
• Rugged individualism – from childhood – a
way of going through life
53
53
What else puts MDs at risk?
• Family history of disabling psychiatric illness
and suicide
• Knowledge of toxicology and access to drugs
• Internalized stigma associated with facing
psychiatric illness in ourselves and accepting
the need for treatment
• Not receiving exemplary treatment
54
54
SUICIDE RISK FACTORS IN MDS
•
•
•
•
•
•
•
Personal history of a depressive episode
Previous suicide attempt (may be denied)
Family history of mood disorder/suicide
Introversion and professional isolation
Lawsuits and/or medical license investigation
Poor treatment adherence
Refractory ‘malignant’ psychiatric illness
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Remember
• There are many physicians living with a mood
disorder and/or substance dependence who
escape attention
• Many are untreated or self-treated
• Many who are in treatment are undertreated
– and/or have not been fully forthcoming with
their treating clinician about suicidal ideation
and a plan
56
56
Protective strategy (NY Times Letter)
“Why Do Doctors Commit Suicide?,” by Pranay Sinha (Op-Ed, Sept. 5), is a
heartfelt and honest testimonial to the two young physicians who recently
died here in New York City. He is spot on when he describes the doubts
and fears that are ubiquitous in newly minted physicians and the
dangerous isolation that can occur. He advocates a medical culture that
stresses openness about vulnerabilities and fosters connection.
I salute his initiative and take it one step further. We who are the
supervisors and mentors of these young doctors must set an example. We,
too, need to share our insecurities — old and new — and unmask our
humanity. This includes disclosing our own psychiatric treatment. This kind
of intimacy and lovingkindness will help save lives.
MICHAEL MYERS
Brooklyn, Sept. 5, 2014
57
What about survivors of suicide attempts?
• The Way Forward: Pathways to hope,
recovery, and wellness with insights from lived
experience
• Prepared by the Suicide Attempt Survivors
Task Force of the National Action Alliance for
Suicide Prevention July 2014
58
What about survivors of suicide attempts?
• In 2012, 11.5 million people in the US
seriously considered suicide
• 4.8 million made a suicide plan
• 2.5 million made a suicide attempt
59
What about survivors of suicide attempts?
• “I’m tired of hiding, tired of misspent and
knotted energies, tired of the hypocrisy, and
tired of acting as though I have something to
hide”
• Kay Jamison in An Unquiet Mind, 1997
60
Survivor of suicide attempt to share
her story
• Kristen Anderson will
share her story at 6
p.m. Wednesday, Oct.
22, at the Wisconsin
Rapids Mid-State
Technical College, 500
32nd St. S., in the
campus auditorium (L
Building).
• Wisconsinrapidstribune.
com
61
A Voice at the Table
• www.voiceatthetable.com
• A 35 minute documentary highlighting the
stories of suicide attempt survivors, those
with lived experience
• Those with lived experience are an inspiration
to those who are or who have been suicidal
• Their words educate all of us working toward
suicide prevention
62
What about survivors of suicide loss?
63
Kay Redfield Jamison, PhD, Professor of Psychiatry,
Johns Hopkins Medical School
“No one who has not been there can comprehend the
suffering leading up to suicide, nor can they really
understand the suffering of those left behind in the wake
of suicide”
from the Foreword “Touched By Suicide: Hope and Healing After
Loss” by Michael F. Myers and Carla Fine
64
How is the grief of suicide different than that of
natural causes or accidents? (Jordan JR 2001)
• You struggle with trying to make sense of an
act that goes against life and living at all costs
• You are flooded with feelings of guilt, blame
and responsibility for your loved one’s death
• You wrestle with feeling abandoned by your
loved one
• You are confused by (or guilty about) your
anger at your deceased loved one for killing
himself/herself
65
How is the grief of suicide different than that of
natural causes or accidents? (Jordan JR 2001)
• You may feel isolated, alone and stigmatized
• The social stigma attached to suicide spills
over onto you – lying is common
• You may feel less supported or understood
than individuals who have lost their loved one
by natural causes or accidents
• Your friends and colleagues may actually care
but are confused and uncertain and don’t
come forward to support you
66
How is the grief of suicide different than that of
natural causes or accidents? (Jordan JR 2001)
• Survivor families tend to be more vulnerable
and you may withdraw from your network of
friends because you feel ashamed
• Unfortunately this may cause your friends to
pull away from you because they feel rejected
= a vicious cycle
• Suicide deaths may tear apart even the
healthiest of families, especially after the
acute phase and over the first year or two
67
How is the grief of suicide different than that of
natural causes or accidents? (Jordan JR 2001)
• If your family is already ‘a bit dysfunctional’
before the suicide, it may seem worse after
• You may actually feel relief, at least partly, if
your loved one was sick for a long time and
had many suicide attempts (he/she’s at peace)
• Or you may feel relieved if your family
member was ‘a bad apple’ – abusive, violent,
controlling, a criminal, etc.
68
Important to know…..
• There are higher rates of depression, PTSD
and sometimes, risk of another family
member dying of suicide
• This is why it is so important to try to learn as
much about the aftermath of suicide as
possible and to be informed, to know what to
watch for and how to get help
69
Challenges and frustrations
• The suicide rate in the United States has been
steadily increasing since 2000 in both men and
women
• Despite much research and many resources,
the suicide death rate of servicemen and
women is not decreasing
• Efforts to diminish access to firearms or
promote gun safety and restriction have been
thwarted in many jurisdictions
70
Challenges and frustrations
• Access to care – timely comprehensive
treatment combining medication +
psychotherapy is extremely variable
• Stigma – although we are making some
progress, the shame associated with mental
illness (and associated suicidal behavior)
remains rampant in some occupational, racial
and ethnic groups – resulting in unacceptable
suffering and death
71
Challenges and frustrations
• Competence – “We expect well-informed
treatment for cancer or heart disease; it
matters no less for depression.” (Jamison, NY Times
8/15/2014)
• Studies have tested suicide prediction models
based on standard risk criteria – none has
demonstrated any ability to predict suicide
• “No harm” contracts being overused and
creating a false sense of security
72
Challenges and frustrations
• Although it is well known that a cluster of
suicides occur within a few days to one month
after hospitalization, follow up measures are
not being standardized or monitored for
compliance – too many patients are falling
through the cracks
• Too many survivors are not getting the kind of
empathic and all-inclusive care that they
deserve
73
Good News
• More and more research findings are being
disseminated to the general public and a
range of professionals (like yourselves) aimed
at prevention and early intervention
• More therapists are receiving training and
Certification in Clinical Suicidology (AAS) and
Assessing and Managing Suicide Risk: Core
Competencies for Mental Health Professionals
(SPRC) – Brad Munger
74
Good News
• More therapists are being trained to assess and treat
survivors and their families
• We know much more about the protective factors
that prevent or abort suicide attempts – 1-800-273TALK, connectedness to other people, long term
medication maintenance and monitoring, specific
and manualized therapies targeting suicidal thoughts
and actions, post-discharge telephone calls, religious
and spiritual affiliation (in some), pets and so forth
75
Action Alliance Framework for
Successful Messaging
• SuicidePreventionMessaging.org = website
• The Framework is a research-based resource
that outlines four key factors to consider when
developing public messages about suicide:
1.
2.
3.
4.
Strategy
Safety
Conveying a “Positive Narrative”
Following applicable guidelines
76
What is conveying a “Positive Narrative”?
• Ensuring that the collective voice of the field is
“promoting the positive” in the form of
actions, solutions, successes and resources
• For too long, the public message has been
about describing or sensationalizing the
problem without delineating actions to
combat the issue or outlining possible
solutions
77
78
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Positive Messaging……
• Suicide Prevention Investment Needed to
Reverse Trend of Increasing Suicide
• American Foundation for Suicide Prevention
Statement on Latest CDC Report
• 10/08/2014
• NEW YORK (October 8, 2014) – In a report
released today by the US Centers for …….
80
• "Suicide prevention is everyone's business"
– Surgeon General Dr David Satcher 2001
81
Resources
• American Association of Suicidology (www.suicidology.org)
• American Foundation for Suicide Prevention
(www.afsp.org)
•
•
•
•
Suicide Prevention Resource Center (www.sprc.org)
CDC (www.cdc.gov)
NIMH (www.nimh.nih.gov)
National Action Alliance for Suicide Prevention
(www.actionallianceforsuicideprevention.org)
• National Suicide Prevention Lifeline
(www.suicidepreventionlifeline.org)
82
Remember
“Yes, a smile would have most definitely helped
in my case……. that person… could well save a
life”
words of Kevin Hines, survivor of suicide
attempt
from “Just a smile and a hello on the
Golden Gate Bridge” (Simon RI 2007)
83
Thank you for being here
84
Creative Q & A
85