Advances in Suicidology: What We Know and What We Don’t Know (Montrose Fall Clinics 2018) Michael F Myers, MD Professor Clinical SUNY Downstate Medical Center Brooklyn, NY Disclosure Slide

• Medical Education Speakers Network – one grand rounds in 2017 • Book royalties – American Psychiatric Association Publishing Inc., Sage, Penguin, Amazon

2 Learning Objectives

1. Delineate up-to-date facts about in America, including recent research initiatives and findings 2. Summarize principles of suicide risk assessment and formulation 3. Discuss approaches to and interventions with individuals in the midst of bereavement following a by suicide

3 Setting the stage….

• “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.” – Kay Redfield Jamison PhD. From the Foreword. MF Myers and C Fine “Touched by Suicide: Hope and Healing After Loss”

4 A shocking week in June 2018

• June 5, 2018 designer Kate Spade died by suicide • June 7, 2018 CDC report: suicide rates have increased by more than 30 percent in half of the states since 1999 • June 8, 2018 celebrity chef Anthony Bourdain died by suicide

5 34.1 % increase in CO (CDC June 7, 2018)

6 An epidemiological approach to 1. Screening, assessment and support in your practice 2. Limit access to lethal means 3. Risk for suicide – identify and support patients at risk 4. Postvention -Crosby AE. Stepping up suicide prevention. Commentary. Medscape August 31, 2018

7 Facts and stats (AAS 2016)

• 44,965 Americans died by suicide • 123 daily • 1 person dies by suicide every 12 minutes • 1 person attempts suicide every 28 seconds • Suicide = 10th ranking (2nd for age 15-24) • 3.4 male deaths by suicide for every female vs 3 female attempts for each male attempt

8 Facts and stats (AAS)

• Elderly = 18 percent of • Youth = 12 percent of suicides • Middle aged = 37 percent • Highest rates in whites

9 Colorado (AAS)

• # 5 = 1168 deaths by suicide in 2016 • Rate = 22.1 • #1 = Alaska at 26.0 • #51 = District of Columbia at 5.9

10 (AAS)

• Firearms = 51.0% of total • Suffocation, hanging = 25.9% • Poisoning = 14.9% • Cut/pierce = 1.9% • Drowning = 1.1% • Other = remaining

11 Commonly stated

• It is generally believed that approximately 85- 90 percent of people who kill themselves have been living with some form of mental illness • Only half of the individuals who die by suicide have a diagnosis before their deaths • Even if diagnosed, they may be untreated or commonly undertreated • BUT THIS IS ALL UNDER STUDY

12 “Suicide is Not Just about Mental Illness” CDC Vital Signs Report June 7, 2018 • There are a range of factors – beyond conditions alone – including relationship, substance use, physical health, job, financial, isolation and legal problems. • Focusing suicide prevention efforts solely in health care settings is insufficient – must involve schools, workplaces, faith communities, neighborhoods

13 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.

14 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

15 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

16 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 Predisposing Proximal Immediate Factors Factors Factors Triggers Familial Major Psychiatric Hopelessness Public Humiliation Risk Syndromes Shame

Substance Serotonergic Intoxication AccessTo Function Use/Abuse Weapons

Neurochemical Personality Impulsiveness Severe Regulators Profile Aggressiveness Defeat

Abuse Negative Demographics Major Syndromes Expectancy Loss

Severe Medical/ Severe Pathophysiology Worsening Neurological Illness Chronic Pain Prognosis

17 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

18 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)

19 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

20 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

21 Zero Suicide in Health and Behavioral Healthcare • http://zerosuicide.actionallianceforsuicideprev ention.org/ • June 26-27, 2014 Suicide Prevention Resource Center (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

22 “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)

23 Acute Suicidal Affective Disturbance

(a) A geometric increase in suicidal intent over the course of hours or days, as opposed to weeks or months (b) One or both of the following: marked social alienation (e.g., severe social withdrawal, disgust with others, that one is a burden on others) or marked self- alienation (e.g., self-disgust, perceptions that one's is a burden) (c) Perceptions that the foregoing are hopelessly intractable (d) Two or more manifestations of overarousal (i.e., agitation, insomnia, nightmares, irritability). Rogers et al Journal of Affective Disorders, 2017-03-15, Volume 211, Pages 1-11

24 as a Risk Factor for Completed Suicide: Even More Lethal Than We Knew • Bostwick et al. Am J Psychiatry 2016; 173(11): 1094-1100. • First lifetime suicide attempts resulting in the subject’s death are routinely ignored in research because they present to the rather than the ED • The authors believe that by including these cases we get a stronger sense of lethality of previous attempts

25 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.”

26 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’” • 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

27 “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 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

28 “Peer Victimization, Cyberbullying and Suicide

Risk in Children and Adolescents” (Gina and Espelage JAMA 2014) • 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

29 For discussion

• LGBTQ individuals • Suicide and youth • Suicide and the elderly • Ethnicity and race • Active service men and women and veterans • Opioid users • Physicians

30 Suicide risk assessment

• Gold standard = Columbia-Suicide Severity Rating Scale (C-SSRS) – endorsed by the CDC and FDA in clinical trials • Simple, efficient, effective, evidence- supported, universal, free – The Columbia Lighthouse Project http://cssrs.columbia.edu/the-columbia-scale-c- ssrs/about-the-scale/

31 Risk Assessment and Risk Formulation

• RA is the process of collecting data from the patient regarding the presence vs absence of criteria we associate with suicide, so called risk factors, and pairing this with protective factors, akin to “ingredients”. • RF involves some understanding of how risk factors combine, interact, fuel and are buffered by protective factors or otherwise form “a recipe” for heightened risk for suicidal behavior. Risk formulation involves clinical judgment and intuition on the part of the clinician assessing and/or treating the patient. – Berman AL, Silverman MT. 2014. Suic Life Threat Behav 44(4):432-443

32 Important facts

• New research shows that passive suicidal ideation is no less serious than active suicidal thinking • Denial of suicidal thinking does not mean that the person is not suicidal • Document, document, document your risk assessment. • Medical legally if the assessment was not documented it is interpreted as not done

33 The bottom line…

• Assessing for suicide risk is only one part of your examination • There is no substitute for time spent with the patient conducting a detailed and thorough comprehensive assessment including a detailed mental status examination • No-suicide contracts should not be used, especially in an emergency setting

34 Create a safety plan

• Keep home environment safe (remove firearms, safe storage, clear out medicine chest, etc) • Warning signs of a suicidal crisis • Using CBT strategies with suicidal thoughts • Knowing who to call – family, friends – if necessary • Crisis line, nearest ED – Stanley B, Brown GK. Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice 2012;19:256-264

35 The Lived Experience

36 Kevin Hines

• Survived a jump from the Golden Gate Bridge in September 2000 • He is major lecturer on suicide prevention and postvention • His website is: http://www.kevinhiness tory.com/

37 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

38 Bereavement following a death by suicide • Characteristics of the • Grief vs major depression • What you can do to help • Self-care

39 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

40 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

41 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

42 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.

43 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

44 Grief vs Major Depression

• Much overlap of Sx especially low mood, sadness and social withdrawal • With grief there can be positive alongside negative ones • Waves of sadness with grief often set off by an internal or external reminder of the individual • Grief is a fluctuating state with individual variability in cognitive and behavioral realms Grief vs Major Depression

• Major depression is more pervasive and there is much difficulty experiencing self-validating or positive feelings • Protracted and enduring low mood, poor work and social functioning, impaired immune functioning, vegetative features, increased risk of suicidal behaviors – Zisook S, Shear K. Grief and bereavement: what psychiatrists need to know. World Psychiatry 2009;8:67-74 Treating survivors of suicide loss

• Create a safe place • Work on your personal comfort level with the painful and raw emotions of this unique loss • Listen attentively and with compassion • Remain humble • Remember always that your patient/client is the one in your office, not the deceased • Accept wide parameters of normality Therapeutic modalities

• Grief counseling • Supportive • Interpersonal therapy (IPT) • CBT – range of strategies for anxiety, depression if needed • Pharmacotherapy plus psychotherapy • Suicide specific : Dialectical behavior therapy (DBT), Collaborative Assessment and Management of Suicidality (CAMS), etc Therapeutic Approaches

• Individual therapy • Couples’ therapy – conjoint mostly • Collaborative – you and another therapist treating various members of the family • Family • Group • Various combinations of the above simultaneously or sequentially Familiarity with resources

• Survivors of suicide support groups – both in person and on line (Feigelman W, Jordan JR, McIntosh JL, Feigelman B. Devastating Losses: How Parents Cope with the Death of a Child to Suicide or Drugs. Springer, NY, 2012) • Recommend websites of AAS, AFSP, SPRC, SAVE, Jed Foundation, Dougy Center, NOPCAS • Volunteer opportunities as part of healing journey • Compassionate Friends Self care

• Unequivocally essential • Watch for burnout, compassion fatigue, vicarious traumatization • Limit setting of work vs one’s personal and family life • Strategies – reflection, reading, spirituality, religion, yoga, meditation, vigorous exercise, etc • Communication with professional peers and mutual support, AAS • Personal psychotherapy 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 remain stubbornly high • Efforts to diminish access to firearms or promote gun safety and restriction have been thwarted in many jurisdictions

52 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

53 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

54 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

55 Good News

• In January 2017, the National Action Alliance for Suicide Prevention announced that it will join with others to reduce the annual suicide rate 20 percent by 2025 – a goal originally set by the American Foundation for Suicide Prevention (AFSP) • 3 targets: National Shooting Sports Foundation, primary care settings, and EDs

56 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

57 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 – 1-800-273- TALK, 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

58 • "Suicide prevention is everyone's business"

– Surgeon General Dr David Satcher 2001

59 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)

60 Thank you for being here today!

• Telephone: 718 270-1166 • Email: [email protected] • Website: www.michaelfmyers.com

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