ask the question: preventing youth suicide...asq – ask suicide-screening questions - youth...

Ask the question: Preventing youth suicide

Jeff Kerber, Ph.D. LMFT Clinic & Program Administrator Counseling & Psychiatry

Takeaways…

1. Understand the Challenge – Perspective from some stats and facts. – Separate Myths from Facts.

2. Understand Risk. 3. Prevention – Gatekeeping. What to do. – Identify/review high risk factors – Ask the question.

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Preventing Youth Suicide

Statistics • Approximately 40,000 people in the U.S. die by suicide each year. About

every 13 minutes someone in this country ends his/her life. Under-reported NASH – what about U?

• National 2017 YRBS results indicate, of 9th – 12th grade respondents: – Considered = 17.2% – Made plan = 13.4% – Attempted = 7.4%

• Suicide is the 2nd leading cause of death in U.S. for people aged 10-24 (CDC, 2015) More teens die by suicide then by cancer, heart disease, AIDS, birth defects, stroke, pneumonia and flu – combined.

• 2nd leading cause of death among 15 – 19 year olds in Iowa (behind car accident and in front of homicide).

• Approximately 4,500 U.S. youth die by suicide each year (CDC, 2014)

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Statistics • Deaths by suicide – 2016 per age (CDC, Fatal Injury Report):

– General US pop 13.42 / 100,000 (very stable 80+ yrs) – > 85 white males 49.8 / 100,000 – > 65 all 14 / 100,000 – 15 – 24 13.15 / 100,000 (highest rate of increase 07-16) – < 15 .73 / 100,000

• By State in 2016 – Iowa 14.6 / 100,000 vs. US rate 13.42 / 100,000

• Teenage girls 3x more likely to attempt; boys 2x more likely to complete (YRBS, 2015)

• GLBTQ (gay, lesbian, bi, trans, queer) youth are 4x’s more likely, and questioning youth are 3 times more likely, to attempt suicide as their heterosexual peers.

• 4 out of every 5 attempters gave clear warning sign (YRBS, 2017)

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Iowa Youth Survey

12,236 respondents • IYS Polk Co (2016)

– Yes – “seriously thought about killing myself?”

• 10% (442) of 6th grade respondents • 14% (571) of 8th grade respondents • 17% (529) of 11th grade respondents

• IYS Polk Co (2016) – Yes – “tried to kill myself?”

• 3% (132) of 6th grade respondents • 5% (204) of 8th grade respondents • 5% (155) of 11th grade respondents

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Suicide FactsCompleted Suicide and Psychiatric Diagnosis

• Psychological autopsy research conducted in various countries over almost 50 years report very similar outcomes:

▪ 90% of people who die by suicide are suffering from one or more psychiatric disorders:

▪ Major Depressive Disorder ▪ Bipolar Disorder, Depressive phase ▪ Alcohol or Substance Abuse* ▪ Schizophrenia ▪ Personality Disorders such as Borderline PD *Primary diagnoses in youth suicides.

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Suicide FactsEven though most people give warning signs of their intent;

communication about suicide is often NOT made to professionals.

• In one psychological autopsy study, only 18% of completers told professionals of intentions. Zero Suicide – we aren’t asking the right question. – 50% of completers had seen PCP within 30 days – higher for middle aged

white males. • In a study of suicidal deaths in hospitals:

▪ 77% denied intent on last communication ▪ 28% had “no suicide” contracts with their caregivers

• Research does not support the use of “no-harm contracts” (NHC) as a method of preventing suicide.

• Research does support developing safety plans with suicidal pts.

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Myth vs. Fact• MYTH: People who threaten suicide don't complete

suicide.

• FACT: The vast majority of people who die by suicide

have given signals or warnings to family and friends of their intentions. Always take comments about suicide seriously.

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Myth vs. Fact• MYTH: Suicidal youth are fully intent on dying.

• FACT: Many people who attempt suicide are unsure if

they want to live or die, they experience “suicidal ambivalence.” Rather, people are trying to relieve unbearable mental pain. They may see suicide as a way out of their pain and suffering. Youth often complete due to impulsive action vs. intent.

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Myth vs. Fact• MYTH: Asking a depressed youth/person about

suicide will increase risk to complete suicide.

• FACT: Research and clinical experience is clear that

people thinking about suicide are not at greater risk when asked to talk about it. Talking, or asking the question; does not increase likelihood of attempt.

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PreventionCritical tasks: 1. Identify - confidently

identify high risk youth. 2. Respond – ask the question

and connect with high risk youth, persuade them to get help.

3. Get help – connect or refer to appropriate resources.

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Gatekeeper Training – QPR QPR (Question, Persuade, and Refer) Training for Suicide

Prevention is a 1-2 hour educational program designed to teach lay and professional "gatekeepers" the warning signs of a suicide crisis and how to respond.

Gatekeepers can include anyone who is positioned to recognize and refer someone at risk of suicide (e.g., parents, friends, neighbors, teachers, coaches, caseworkers, police officers).

The process follows three steps: (1) Question the individual's desire or intent regarding suicide, (2) Persuade the person to seek and accept help, and (3) Refer the person to appropriate resources.

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Understanding RiskPutting the pieces together…

Goal. Translate the facts and stats into a functional understanding of risk.

• Risk is dynamic, not static. It changes for people and depending on how we respond.

• Several important elements of a persons risk for suicide include understanding: – Mental Health – Depression – Environment, or context of their lives, both real

and perceived.

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Risk – Mental Health Psychiatric Disorders • Most common psychiatric risk factors resulting in suicide:

– Depression* • Major Depression • Bipolar Depression

– Anxiety Disorders, e.g. PTSD, OCD – Alcohol / drug abuse and dependence – Post partum dep – women esp w/psychotic features – SMI – e.g. Schizophrenia, paranoid type

• Developmental Psychology: – Maturational imbalance – teen reward focused behavior outpaces inhibitory control.

Pre-frontal cortex is not fully developed – women looking at 20/21 men 24/25. – Too much acceleration without fully developed braking system, leads to emotionally

impulsive actions.

*Especially when combined with alcohol and drug abuse and conduct d/o.

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Risk - Depression

Depressed Mood &/or Loss of Interest – min 2 wks & different from baseline + (4) SIGECAPS • Sleep • Interests & isolation • Guilt – self esteem (shame – blame self for trauma) • Energy levels • Concentration • Appetite • Psychomotor agitation • Suicide Ideation - Plans - Methods

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Risk – Environment Means/Context/Relational Risk Factors

– Easy access to lethal means • Top three methods used by young people include: firearm,

suffocation, poisoning • Younger children – running into traffic • CALM – Counseling on Access to Lethal Means

– Loss - Recent death or breakup – lacking perspective

– Affluence – stems resilience – little experience with frustration, disappointment, delayed gratification, altered perspective. • Recent surveys of law enforcement academies - graduating officers expect to

work daytime hours, no overnight and Holidays off.

– Social media – relational influence contributes to perception and experience of isolation, e.g. “everybody hates you.” We can’t control others use of social media – we can control access and use of the device.

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Risk – Environment Means/Context/Relational Risk Factors

– Gender – males more often complete – females internalization leads to increased attempts

– Prolonged stress – external locus of control. Bullied – academic struggle – violence at home

– Contagion - Local clusters of suicide that have a "contagious influence“

– Trauma history - family distress – separation or divorce – Adverse Childhood Experiences - ACES

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Prevention – What to do… • Learn to look for risk factors:

– Mental health disorders, e.g. depression. – Environmental, e.g. lethal means – Trauma history, e.g. family/relational changes,

divorce, ACES – Precipitating event, e.g. bullying

• Past Attempts – already “crossed the line” (40-50% more likely to attempt – descends over time – NIMH). – NSSI – Non Suicidal Self Injury – phys pain releases

brain chemicals provides temp relief of mental pain • Take it seriously 50 – 75% of people who

complete gave some warning sign to friends/family (AFSP).

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Prevention Ask the Question(s) • Stability posture - Don’t try to solve the person's problems –

engage, listen and understand them. – Are you thinking about suicide? – Are you thinking about harming yourself, ending your life? – What has happened that has led you to feeling this way? – How long have you been thinking about suicide? – Have you thought about how you would do it, i.e. plan? – Do you have (or access to) __? (Insert the lethal means they

may have mentioned) – (Explore ambivalence) Do you really want to die? Or do you

want the pain to go away? – Be willing and able to Listen – “stability” vs. “change”

response.

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Prevention AsQ – Ask Suicide-screening Questions - Youth Developed in response to Joint Commission Sentinel Event analysis that identified the root cause of suicide death in medical settings was lack of proper “assessment.” In 2016 the JC issued a Sentinel Event Alert recommending “all medical pts in hospitals also be screened for suicide risk.”

AsQ was developed in Pediatric ER study at 3 locations and derived the following 4 question screen. For people ages 10-24.

1. In the past few weeks, have you wished you were dead? Y/N

2. In the past few weeks, have you felt that you or your family would be better off if you were dead? Y/N

3. In the past week, have you been having thoughts about killing yourself? Y/N

4. Have you ever tried to kill yourself? Y/N

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Prevention Means Restriction • Firearm safety – enhanced supervision. Use of gun

safes, trigger locks and separation of weapon and ammunition.

• Construction of barriers at jumping sites

• Improved use of catalytic converters in motor vehicles

• Reduce lethality or toxicity of prescriptions

– Use of lower toxicity antidepressants – Change packaging of medications to blister

packs – Restrict sales of lethal hypnotics (i.e.

Barbituates)

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Prevention IS PATH WARM?

– Ideation – does person report thoughts of wanting to kill themselves or die? – Substance Abuse – does the person use substances and to what degree? – Purposelessness – lacking future orientation or “reason to live” – Anger – is the person frequently irritable? – Trapped – is the person experiencing “tunnel vision” and sees no alternative

to their pain? – Hopelessness – negative sense of self, they can see a future – but its

hopeless. – Withdrawing – isolation. – Anxiety – agitated, unable to sleep, no peace, etc. – Recklessness – engaging in high risk behaviors. – Mood change – does the person report/show dramatic mood shifts –

instability?

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Prevention What to do if you are with someone you believe is at risk of imminent harm:

– Do not leave the person and summon help. Unless… your safety is at risk. If a firearm or other weapon is involved; leave the scene and call 911.

– Restrict access to lethal means (e.g. weapons, strangulation, pills, car keys, etc.)

– Ask the question – “Are you thinking about killing yourself?” Patiently - wait and listen for the response.

– Get the person to a Behavioral Access facility, ER or call 911.

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Prevention

“Prevention may be a matter of a caring person with the right knowledge being available at the

right place at the right time.” - American Foundation for Suicide Prevention

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Prevention, is not luck!

What will you do? • Develop your radar. • Share your concerns. • Ask the question(s). • Listen. • Get help.

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Resources • Suicide Prevention Lifeline - 1-800-273-8255

www.suicidepreventionlifeline.org

• National Institute for Mental Health www.nimh.gov

• American Foundation for Suicide Prevention www.afsp.org

• National Center for Health Statistics www.cdc.gov/nchs

• Jason Foundation – www.jasonfoundation.com

• Substance Abuse & Mental Health Services Administration www.samhsa.gov

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Thank you! Questions?

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