Preventing Suicide…, It’s What
People Do
Paul Quinnett, Ph.D.
The QPR Institute
Getting to zero suicide…
“You can’t hit what
you don’t aim at.”
JFK
Things to think about today…
Doing nothing is not working
Doing something will save lives
If, by the end of today, you are comfortable
with the status quo, you spent too much time
texting on your cell phone
Questions to ask ourselves…

Does education and training
matter?

Does patient safety matter?

If a loved one becomes suicidal
tomorrow, who are you going call in
your community?
Two facts and a challenge
At the time of death 95%+ of all US suicide victims
were suffering from one or more untreated or
under-treated Axis I psychiatric disorders
2. Between 31 and 37% died while in active care of a
health professional (NVDRS)
Challenge – in your community:
 Who will detect untreated new cases?
 Who will assess untreated new cases?
 Who will treat new cases?
1.
Attention clinicians…
If you don’t want to know if your patients have
fevers, don’t take their temperatures.
If you don’t want to know if your patients are
suicidal, don’t ask.
If you do ask, be ready…
Remember, you can’t mitigate or manage risk you
don’t know about…
The risk detection problem
* Of 100 ED severe attempters, 83 had seen PCP or MHP
within 1 month
- 55 were not asked about suicide
* Of 310 active care suicidal MH outpatients
- 177 were not asked (said “yes” on intake
form)
Odds of being assessed for suicide risk if you are
suicidal on a given office visit = less than 50%
(Hall, et al, Psychosomatics, 1999) ( Brown, et al, Crisis, 2003)
Bottom line?
We can’t help suicidal people in our communities we
don’t know about.
To find them we must act, we must change how we
do things.
We must embrace a thing we fear.
And must learn to talk openly and confidently about
suicide.
Readiness for change…





Why does a community act?
When will it act?
What tools does it need?
Who needs to be trained to do
what?
What can it expect if
successful?
Suicide prevention is violence prevention!
“… safety and security don’t just
happen; they are the result of
collective consensus and public
investment.”
Nelson Mandela, 2002
Fundamentals

3 Cornerstone theoretical
assumptions

5 Simple truths about suicidal people

3 Questions every community
must ask
Theoretical Assumption #1
All communities care about human life and
will go to great lengths to prevent and
mitigate human suffering.
Feeling suicidal is one measure of supreme
human suffering; surviving a loved one’s
suicide is another.
Once this suffering is understood,
communities will rally to alleviate this pain.
Theoretical Assumption #2
Once communities are equipped with
specific knowledge, training, skills, and
leadership, efforts to reduce suicidal
behavior will be successful.
… evidence is growing every day…
Theoretical Assumption #3
By building shared community
responsibility, and individual and group
competence to prevent suicide,
communities can define themselves as
caring, confident, and successful in
reducing self-harm and preventing suicidal
self-directed violence among their fellow
citizens.
Simple truths about suicidal
people…
What we know should guide
what we do…
Simple truth #1
Suicide is not a Mystery
Suicidal behaviors are not rare…
Suicide is understandable…
Suicide makes sense to the suicidal person….
Suicide is not a crime
Suicide is not a sin
Suicide is the final solution to the experience of
unbearable psychological pain which the sufferer
believes is unending… Relieve this pain just a
little, and the person will live.
Simple truth # 2
Those who are most at risk for suicide are
the least likely to ask for help.
Thus, we must find our at-risk fellow
citizens and help them where they are.
If we require them to ask for help, they will
continue to die.
Simple truth #3
The person most likely to prevent you
from dying by suicide is someone you
already know.
Thus, those around us must know what to
do if we become suicidal and know how to
recognize and respond to our pain with
bold, positive action.
Simple truth #4
When we solve the problems people kill
themselves to solve, the reasons for
suicide disappear.
Thus, compassionate support, crisis
intervention, problem resolution, and
treatment will save lives.
Simple truth #5
Prior to making a suicide attempt, those
in a suicide crisis are likely to send
warning signs of their distress and
suicidal intent to those around them.
Thus, learning these warning signs and
taking quick, competent action during
these windows of opportunity can save
lives.
3 Community Questions
Does it hurt?
Do we want to fix it?
Do we have budget?
Does it hurt?



Psychological pain and avoidance of psychological
pain is one of the few things that moves us to
change our behavior.
Grief, sorrow, anger…, these are the states of mind
that change states.
We would not be here today except for the personal
suffering and demand for action by those in this
audience who have lost loved ones to suicide.
“Things do not happen.
Things are made to
happen.”
John F. Kennedy
Do you want to fix it?
- Colorado Community College System
- EAP Director major international
(following pilot suicide)
airline
- CEO public mental health service: “Patient
suicide is part of the cost of doing business”
Points to consider



Suicide prevention is too important to be left
to government.
The pain to motivate change is at the family,
community, and county level, not at the top of
government.
Suicide prevention begins at community level
or it does not begin at all.
Hopi Elder advice…
“It is time to speak your truth,
create your community and
do not look outside yourself
for the leader. We are the
ones we've been waiting for.“
Pain in Washington State:
a snapshot






1,027 completed suicide in 2013 (roughly 3/day, 2
youth/week) = 6,000+ survivors in pain
Attempt rate is not reliably captured, as many nonfatal suicide attempts are disguised as accidents,
near-crash MVAs, last-second aborted attempts by
the suicidal person, misdiagnosed cause of injury in
EDs.
But among >18 years CDC 2011 MMWR for 20082009:
* Suicidal thoughts: 4.7% or 230,000 of our fellow
citizens
* Planned to kill themselves: 1.4% or 68,000
* Reported a non-fatal attempt: 0.7% or 36,000
Completed suicides are the ….
Thoughts of suicide, planning, attempts,
and self-inflicted injuries and deaths
equal a community’s
Misery Index
“Never morn wore to eve but some heart did break.” Tennyson
From the Surgeon General
“Suicide is our most preventable
form of death.”
Dr. David Satcher, 2001
Really?
If suicide is preventable,
then
Why did my brother die after
I brought him to you for
care?
The business case for suicide prevention
What is the cost of doing
nothing in your county?
Source: Business case analysis and ROI work done in collaboration with
the University of Idaho School of Business and Economics, 2010
The suicidal suffering burden…
Spokane County population = 465,000
 Ideation rate 2008-2009 = 22,000 adults
 Average annual suicide events (SRHD, 2008):
- 800 emergency room visits
- 300 hospitalizations for attempts
- 70 completed suicides
1 year total recorded suicide events: 1,170

- 90% hospital admissions were through ER, but
costs were incurred at each portal -
Suicide-related hospitalizations are also
the ….
Estimated 12-month direct hospital costs for
self-directed violence with and without injury
800 ED visits @$1,000 each =
$800,000
300 hospitalized suicide attempts =$6,081,000
Total cost for hospital visits = $6,881,000
Prevent one ED visit, save $1,000
Prevent one hospital admission, save $20,270*
Prevent one death by suicide, $6.9 million
*Cost source AFSP. Per hospitalized attempt: $11,146 in work loss and $9,127 direct
medical
The business case is growing…



Big data and new health analytics are answering
some of the cost-of-doing-nothing questions.
Suicide is emerging as a preventable adverse
event with a positive return on investment for
spending money on the problem.
Suicide rates are going up, not down, and
large employers are gaining awareness that to
do nothing is not acceptable.
Houston, we have a problem…
Wrong assumption…
Once a suicidal person is
identified and referred for care
to his or her doctor, or to a
mental health professional,
they should not kill themselves.
20 years ago…
My son died by suicide in1993 and in the process of
suing the hospital and the doctor, the last
professional to see my son for therapy was a Ph.D. in
Psychology. When this person was deposed, he
reported that he never asked him if he was suicidal
(Todd was two days post discharge from a suicide
attempt) and said that 'he was a bright young adult, if
he was suicidal, he would have told me.' Two days
later, Todd hung himself. I won the case out of court
without going to a jury!
Sherry Bryant, LCSW, CADC, LMFT
What do behavioral health folks know
about suicide prevention?



1,100 MHPs practicing in 13 states
Standardized 25-item quiz (SRMI) covering suicide
statistics, risk and protective factors, risk
management and safety practices in clinical settings.
Findings have been twice replicated (N>500 in >50
clinical settings)
◦ We wish to thank the Devereux Foundation for contributing
to this database.
Nationally standardized exam results: Prepost Pass-fail rates by profession…
100
% Passed
75
50
All
Other
Interns
Nurses
Therapists
Psychiatrists
Social Workers
0
Psychologists
25
Pre-test
Post-tes
Your odds just improved: The Matt Adler Bill
What communities can do?
- Train ordinary citizens (one adult per family)
- Train all first responders
- Train all health professionals
- Train all clergy
- Train all schools
To create a SYSTEM OF SUCIDE CARE
Survival depends on surveillance from
sentinels or gatekeepers…
In your community, how likely is it that if someone
develops suicidal ideation and begins to plan a suicide
attempt, that he or she will be identified and helped
before a potential tragic outcome?
The gatekeeper role?
Recognize and refer someone emitting suicide warning
signs.
Everyone can do something
Gatekeepers at work…
Having an out-of-hospital heart attack in the US?
What city should you be in?

Average US city = less than 10%

Best city in the US = 62%

Where is the very best place? = 70+%
Late Life Suicide

>65 years = highest rate per capita

Highest risk = white male 85+ (51/100K)

74% of males use a firearm

Lethal planning + lethal methods =fatal outcomes

Up to 75% of elders die on the first attempt

Less likely to talk to others of suicidal desire and intent (send
fewer warning signs?)
What do we need for old white guys?



Most will have no prior history of suicidal
behavior and will not seek psychiatric
treatment
Psychological autopsy studies find most
common DX in 85-90% of older adults who
died by suicide is untreated depression.
Solution: routine medical screen – e.g., PHQ-9
– positives get full SRA and follow up
- one story -
Missed opportunities..

75% of older adult suicides see a PCP within 1 month of
death. (Y. Conwell, 2000, SLTB)

35 million Americans are 65+ and 2 million have a
depressive illness

Another 5 million have a “sub-syndromal depression” (not
much fun at parties)

Just cause you’re old does not mean you’re depressed.
Ageism lives!
Scenario: 75 yr-old veteran in
crisis over pending surgery and
onset of depression – with marital
problems. Suicide warning signs
sent to network.
Suicidal network communications
Adult Son
VA Doc
No Clues
Friend
Clear Verbal Threats
nurse
Older
Frail
Vet in
Crisis
& Uncoded Clues
VA
Diagram 1
Coded Clues
Adult
daughter
Pastor
• Self-referral unlikely
• Hotline call unlikely
• Intervention unlikely
Wife
Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention
Gatekeeper network
Gatekeeper trained
Additional Resources
Pastor
Son
Daughter
Not trained
VA doc.
Nurse applies
screen finds
SI
Screening Intervention
Vet
VA Nurse
Hotline
Other
supports
Vet out of
Crisis
VA nurse implements
assessment, RX, and follow
up process.
Suicide attempt averted
Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention
Form and format of Elder SWSs
•
•
•
•
To VA doc: “Is this enough medicine to kill someone?” (indirect/coded/rhetorical).
To VA nurse: “When I can’t sleep like this, I don’t give a shit about life.”
(indirect/coded)
To Adult son: “I’m going home soon, and I want you to have my gun collection.”
(indirect/coded)
To Adult daughter: “ You’ll need to look after your mother when I’m gone.”
(indirect/coded)
•
To a best friend and pastor: No warning signs sent
•
To his wife: “Why don’t I just shoot myself?” (direct/un-
coded)
Hi!
Here’s my community!
We are 150 strong!
Hi!
This is my county. Some
people here can help!
Hi!
This is my county
Everyone here can help!
Your first challenge?
To train enough community members
in your county to recognize and
intervene with a sufficient number of
suicidal persons to reduce suicide
events to __?__ over the next ___?___
years.
You can’t hit what you don’t aim at. JFK
Your second challenge?
Sustain your first challenge, create new policies,
change practices, change culture, change work rules
and aim for zero errors…
“How many children have died in a school fire in the
past 30 years?”
Why? Because the loss of a single child in a school fire
is an unacceptable outcome for any community…
1958 Lady of the Angels School fire (93/3)
To guide your efforts…
Make suicide difficult
Make treatment easy
Make suicide difficult…
- IDF ordered soldiers to leave weapons on base over the
weekends
Result: 40% reduction in military suicides
- UK removed toxic gas from home use
Result: 33+% drop in suicide rates
- Sri Lanka placed restrictions on sales of highly human-toxic
pesticides
Result: 50% drop in suicides form1996 to 2005
- Painkillers packaged in bottles (US practice) vs. Brittan (blister packs)
Result: British ODs of Tylenol dropped 44 % over 11 years
Treatment easy…
- 20+ studies show that where SSRIs are widely available
Result: suicide rates are lower
- 1991-1996 Swedes used 240% more SSRIs than
comparable countries
Result: rates fell by 19%
- Danes gave 65K suicide attempters 10 sessions of “a
safe, comfortable place to talk”
Result: 25+% drop in second attempts and deaths
Good news from Lancet – Mindfulness-based
cognitive therapy as good as antidepressants in preventing
relapse in depression.
Finally…. New state plans!







We know the order of march
We know who to train 1st, 2nd, and 3rd
We know what to teach them (evidence)
We know where to teach them
(web/classroom/blended)
We have evidence that interventions work
We have the measures to monitor our outcomes
We have leadership -- all we need is a “go!”
What do optimists know?
You may never know what
results come from your action.
But if you do nothing, there will
be no result.
Mahatma Gandhi
What if everyone had a job and everyone
was trained?
What might we expect?
Contact information
Paul Quinnett, Ph.D.
 pquinnett@mindspring.com
 509-235-8823
 www.qprinstitute.com
P.O. Box 2867
Spokane, WA 99220

Free e-book, phone apps, information and online
training…
Orientation to QPR Gatekeeper Training
and the QPR Institute
Goals
 What is QPR?
 Why is it important?
 How does it work?
 Who is using it?
 How long does it take to learn and what else
do we need?
QPR
◦ stands for Question, Persuade and Refer,
an emergency mental health intervention that
teaches lay and professional Gatekeepers
to recognize and respond positively to someone
exhibiting suicide warning signs and behaviors.
Why QPR?

Each letter in QPR represents an idea and an action

QPR intentionally rhymes with CPR – another universal
emergency intervention

QPR is easy to remember

Asking Questions, Persuading people to act and
making a Referral are established adult skills
step
“Out of clutter, find simplicity”
Albert Einstein
QPR



Is a simple, direct, behavioral intervention designed
to produce a predetermined outcome: a referral for
professional help
Is designed to produce a helpful dialogue between
someone at risk for suicide and a trained
Gatekeeper
Teaches Gatekeepers to get the person to a
professional
What is QPR?

QPR is theory-based

Recognizes that even socially isolated suicidal
individuals have contact with potential rescuers

QPR reaches out to high-risk people within their
own environments and does not require suicidal
people to ask for help.
The QPR Chain of Survival
(CPR)
1.
2.
3.
4.
4 links…
Early recognition of warning signs
Early application of QPR
Early referral to professional care
Early assessment and treatment
Knowledge + Practice = Action
QPR PREVENTION STRATEGY
AWARENESS
Suicidal
Thoughts
Perceived
Insoluble
Problem
SURVEILLANCE
Suicidal
Warning Signs
DETECTION
Suicide
Attempt
Suicide
injury or
death
INTERVENTION
OPPORTUNITIES
Question
Persuade
Treat
Refer
QPR Activities








7,000+ active Certified QPR Instructors
2 million gatekeepers trained
500+ college and university users
10,000+ professionals trained
Research – 20+ studies – 3 RCTs
Best Practice Registries
20K gatekeepers trained per month
Online courses for a variety of professionals