Resources for At-Risk Veterans and the Practicing Bar: the Suicide Epidemic

RESOURCES FOR AT-RISK VETERANS AND THE PRACTICING BAR: THE SUICIDE EPIDEMIC

CLE Credit: 1.0 Sponsor: KBA Military Law Committee and KYLAP Wednesday, June 12, 2019 11:50 a.m. – 12:50 p.m. Carroll-Ford Galt House Hotel Louisville, Kentucky

A NOTE CONCERNING THE PROGRAM MATERIALS

The materials included in this Kentucky Bar Association Continuing Legal Education handbook are intended to provide current and accurate information about the subject matter covered. No representation or warranty is made concerning the application of the legal or other principles discussed by the instructors to any specific fact situation, nor is any prediction made concerning how any particular judge or jury will interpret or apply such principles. The proper interpretation or application of the principles discussed is a matter for the considered judgement pf the induvial legal practitioner. The faculty and staff of this Kentucky Bar Association CLE program disclaim liability therefore. Attorneys using these materials, or information otherwise conveyed during the program in dealing with a specific legal matter have a duty to research the original and current sources of authority.

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TABLE OF CONTENTS

The Presenters ...... i

Untreated Depression and the Risk of Suicide Among Lawyers and Veterans Who are Lawyers ...... 1

At Risk Veterans: The Suicide Epidemic ...... 21

THE PRESENTERS

P. Yvette Hourigan Kentucky Bar Association Frankfort, Kentucky 40601 (502) 226-9373 [email protected]

YVETTE HOURIGAN is the director of the Kentucky Lawyer Assistance Program (KYLAP). KYLAP provides assistance to all Kentucky law students, lawyers and judges with mental health issues and impairments including depression, substance or alcohol addictions, process addictions and chronic anxiety disorders. Ms. Hourigan is a graduate of the University of Kentucky College of Law and practiced law in Lexington in all areas of civil litigation including plaintiff’s personal injury work before being appointed as the KYLAP director. She is credentialed as a Certified Employee Assistance Professional, an Adult Peer Support Specialist, and is a QPR-trained Gatekeeper for suicide prevention. Ms. Hourigan is a member of the ABA Commission on Lawyer Assistance Programs, Chair of the ABA/COLAP Diversity & Inclusion Committee, and a member of the National Task Force on Lawyer Well-Being. In 2014, she was awarded the Dave Nee Foundation’s Uncommon Counselor Award which is given to a member of the legal profession who exhibits “extraordinary compassion and concern for co-workers, family, friends, and community.” Ms. Hourigan speaks locally and nationally on topics impacting lawyer well- being, addiction and suicide prevention. She shares her personal experiences as lawyer, employee assistance professional, and recovering person.

Dennis W. Shepherd Kentucky Department of Veterans Affairs 111 B Louisville Road Frankfort, Kentucky 40601 (859) 552-0983 [email protected]

DENNIS SHEPHERD is General Counsel for the Kentucky Department of Veterans Affairs in Frankfort. Mr. Shepherd earned his undergraduate degree from the University of Kentucky, his J.D. from the University of Kentucky College of Law, and his LL.M. from George Washington University.

UNTREATED DEPRESSION AND THE RISK OF SUICIDE AMONG LAWYERS AND VETERANS WHO ARE LAWYERS Yvette Hourigan, KYLAP

I. INTRODUCTION

The purpose of this program is to educate lawyers about depression, the severity of the problem here in Kentucky, and how untreated depression may lead to suicide. We hope this information will encourage those who are suffering from anxiety and/or depression, and who may be at risk for suicide, to seek help; as well as to educate Kentucky Bar members how to identify warning signs among our colleagues and our clients and be willing to explore ways we can offer assistance.

Depression rates in the Appalachian region of the United States have historically been high. According to a 2016 study focusing on the Appalachian region of the United States, things seem to be depressing in more ways than one for its inhabitants. According to a July 2018 USA Today report, Kentucky is the sixth most miserable place to live in the country. According to their research, we have the second lowest job satisfaction rating (that is, 70 percent express job dissatisfaction), we have the third worst health in the country (with the highest percentage of smokers at 25 percent of adults), and we are the fourth poorest state (the fourth highest poverty rate). In this study and in numerous others, Kentucky is always in the top five most depressed states; is always in the top three in rates of addiction and is now in the top states in overdose deaths. In 2018 there were 1,468 overdose deaths.

On average, people with depression go for nearly a decade before receiving treatment. Id. It is likely that lawyers go much longer without seeking help than the average person does, since lawyers seem to have a greater concern about the stigma of treating mental health issues. In fact, a recent ABA/COLAP study indicates that the stigma associated with getting mental health assistance is the greatest barrier to treatment for the legal population.

The 2 most common barriers were the same for both groups: not wanting others to find out they needed help (50.6 percent and 25.7 percent for the treatment and nontreatment groups, respectively), and concerns regarding privacy or confidentiality (44.2 percent and 23.4 percent for the groups, respectively). Krill, Johnson, Albers, J Addict Med 2016;10: 46–52.

As lawyers, we have a belief, perhaps it’s even subconscious, that because we are paid to solve the problems of others, we must be able to solve our own problems, including our mental health problems. This is, of course, false. There is a saying in mental health that “a sick brain can’t fix a sick brain.” We frequently hear lawyers saying, “I thought I could think my way out of it,” or “I thought it would pass.” Unfortunately, most mental health problems, and particularly a major depressive episode, do not spontaneously repair themselves.

II. SITUATIONAL DEPRESSION V. CLINICAL DEPRESSION

There are two very general types of depression. Everyone feels sadness during certain times, events, or under certain circumstances. This is referred to as situational depression. But clinical depression is a far more serious mental health condition that can have profound and even deadly impacts on a person’s life.

Situational depression is quite common. The medical diagnosis is adjustment disorder with depressed mood. Situational depression is a short-term form of depression that results after a traumatic event or significant life change (or a string of life changes). Triggers can include:

• Divorce

• Empty nest (when the last child leaves home)

• Loss of a job

• Death of a close friend

• Serious accident

• Retirement

The depression that occurs is the struggle and difficulty in coming to terms with the dramatic life changes. Some of the symptoms of a situational depression can include:

• Listlessness

• Feelings of hopelessness and sadness

• Sleeping difficulties

• Frequent episodes of crying

• Unfocused anxiety and worry

• Loss of concentration

• Withdrawal from normal activities, families and/or friends

Situational depression usually occurs within 90 days of the triggering event. It’s a natural response to a traumatic event. It will usually resolve:

• As time passes after the stressful situation or event

• As the situation improves

• When the person recovers from the life event

As stated before, it’s only short-term. Mild cases of situational depression will often resolve without active treatment. Lifestyle changes, including exercise, a well- balanced diet, good sleep hygiene, interaction with family and friends, can all help with easing a situational depression.

Compare that with clinical depression or Major Depressive Disorder (MDE) which can develop when an individual does not recover from a depression. This is the more severe and serious mental health condition that requires medical treatment. Clinical depression is severe enough to interfere with a person’s daily functioning.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V) classifies clinical depression or Major Depressive Disorder (MDE), as a mood disorder. Depression can alter a person’s thought processes and bodily functions. Disturbances in levels of brain chemicals – neurotransmitters – are thought to be at the root of it. But other factors play a role, too, and we’re just learning of the impact of the following situations:

• Genetic factors may influence an individual’s response to an experience or event;

• Major life events can trigger negative emotions, such as anger, disappointment, or frustration;

• Alcohol and drug dependence have direct links to depression.

The DSM-5 outlines the following criteria to make a diagnosis of depression. The individual must be experiencing five or more symptoms during the same two-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.

• Depressed mood most of the day, nearly every day.

• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

• Significant weight loss when not dieting or weight gain; or decrease or increase in appetite nearly every day.

• A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).

• Fatigue or loss of energy nearly every day.

• Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

• Diminished ability to think or concentrate, or indecisiveness, nearly every day.

• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for dying by suicide.

To receive a diagnosis of depression, these symptoms must cause the individual clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms must also not be a result of substance abuse or another medical condition.

An MDE (clinical depression), will not resolve itself, and treatment can last for a long time, and may require more long-term management and in-depth treatment plan. A therapist or doctor may recommend counseling and medication. A primary care doctor can prescribe medications or make referral to mental health professionals if the individual requires this level of care. In the most severe cases, the individual may need hospitalization or attend an outpatient treatment program in the event they have tried to self-harm.

We often hear lawyers complaining about their work, or “hating the practice of law.” This is not an insignificant complaint. In fact,

Using your strengths and enjoying what you do every day can greatly contribute to a sense of purpose -- one of the most important pillars of personal well-being. In Kentucky, just 70.6% of adults like what they do every day, and 63.3% use their strengths to maximize their potential every day -- the second smallest and smallest shares of any state, respectively. The relatively weak sense of purpose may partially explain the prevalence of depression in the state. Some 23% of respondents in Kentucky have had a depression in their lifetime, the fourth largest share of any state.

What is America's most miserable state? Answer may – or may not – surprise you. https://www.usatoday.com/story/money/economy/2018/07/24/ame rica-happiest-and-most-miserable-states-well-being/36959203/

III. MANIFESTATION OF SEVERE DEPRESSION IN LAWYERS AND ETHICAL CONCERNS

There are very few studies of lawyer impairment and its impact on ethical breaches, and this is so for a couple of reasons. First, much of lawyer impairment is hidden, and the client never knows there is an impairment or that there is an ethical breach (i.e., the client generally has no idea whether the lawyer is filing pleadings timely). Second, disciplinary counsels of most state boards typically don’t keep records of the relationship of mental health impairment to ethical violations, and so it is not reported in any usable statistical form. There are, however, some general statistics. For example, a study of discipline cases in Ontario, Canada reveled that nearly 50 percent of lawyers facing serious disciplinary sanctions there have admitted to either alcohol, drug or psychiatric impairment. Legal Profession Assistance Conference, Addiction and Psychiatric Impairment of Lawyers and Judges; A Search for Meaningful Data. Discipline Digest, LSUC, October 1992 - October 1995.

The American Bar Association’s former Commission on Impaired Attorneys (now the Commission on Lawyer Assistance Programs) has suggested that as many as 90 percent of all serious trust fund disciplinary matters involve severe mental health issues and/or substance abuse, primarily alcoholism.

The areas in which Kentucky and other bar associations see the highest level of complaints are not coincidentally the three areas in which the severely depressed or impaired attorney will have the greatest struggle. Refer to the identifying traits, supra. Specifically: communication, competency and diligence.

A. Pursuant to SCR 3.130(1.4) Communication:

(a) A lawyer should keep a client reasonably informed about the status of a matter and promptly comply with reasonable request for information.

(b) A lawyer should explain a matter to the extent reasonably necessary to permit the client to make informed decisions regarding the representation.

B. Pursuant to SCR 3.130(1.1) Competence:

A lawyer shall provide competent representation to a client. Competent representation requires the legal knowledge, skill, thoroughness and preparation reasonably necessary for the representation.

Commentary:

Thoroughness and Preparation

(5) Competent handling of a particular matter includes inquiry into and analysis of the factual and legal elements of the problem, and use of methods and procedures meeting the standards of competent practitioners. It also includes adequate preparation. The required attention and preparation are determined in part by what is at stake; major litigation and complex transactions ordinarily require more elaborate treatment than matters of lesser consequence.

Maintaining Competence

(6) To maintain the requisite knowledge and skill, a lawyer should engage in continuing study and education. If a system of peer review has been established, the lawyer should consider making use of it in appropriate circumstances.

C. Pursuant to SCR 3.130 (1.3) Diligence:

A lawyer shall act with reasonable diligence and promptness in representing a client.

Each of these requirements - communication, competency and diligence - become harder and harder for the depressed attorney to complete or maintain as the depressive illness progresses. Hence, hopelessness begins to set in. The more

difficult the circumstance, the more likely that attorney’s thoughts may turn to suicide and escape.

IV. SUICIDE WITHIN THE PRACTICE OF LAW

Risk factors for suicide include depression, anxiety, substance abuse, divorce and stress. Lawyers experience ALL of these risk factors at a higher rate than the general population. Lawyers are also more likely to be perfectionists and competitive - personality traits which make a person considering suicide less likely to seek help. Larry Berman, Executive Director, American Association of Suicidology.

As stated by Robin Frazer Clark, Georgia Bar President, in her President’s Page of the Georgia Bar Journal, December, 2012, “[F]ailure is not an option in a high- stakes profession such as ours.”

The natural progression of depression, when untreated, is suicide. Lest there be any doubt, if left untreated, depression can be fatal. In an 18-month period, at least nine members of our Kentucky bar died by suicide. Sadly, these were deaths that were almost completely preventable had the signs been clear or recognized. Unfortunately, many times we, as lawyers, have gotten so good at hiding our true feelings and repressing our actual emotions (skills which are not only useful, but imperative if we are to be effective advocates for our clients), that it is nearly impossible -- even for our loved ones -- to understand or recognize the symptoms. No one is to blame. We only have an obligation to act when we know the signs of which to be aware. That said, acknowledging that we, as lawyers, may be masters of repressing our true feelings, means that we must be hyper-vigilant with our colleagues. After we have been educated, we are responsible. There is a duty to help your colleagues when you see the signs that may be preceding an attempted suicide. It is better to be safe than sorry. It is better to have courage than regret.

Thoughts of suicide are not the distressed individual’s problem. They are the distressed individual’s perceived solution to the real problem or problems. Suicide has been called “a permanent solution to a temporary problem.” Our obligation is to recognize when someone is anticipating or seriously considering this “final solution” and guide them in the direction of real solutions and help. When the mental health issues that may lead to suicide are recognized early, experts agree that suicide is almost entirely preventable.

It is tempting when looking at the life of anyone who has committed suicide to read into the decision to die a vastly complex web of reasons; and, of course, such complexity is warranted. No one illness or event causes suicide; and certainly no one knows all, or perhaps even most, of the motivations behind the killing of the self. But psychopathology is almost always there, and its deadliness is fierce. Love, success and friendship are not always enough to counter the pain and destructiveness of severe mental illness.

Kay Redfield Jamison, Night Falls Fast: Understanding Suicide.

V. GENERAL POPULATION STATISTICS

Suicide is the 11th leading cause of death among all Americans. (Anderson & Smith, 2003), the second leading cause of death among Americans ages 25-34, and the third leading cause of death among Americans ages 10 to 14 and 15 to 24 (Centers for Disease Controls, 2005). Annual death certificates in the U.S. suggest that over 30,000 persons die by suicide each year. (National Center for Health Statistics, 2006).

Approximately 89 persons in the United States die by suicide every day (McIntosh, 2006). This equates to nearly four suicides each hour, or one suicide every 16 minutes (McIntosh, 2006).

In Kentucky, the general population facts about suicides are as follows:

• Kentucky loses more than twice as many citizens to suicide each year as to homicide. (Closer to three times as many.)

• Someone dies by suicide every 12 hours in Kentucky.

• There is an average of 5.7 suicide attempts every day in Kentucky.

• Kentucky’s suicide death rate in 2018 was the 20th highest in the nation (up from prior years).

• Suicide is the second leading cause of death for Kentuckians ages 15 to 34.

• Suicide is the fourth leading cause of death for adults ages 35 to 44.

• Our elderly have a higher suicide rate than the national average.

• Firearms caused 62 percent of suicide deaths in Kentucky.

• Two out of three Kentuckians (64 percent) know at least one person who has attempted or died by suicide.

• One out of three (33.8 percent) consider themselves to be a suicide survivor (someone who has lost a loved one or close friend to suicide).

• Experts believe most suicidal people don’t want to die, they just want to end their pain. When suicidal behaviors are detected early, lives can be saved.

www.kentuckysuicideprevention.org

In the United States, the suicide rate in the general population is 13.42 per 100,000 deaths. In Kentucky, the rate is 16.79 suicides per 100,000 deaths. That is, Kentucky’s overall rate of suicide is 25 percent higher than the national average.

VI. LAWYER STATISTICS VERSUS GENERAL POPULATION

As compared to 13 deaths by suicide for each 100,000 deaths in the general population, the national average rate for lawyers is 66 suicides per 100,000 deaths. Lawyers are more than five times higher than general population, to die by suicide (National Institute of Mental Health). And that number should be raised by 25 percent in Kentucky to reflect our higher rate of suicide over the national average. That is far too great a loss.

In a 2015 ABA/HazeldenBettyFord national study, 11.5 percent of the attorneys responding reported suicidal thoughts at some point during their career, 2.9 percent reported self-injurious behaviors, and 0.7 percent reported at least 1 prior suicide attempt.

Male lawyers between the ages of 20 and 64 are more than twice as likely to die from suicide as men of the same age in other occupations. National Institute for Safety and Health Study.

Suicide was the 3rd leading cause of death among lawyers insured by the Canadian Bar Insurance Association. (It’s the 10th leading cause of death in US in general). Canadian Bar Association Study.

Unfortunately, these shockingly high suicide numbers set forth above may inaccurately reflect the real numbers and real impact of US suicides. (Granello & Granello, 2007; Granello & Juhnke, in press). This is because suicide data is based on causes of death as reported on death certificates only. Given that many suicides are likely misreported -- not as suicides, but as automobile accidents, hunting accidents, swimming accidents, or accidental alcohol or drug overdoses -- the true suicide number is most likely significantly higher. (Juhnke, Granello & Lebron-Striker, Professional Counseling Digest, 2007).

“If they tell you that she died of sleeping pills, you must know that she died of a wasting grief, of a slow bleeding at the soul.” Clifford Odets

Not insignificantly, the current suicide rates fail to address the number of suicide attempts that were not completed. Since there is no standardized method of data collection among doctors or hospitals related to suicide attempts, there is no hard data to reflect these numbers. However, the American Association of Suicidology (2006) has estimated that at least 25 suicide attempts occur for each completed suicide. (Juhnke, Grenello & Lebron-Striker, supra). Based on this number, it is suggested that approximately 811,000 persons in the US made unsuccessful suicide attempts in 2004. This equates to one suicide attempt every 39 seconds (McIntosh, 2006).

VII. RISK FACTORS FOR SUICIDE

A. Psychiatric Disorders

At least 90 percent of people who take their own lives have a diagnosable and treatable psychiatric illness -- such as major depression, bipolar disorder, or some other depressive illness, including:

1. Schizophrenia.

2. Alcohol or drug abuse, particularly when combined with depression.

3. Post-Traumatic Stress Disorder, or some other anxiety disorder.

4. Bulimia or anorexia nervosa.

5. Personality disorders especially borderline or antisocial (and lawyers are at a higher risk for antisocial behavior than the general population, too)

B. History of Attempted Suicide

Between 20 and 50 percent of people who kill themselves had previously attempted suicide. Those who have made serious suicide attempts are at a much higher risk for actually taking their own lives.

C. Genetic Predisposition

Family history of suicide, suicide attempts, depression or other psychiatric illness.

D. Neurotransmitters

A clear relationship has been demonstrated between low concentrations of the serotonin metabolite 5-hydroxyindoleactic acid (5-HIAA) in cerebrospinal fluid and an increased incidence of attempted and completed suicide in psychiatric patients.

E. Impulsivity

Impulsive individuals are more apt to act on suicidal impulses.

F. Demographics

1. Sex: Males are three to five times more likely to die by suicide than females.

2. Age: Elderly Caucasian males have the highest suicide rates.

VIII. WARNING SIGNS OF A SUICIDE RISK

Suicide can be prevented. While some suicides occur without any outward warning, most people who are suicidal do give advance warnings. You may be able to reduce the likelihood of suicide by loved ones by learning to recognize the signs of someone at risk, taking those signs seriously, and then knowing how to respond to them.

A. General Warning Signs of Suicide Include:

1. Observable signs of serious depression:

a. Unrelenting low mood.

b. Pessimism.

c. Hopelessness.

d. Desperation.

e. Signs of Anxiety (including panic, insomnia and agitation).

f. Withdrawal from usual activities or loved ones.

g. Sleep problems.

2. Increased alcohol and/or drug use.

3. Recent impulsiveness and taking unnecessary risks; reckless behavior.

4. Threatening suicide or expressing a strong wish to die.

5. Making a plan.

a. Giving away prized possessions.

b. Sudden or impulsive purchase of a firearm.

c. Obtaining other means of killing oneself such as poisons or medications.

6. Unexpected rage or anger or any other dramatic mood change.

B. Larry Berman, Executive Director, American Society of Suicidology, supra

The emotional crisis (or crises) that usually precede suicide is often recognizable and treatable. Although most depressed people are not suicidal, most suicidal people are depressed. Serious depression can be manifested in obvious sadness, but often it is rather expressed as a loss of pleasure or withdrawal from activities that had been enjoyable. One can help prevent suicide through early recognition and treatment of depression and other psychiatric illnesses.

IX. OTHER INDICATORS THAT SOMEONE MAYTAKE THEIR LIFE

Most suicidal individuals give some warning of their intentions. But there may be less obvious signs. The most effective way to prevent a friend or loved one from taking his or her life is to recognize the factors that put people at risk for suicide, take warning signs seriously and know how to respond. Don’t be afraid to talk about it. There is too much at stake to avoid these early warning signs.

Know the Facts:

A. Psychiatric Disorders

More than 90 percent of people who die by suicide are suffering from one or more psychiatric disorders, in particular:

• Major depression (especially when combined with alcohol and/or drug abuse).

• Bipolar disorder.

• Alcohol abuse and dependence.

• Drug abuse and dependence.

• Schizophrenia.

• Post-Traumatic Stress Disorder (PTSD).

• Eating disorders.

• Personality disorders.

Depression and the other mental disorders that may lead to suicide are -- in most cases -- both recognizable and treatable.

The core symptoms of major depression are a "down" or depressed mood most of the day or a loss of interest or pleasure in activities that were previously enjoyed for at least two weeks, as well as:

• Changes in sleeping patterns.

• Change in appetite or weight.

• Intense anxiety, agitation, restlessness or being slowed down.

• Fatigue or loss of energy.

• Decreased concentration, indecisiveness or poorer memory.

• Feelings of hopelessness, worthlessness, self-reproach or excessive or inappropriate guilt.

• Recurrent thoughts of death or suicide.

B. Past Suicide Attempts

Between 25 and 50 percent of people who kill themselves had previously attempted suicide. Those who have made suicide attempts are at higher risk for actually taking their own lives.

1. Availability of means.

In the presence of depression and other risk factors, ready access to guns and other weapons, medications or other methods of self- harm increases suicide risk.

2. Recognize the imminent dangers. The signs that most directly warn of suicide include:

a. Threatening to hurt or kill oneself.

b. Looking for ways to kill oneself (weapons, pills or other means).

c. Talking or writing about death, dying or suicide.

d. Has made plans or preparations for a potentially serious attempt.

3. Other warning signs include expressions or other indications of certain intense feelings in addition to depression, in particular:

a. Insomnia.

b. Intense anxiety, usually exhibited as psychic pain or internal tension, as well as panic attacks.

c. Feeling desperate or trapped -- like there's no way out.

d. Feeling hopeless.

e. Feeling there's no reason or purpose to live.

f. Rage or anger.

4. Certain behaviors can also serve as warning signs, particularly when they are not characteristic of the person's normal behavior. These include:

a. Acting reckless or engaging in risky activities.

b. Engaging in violent or self-destructive behavior.

c. Increasing alcohol or drug use.

d. Withdrawing from friends or family.

X. WHAT CAN YOU DO?

A. Take it Seriously

1. Fifty to 75 percent of all suicides give some warning of their intentions to a friend or family member. 2. Imminent signs must be taken seriously.

B. Be Willing to Listen

1. Start by telling the person you are concerned and give him/her examples.

2. If he/she is depressed, don't be afraid to ask whether he/she is considering suicide, or if he/she has a particular plan or method in mind.

3. Ask if they have a therapist and are taking medication.

4. Do not attempt to argue someone out of suicide. Rather, let the person know you care, that he/she is not alone, that suicidal feelings are temporary, and that depression can be treated. Avoid the temptation to say, "You have so much to live for," or "Your suicide will hurt your family."

C. Seek Professional Help

1. Be actively involved in encouraging the person to see a physician or mental health professional immediately.

2. Individuals contemplating suicide often don't believe they can be helped, so you may have to do more.

3. Help the person find a knowledgeable mental health professional or a reputable treatment facility and take them to the treatment.

XI. WHAT IS A SUICIDE CRISIS?

A “suicide crisis” is a time-limited occurrence signaling immediate danger of suicide. This is as opposed to a “Suicide risk”, (discussed above), which is the broader term that includes the above factors such as age and sex, psychiatric diagnosis, past suicide attempts, and traits like impulsivity.

The signs of crisis (again, immediate danger) are:

A. Precipitating Event

A recent event that is particularly distressing, such as loss of loved one or career failure. Sometimes the individual’s own behavior precipitates the event: for example, a man's abusive behavior while drinking causes his wife to leave him.

B. Intense Affective State in Addition to Depression

Desperation (anguish plus urgency regarding need for relief), rage, psychic pain or inner tension, anxiety, guilt, hopelessness, acute sense of abandonment. C. Changes in Behavior

1. Speech suggesting the individual is close to suicide. Such speech may be indirect. Be alert to such statements as, "My family would be better off without me." Sometimes those contemplating suicide talk as if they are saying goodbye or going away.

2. Actions ranging from buying a gun to suddenly putting one's affairs in order.

3. Deterioration in functioning at work or socially, increasing use of alcohol, other self-destructive behavior, loss of control, rage explosions.

XII. WHAT TO DO IN AN ACUTE CRISIS

• If a friend or loved one is threatening, talking about or making plans for suicide, these are signs of an acute crisis.

• Do not leave the person alone.

• Remove all alcohol from the person or the home.

• Remove from the vicinity any firearms, drugs or sharp objects that could be used for suicide.

• Take the person to an emergency room or walk-in clinic at a psychiatric hospital.

• If a psychiatric facility is unavailable, go to your nearest hospital or clinic.

If the above options are unavailable, call 911 or the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or 1-800-SUICIDE. OR Text 741741. Veterans can text 741741 and press Option 1.

A. Follow-up on Treatment

1. Suicidal individuals are often hesitant to seek help and may need your continuing support to pursue treatment after an initial contact.

2. If medication is prescribed, make sure your friend or loved one is taking it exactly as prescribed. Be aware of possible side effects and be sure to notify the physician if the person seems to be getting worse. Usually, alternative medications can be prescribed.

3. Frequently, the first medication doesn’t work. It takes time and persistence to find the right medication(s) and therapist for the individual person. Encourage the individual to “keep trying.”

B. What to Do if You Notice Someone (of any age) Exhibiting Signs of Suicide Risk:

1. Open a dialogue.

Asking questions will help you to determine if your client or colleague is in immediate danger. Always take thoughts of, or plans for, suicide.

The question you NEVER ask: “You’re not thinking about committing suicide, are you?” This question tells the person you want them to say “No.” It’s the wrong form.

Be direct. Talk openly and matter-of-factly about suicide. Ask, “Do you ever feel so badly that you think about suicide?" or "Do you have a plan to end your life?”

2. Be willing to listen. Allow expressions of feelings.

3. Be non-judgmental.

Don’t debate whether suicide is right or wrong, or whether feelings are good or bad. Lecturing (for example, on the value of life or the impact on family) or being shocked will put distance between you.

4. Be available. Show interest and support.

Offer hope that alternatives are available. Depression is among the most treatable of mental disorders. Between 80 percent and 90 percent of people with depression eventually respond well to treatment and almost all patients gain some relief from their symptoms.https://www.psychiatry.org/patientsfamilies/depression/ what-is-depression

5. Take action. Do not leave the person alone, if you think they might harm themselves, until the next steps are accomplished.

a. Let them know you are you are going to do what you can to help them.

b. While they are with you, call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or 1-800-SUICIDE to be connected to the nearest available crisis center for a referral to local mental health resources.

c. You can also TEXT 741741 to “chat” with the National Suicide Prevention Lifeline. (For veterans, hit option “1”).

This is a good option if you are having suicidal thoughts or are feeling desperate but are not ready to talk openly and feel more comfortable texting.

6. If the person at risk is a colleague, take all the steps previously mentioned, AND also refer the colleague to KYLAP at 1-502-226- 9373.

KYLAP is a CONFIDENTIAL service, and the phone is answered 24 hours a day. In emergencies, the after-hours service will make sure there is an appointment with a healthcare provider within 24 hours. In non-emergencies, appointments are available within 48 hours. When financial problems exist, and certain criterion are met, an individual can receive up to four free mental health visits. Additional funds may be available through the KYLAP Foundation through forgivable loans for mental health assistance, including inpatient treatment, outpatient treatment, therapies and medications (paid directly to providers). www.kylap.org/Foundation.

APPENDIX A

I. STATE OF KENTUCKY – SUICIDE RESOURCES AND SUPPORT GROUPS

A. Kentucky suicide prevention group: www.kentuckysuicideprevention.org

Kentucky Suicide Prevention Group 1603 Vivian Lane Louisville, KY 40205 TELEPHONE: (502) 931-3999

Jan Ulrich State Suicide Prevention Coordinator Kentucky Dept for Behavioral Health, Developmental and Intellectual Disabilities 100 Fair Oaks Lane, 4E-D Frankfort KY 40621 Email: [email protected] TELEPHONE: (502) 564-4456 Ext: 4436

B. State Suicide Prevention Website http://dbhdid.ky.gov/dbh/sp.aspx

C. Suicide Prevention Resource Center https://www.sprc.org/states/kentucky

II. OTHER RESOURCES

A. Veterans Outreach Toolkit - Preventing Suicide. https://www.va.gov/ve/docs/outreachToolkitPreventingVeteranSuicideIsE veryonesBusiness.pdf

B. Start the Conversation: Veterans Dealing with Depression: https://starttheconversation.veteranscrisisline.net/media/1043/vasp- depression-508-11.pdf

C. Start the Conversation: Talking to a Veteran when you are Concerned: https://starttheconversation.veteranscrisisline.net/media/1045/vasp_when -you-are-concerned_final-508-11.pdf

D. Talking with a Veteran in Crisis: https://www.va.gov/ve/docs/talkingWithVeteranInCrisisHandout.pdf

E. ACES Test for Resiliency: Take it anonymously online at, https://www.npr.org/sections/health-shots/2015/03/02/387007941/take- the-ace-quiz-and-learn-what-it-does-and-doesnt-mean

F. Nicholson McBride Resilience Questionnaire (NMRQ) Abbreviated: https://www.nwpgmd.nhs.uk/sites/default/files/resiliencequestionnaire.pdf

APPENDIX B

SUICIDE AMONG TEENS -- Frequently Asked Questions

There is also a growing number of teens and young adults who attempt suicide. To address these issues, here are some frequently asked questions. Many of these questions came from young teens struggling to understand the suicide attempts of friends and trying to learn how they can help.

1. What percentage of college students who kill themselves are male? Why do you think more/ less boys than girls kill themselves?

Seventy-five to 80 percent are boys although more girls attempt suicide. Boys are more involved than girls in all forms of aggressive and violent behavior.

2. I've heard that suicides are more frequent around the holidays? Is this true, and if so, how much do they increase at that time?

Suicides are not more frequent during the holidays. It appears that the rates are the highest in April, and the summer months, June and July.

3. It is often said that a suicidal person goes through a period where he seeks help from other people. Does this then mean that it could be ultimately the fault of other people (because they don't appear concerned enough) that one decides to kill him/herself?

Not a fair conclusion, although it could be a contributing factor in some cases particularly with elderly, terminally ill people.

4. What is the biggest cause of suicide among college students?

Ninety-five percent are suffering from mental illness, usually depression. If depressed, substance abuse, anxiety, impulsivity, rage, hopelessness and desperation increase the risk.

5. Apart from talking to a suicidal person and encouraging him/her to go for counseling, what else can we do to prevent this?

Going with someone to the counselor often helps. If the person won't listen to you, you may need to talk to someone who might influence him or her. Saving a life is more important than violating a confidence.

6. People often get uncomfortable when one discloses something as intimate and frightening as suicidal thoughts. What do you think can be done to reduce this stigma, either of suicidal people, or of depressive patients? Can people actually "change" their minds and accept someone who is suicidal?

As people recognize that suicidal behavior is the result of a medical condition not a sign of weakness or character defect it will change.

7. What is the most frequent method of suicide? Is the most frequent method different for men and women?

Fifty-two percent of all people who kill themselves do so with a firearm, accounting for almost 17,000 deaths each year in the U.S. Use of a firearm is the number one method in those aged 35 and up.

AT RISK VETERANS: THE SUICIDE EPIDEMIC Dennis W. Shepherd

I. OVERVIEW: THE NATURE OF THE PROBLEM

“The report shows the total is 20.6 suicides every day. Of those, 16.8 were veterans and 3.8 were active-duty servicemembers, guardsmen and reservists, the report states. That amounts to 6,132 veterans and 1,387 servicemembers who died by suicide in one year.” Stars and Stripes, 20 June 2018, referring to a recent report by the U.S. Dept. of Veterans Affairs.

II. LIFE FACTORS, STRESSORS, PRESSURE POINTS MILITARY MEN AND WOMEN ENDURE

A. Deployment Trauma

B. In the Crucible of Life and Death

C. Making the Ultimate Decision to Kill

D. Object of Physical, Psychological, or Sexual Abuse/Assault

E. Personality Disintegration

F. Aftermath of Combat: Mental, Physical, Psychological Deficit

III. THE DIRTY WORD SYNDROME: DON’T COMPLAIN; JUST PUT UP WITH IT

A. World War I

1. Charles Samuel Myers, English physician, described “shell shock.”

2. “A Contribution to the Study of Shell Shock” Lancet, 13 Feb. 1915.

3. Myers also referred to condition of “war neurosis.”

4. Fatigue, shell shock, battle fatigue, and combat neurosis.

B. World War II

1. Abram Kardiner, War Stress and Neurotic Illness, 1947.

2. Kardiner referred to condition of “physioneurosis.”

C. Vietnam

1. From Shell Shock and War Neurosis to Posttraumatic Stress Disorder: A History of Psychotraumatology by Marc-Antoine Crocq, MD.

2. 700,000 returning from Vietnam required psychological help.

3. In 1980, the Diagnostic and Statistical Manual of Mental Disorders Third Edition (DSM-3) recognized Posttraumatic Disorder.

4. DSM-5 continues to recognize PTSD.

D. Wars in Iraq and Afghanistan

1. Invasion of Iraq: 2003.

2. Veterans exiting military 2003-2019: est. 4.3 million.

3. Post-9/11 Veterans: Up to 30 percent seek mental health treatment or greater than 1,000,000. See “U.S. Military Veterans’ Difficult Transitions Back to Civilian Life and the VA’s Response,” Anna Zogas, February 2017, Watson Institute, Brown University.

IV. THE DIRTY WORD SYNDROME: SUICIDE

A. People Commit Suicide; Other People Speculate on Motive

1. Kate Spade (fashion designer).

2. Anthony Bourdain (chef, traveler, TV personality).

B. Open Up; Stop Being Judgmental

C. “If people felt as comfortable talking about their PTSD, bipolar or anxiety as they did talking about their eczema or tennis elbow, it would markedly reduce the suffering of those with mental illness and the ability of those around them to support them.” Margie Warrell, “The Rise and Rise of Suicide: We Must Remove the Stigma of Mental Illness,” Forbes Magazine.

D. Case Study: Daniel Somers

1. “My mind is a wasteland, filled with visions of incredible horror, unceasing depression, and crippling anxiety.”

2. Graphic suicidal thoughts captured in Daniel’s own words.

V. WHAT ARE WE DOING TO PREVENT SUICIDE INTERNATIONALLY?

A. Positive Trend Country by Country to Prevent

B. World Health Organization, “Global Mental Health Action Plan”

C. Suicide Prevention in an International Context (2017) by Ella Arensman

1. Small countries create suicide prevention programs.

2. Suriname, Bhutan, Guyana, Afghanistan.

D. Arensman’s Suicide Prevention Model

1. Statistics/database.

2. Restricting access to lethal means.

3. Responsible media reporting of suicides.

4. Training and education.

5. Treatment.

6. Reducing/eliminating the stigma of suicide discussion.

7. Postvention: continuing discussions with those affected.

8. Crisis intervention means.

VI. UNITED STATES AND NATIONAL SUICIDE PREVENTION

A. 1958: First Suicide Prevention Center Opens in Los Angeles

B. Suicide Prevention for Youth Act, 42 U.S.C. §290BB-36a

C. Suicide Prevention for Adults, 42 U.S.C. §290bb-43

D. Senate Bill 3460 (115th Congress): Native American Suicide Prevention Act of 2018 (not passed)

VII. UNITED STATES AND STATE PROGRAMS FOR SUICIDE PREVENTION

A. “So far in 2018, at least 10 bills in eight states have been enacted around suicide prevention in schools. These include Colorado, Idaho, Indiana, Iowa, Kentucky, Rhode Island, Utah and New Mexico, which has requested a study specifically on preventing suicide with firearms at schools.” Education Dive newsletter, 20 September 2018.

B. Kentucky Laws on Suicide and Suicide Prevention

1. KRS 210.366 – Training program in suicide assessment, treatment, and management.

2. Requires licensed professionals (social workers, psychologists, alcohol/drug counselors, alcohol/drug peer support specialist, etc.) completes such a program.

3. KRS 156.095: Kentucky Schools.

By August 1, 2010, the Kentucky Cabinet for Health and Family Services shall post on its webpage suicide prevention awareness information, to include recognizing the warning signs of a suicide crisis. The webpage shall include information related to suicide prevention training opportunities offered by the cabinet or an agency recognized by the cabinet as a training provider.

4. KRS 216.302 Causing a suicide -- Assisting in a suicide.

(1) A person commits a Class C felony when the person knowingly by force or duress causes another person to commit or to attempt to commit suicide.

(2) A person commits a Class D felony when the person, with the purpose of assisting another person to commit or to attempt to commit suicide, knowingly and intentionally either:

(a) Provides the physical means by which another person commits or attempts to commit suicide; or

(b) Participates in a physical act by which another person commits or attempts to commit suicide. Effective: July 15, 1994

VIII. UNITED STATES AND VETERAN SUICIDE PREVENTION

A. Female Veteran Suicide Prevention Act (2016)

B. Clay Hunt Suicide Prevention Act for American Veterans (2015)

• Who was Clay Hunt?

o Marine injured in Iraq.

o Redeployed in 2008 to Afghanistan.

o Suffered depression after military service; suicide in 2009.

o Loan repayment for psychiatric medicine practitioners.

IX. RESOURCES TO HELP VETERANS AT RISK FOR SUICIDE

A. United States Department of Veterans Affairs

1. An at-risk veteran COMMUNICATES WITH SOMEONE.

a. Calls the Veterans Crisis Line at 1-800-273-2255.

b. Texts the Veterans Crisis Line at 838255.

c. Chats online.

2. Communities must practice suicide prevention.

Integrate prevention lessons into the local community.

a. Health clubs, gyms.

b. City council.

c. Places of worship.

d. Veteran peer support groups (Veterans Treatment Court).

3. What can attorneys and paralegals do?

a. Promote community-based suicide prevention.

b. Participate in city councils, town halls, pro bono forums.

c. Learn what your community does for suicide prevention.

d. Work to get PSAs donated by local media.

e. Contact a U.S. Department of Veterans Affairs Suicide Prevention Coordinator and invite to speak, train, assist.

i. Available at all VA Medical Centers.

ii. Lexington VA Medical Center.

iii. Louisville Robley Rex VA Medical Center.

iv. Cincinnati VA Medical Center.

v. Marion, Ill. VA Medical Center.

B. Kentucky Resources

1. County-by-county 24-hour crisis lines.

2. Veterans Crisis Line: 1-800-273-8255 (PRESS 1).

C. Kentucky Legislative Update: Green Alert

"Veteran at risk" means a veteran or an active-duty member of the Armed Forces, the National Guard, or a military reserve component of the United States who is known to have a physical or mental health condition, to include post-traumatic stress disorder (PTSD), that is related to his or her service.

X. REFERENCE MATERIAL ON VETERAN AND NON-VETERAN SUICIDES

A. USDVA Fact Sheet: Suicide Among Women Veterans

B. “The Missing Context behind…22…a day”

C. Kentucky Veteran Suicide Data Sheet, 2016

D. Suicide Safety Assessment by National Institute of Mental Health

E. Clay Hunt Suicide Prevention for American Veterans Act

F. Female Veteran Suicide Prevention Act

G. “A Soldier’s Last Words” by Clay Somers

H. “The Parking Lot Suicides” by Emily Wax-Thibodeaux