Suicide

1. Suicide “There is but one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.” Albert Camus, The Myth of Sisyphus (1942)

2. Outline: • What suicide is and how it is studied • What it isn’t: myths and opinions vs. facts • Epidemiology, especially pediatric • Warning signs • Prevention, intervention, and postvention • Suicide and your clinical skills: assessment, intervention, and risk

3. Facing the facts: • 900,000 per year, worldwide; about 1% of deaths; • 1 death by suicide every 40 seconds; • 10-20 million suicide attempts per year: 1:8 ratio of attempters vs. completers; • 395,000 emergency department visits per year are self-inflicted injuries • 3rd leading cause of death among 15-24 year olds (following accidents and homicide); • 2nd leading cause among 25-34 year olds; • 8 per 100,000 among US college students;

4. Suicidolgy, epidemiologyCDC, WHO, NASP, IASP Methods of suicide Table 1 also indicates the most common methods of suicide in the participating countries. In Australia, Japan, New Zealand, Pakistan, and Thailand, hanging dominates as the most common method of suicide. In China, Hong Kong SAR, and Singapore, jumping (typically from apartment buildings) is the most frequent method used (Ung, 2003; Yip,1996). In countries with larger rural populations, such as China, India and the Republic of Korea, poisoning (usually by pesticides) is common (Bose et al., 2006; Shin et al., 2004). Some new methods are also emerging, such as carbon monoxide poisoning by intentionally burning charcoal in a confined space. In China, Hong Kong SAR charcoal-burning accounted for a single suicide in 1997 but it is currently among the top three most common methods of suicide (Chan et al., 2005; Chung et al., 2001; Yip et al., 2007) (italics added).

5. Suicide Trends Among Youths and Young Adults Aged 10--24 Years --- United States, 1990--2004 In 2004, suicide was the third leading cause of death among youths and young adults aged 10--24 years in the United States, accounting for 4,599 deaths (1,2)…. From 2003 to 2004, the rate increased by 8.0%, from 6.78 to 7.32 (2), the largest single-year increase during 1990--2004. CDC analyzed data recorded during 1990--2004, the most recent data available. Results indicated that, from 2003 to 2004, suicide rates for three sex-age groups (i.e., females aged 10--14 years and 15--19 years and males aged 15--19 years) departed upward significantly from otherwise declining trends. Suicides both by hanging/suffocation and poisoning among females aged 10--14 years and 15--19 years increased from 2003 to 2004 and were significantly in excess of trends in both groups. The results suggest that increases in suicide and changes in suicidal behavior might have occurred among youths in certain sex-age groups, especially females aged 10--19 years. Closer examination of these trends is warranted at federal and state levels. Where indicated, health authorities and program directors should consider focusing suicide-prevention activities on these groups to help prevent suicide rates from increasing further. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a2.htm

6. Suicidology: Important caveats: • Many actual suicides fail to be classified as such. • Suicide rates vary by country, gender, and age. • Studies of suicide are hampered by low base rates and after-the-fact data. • It is a social construction. Societies view suicides very differently!

7. More epidemiology • 4:1 Male to female ratio worldwide • Firearms, poison, suffocation and/or hanging; • Access to firearms is the #1 predictor among pediatric suicides in the US; • Teens and elderly are most at risk worldwide; • Physician suicide rate is four times the national average.

8. What it is: • Medical: one of 4 modes of death (NASH) • Legal: the deliberate taking of one’s life; in common law, formerly considered a crime, but no longer; • Historical/cultural: ever evolving (e.g. early Christian martyrs vs. the contemporary Vatican stance. • “the fruit of illogical action resulting from funnel thinking, which prevents a person from perceiving alternatives to self-destruction” (Hef) • “alienation’s last word” (Gomezil) • “the most tragic decision of a man who found nobody to hold out a hand to him” (Kielanowski) • “a conscious act of self-induced annihilation, best understood as a multidimensional malaise in a needful individual” (Schneidman)

9. Definition(s): • The act of causing ones own death. • Positive: taking ones own life with purpose and intention. • Negative: not doing what is necessary to escape death (not leaving a burning building; stopping insulin treatments). • Direct: havingthe intention of causing ones own death, either as an end, or as a means to an end (to avoid ruin or disgrace, or escape condemnation). • Indirect: (and not usually called suicide) death is not necessarily desired, but one commits an act which courts death, as in tending someone with SARS knowing that one may succumb to the same illness.

10. What suicide is NOT • A disease • An immorality • A biological anomaly • A neurological dysfunction It is unlikely that any one theory will ever explain phenomena as complex and varied as acts of human self-destruction. (Leenars, 1995)

11. Facts vs. Myths • Myth: People who talk about suicide won’t really do it. • Fact: 8 of 10 suicides have given a definite warning.

12. Facts vs. Myths • Myth: Suicide happens without warning. • Fact: Almost all suicidal people give many warnings.

13. Facts vs. Myths • Myth: Suicidal persons are fully intent on dying. • Fact: Most are undecided and ambivalent.

14. Facts vs. Myths • Myth: Once a person is suicidal she/he is suicidal forever. • Fact: Individuals who wish to kill themselves are suicidal for only a limited period of time.

15. More facts and myths • Myth: Improvement following suicide crisis means the risk is over. • Fact: Most suicides occur within 3 months of “improvement” when the person has more energy to carry through. • Myth: Suicides strike more among the rich (or poor). • Fact: Suicide is very democratic and represented proportionally among all levels of society.

16. Facts vs. Myths • Myth: All suicide individuals are mentally ill, and suicide is always the act of a severely depressed or psychotic person. • Fact: Studies of hundreds of suicide notes indicate that although the person was in unbearable pain, he or she was not necessarily mentally ill. About 15-20 percent of suicides do NOT have a mental illness.

17. Probably the most dangerous myth: • Asking about suicide or suicidality will increase the risk of suicide. • Fact: Assessing suicidal thoughts and behaviors prevents suicide by identifying individuals at risk and by inviting people who are in pain to communicate.

18. Unbearable psychological pain • Depression • Masked depression • Hostility, anxiety, guilt, shame, hopelessness • Overwhelming, painful EMOTION, not depression per se • Constricted thinking as a result of emotional pain

19. Cognitive constriction • Rigid • Narrow focus (tunnel vision) • Concreteness • Dysfunction in emotions, logic, perceptions • Inability to adjust • Aggression, confusion, humiliation

20. PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE • Hopelessness • Impulsivity / Aggression • Anxiety • Command hallucinations

21. Interpersonal difficulties • Rejection • Aggression • Identification with a lost loved one • Shame and humiliation that is deemed unfair, especially public shame (losing one’s license to practice; failing out of school)

22. Biology of suicide • Learning disabilities: right brain dysfunction • Physical illness and disabilities • Biomarkers: corticosteroids, thyrotropin releasing hormone, norepi:epi ratio • Small samples sizes, problems with data collection, confounding variables

23. Family background of suicide • Lack of generational boundaries • Inflexible family system (secretiveness, denial, poor communication, patterns of authoritarian discipline • Symbiotic parent-child relationship • Long term family disorganization • Adolescents who feel a lack of control over their environment

25. SUICIDE: A MULTI-FACTORIAL EVENT Psychiatric IllnessCo-morbidity Neurobiology Personality Disorder/Traits Impulsiveness Substance Use/Abuse Hopelessness Severe Medical Illness Suicide Family History Access To Weapons Psychodynamics/ Psychological Vulnerability Life Stressors Suicidal Behavior Jacobs, 2003

26. Suicidal Behavior in Children and Youth: An Overview • Suicide is the third-leading cause of death among children and adolescents in the U.S. • Suicide rate among children and youth has increased over 300% since the 1950s • A child or adolescent commits suicide in the U.S. approximately every 2 hours • Suicide rates are highest among high school students, although there have been recent increases among middle school students

27. Suicidal Behavior in Children and Youth: An Overview • More children and adolescents die annually from suicide than from cancer, heart disease, AIDS, birth defects, and other medical conditions combined • Survey research suggests approximately 20% of high school students experience serious suicidal thoughts in a given year, and that about 4-8% make actual attempts • Over 2000 children and adolescents commit suicide annually • These statistics likely underestimate actual figures, although the degree to which this occurs is uncertain (National Association of School Psychologists)

28. Suicidal Behavior in Children and Adolescents • In any given year in a typical high school class of 30 students: • 6 will seriously consider suicide • 2 to 3 will attempt suicide • 1 will make an attempt sufficiently harmful to require medical attention

29. Suicidal Behavior in Children and Adolescents: Demographics • Gender • Adolescent females attempt suicide at a rate of 2:1/ 3:1 compared to adolescent males • Adolescent males commit suicide at a rate of nearly 5:1 compared to adolescent females • Age • Rates of suicidal behavior increase as children get older, hitting peak in early 20s

30. Suicidal Behavior in Children and Adolescents: Demographics • Race • White males currently at highest risk • Other high risk groups: Native-American youth; African-American males • Limited data available on other groups • Geography • Highest suicide rates in Western states and Alaska • Lowest suicide rates in Northeastern states • Higher suicide rates in rural than in urban areas

31. Suicidal Behavior in Children and Adolescents: Demographics • When: • Slightly more suicides occur during Spring • Month with least amount of suicides: December • Suicide rates lower just before and during holidays • Where: • Most adolescent suicides occur at home, where primary means for suicide (typically firearms) are available

32. Suicidal Behavior in Children and Adolescents: Demographics • How: • Firearms are most popular method among both males and females who commit suicide in U.S. • Worldwide, hanging is the most frequently used method of youth suicide, and the second most popular method among U.S youth. • Risk of suicidal behavior is a function of intent and lethality; youths with high level of intent who use methods of high lethality (e.g., firearms) present the greatest risk.

33. Suicide Ideation, Attempts, and Completion • Three different types of suicidal behaviors (ideators, attempters, and completers) reflect different types of individuals • Typical youth suicide attempter: Adolescent female who ingests pills in front of her family during an argument • Typical youth suicide completer: Adolescent male who is a victim of a gunshot wound

34. Attempters vs. Completers • An overlapping group • 8:1 ratio overall • In young people, 50:1 ratio • Parasuicide • Distinguishing among the two: a slippery slope • Perturbation and lethality are rated high, medium, or low, on a 1-9 scale • Lethality is what kills. • ALL ATTEMPTS SHOULD BE TAKEN AS A SERIOUS COMMUNICATION. • Words like blackmail, manipulation, and attention seeking are perjorative and only reveal our own attitudes and fears. • A third group = contemplators, very little research on them

35. Common Myths About Youth Suicide • Adolescents who talk about suicide are just looking for attention; • Listening to certain types of music (e.g., “heavy metal”) or engaging in certain activities (e.g., watching particular movies) causes people to become suicidal; • Preventing access to lethal means will not prevent suicide - students will simply choose another method; • Most dangerous myth: Talking about suicide will encourage suicidal behavior

36. Prevention • Schools and communities. • EDUCATION and knowledge vs. fear and judgments. • Secondary prevention: identification and intervention. • Tertiary prevention: siblings, children of people who complete suicide. • Pediatricians and postpartum depression or postpartum psychosis.

37. ASSESSMENT AND INTERVENTION

38. Protective Factors in General Population • Children in the home, except among those with postpartum psychosis • Pregnancy • Deterrent religious beliefs • Life satisfaction • Reality testing ability • Positive coping skills • Positive social support • Positive therapeutic relationship

39. Child/Adolescent Risk Factors in Youth Suicide • Previous suicide attempt • Current suicidal ideation, intent, and plan • Psychiatric Disorders and Problems • Depression • Hopelessness • Conduct problems • Drug and/or alcohol abuse • Impulse control problems (e.g., shoplifting; gambling; eating disorders; self-injury)

40. Child/Adolescent Risk Factors in Youth Suicide • Gay or lesbian sexual orientation • Unwillingness to seek help because of perceived stigma • Feelings of isolation or being cut off from others • Ineffective coping • Inadequate problem-solving skills, low emotional intelligence • Cultural and/or religious beliefs (e.g., belief that suicide is a noble or acceptable solution to a personal dilemma)

41. Environmental/Situational/Family Risk Factors in Youth Suicide • Access to lethal methods, especially firearms; • Exposure to suicide and/or family history of suicide • Loss (e.g., death; divorce; relationships); • Victimization/exposure to violence (e.g., bullying); • School crisis (e.g., disciplinary; academic); • Family crisis (e.g., abuse; domestic violence; running away; child-parental conflict); • Influence (either through personal contact or media representations) of significant people who died by suicide; • Barriers to accessing mental health treatment.

42. Environmental/Situational/Family Risk Factors in Youth Suicide • Experiences of disappointment or rejection; • Feelings of stress brought about by perceived achievement needs; • Unwanted pregnancy, abortion; • Infection with HIV or other sexually transmitted diseases; • Serious injury that may change the individual’s life course (e.g., Traumatic Brain Injury); • Severe or terminal physical illness; • Death of a loved one; • Separation from family or friends.

43. Suicide Clusters (Copycat suicides) • Defined as more suicides or suicide attempts than expected, close together in time and location. • Teens most susceptible to contagion. • Appears to represent 1-5% of all suicides. • Centers for Disease Control (CDC) estimates that 100-200 teens die in clusters annually. • Media reporting may contribute to clusters

44. Youth Suicide Clusters:Community Characteristics • Lack of integration and belonging • Rapid community growth and large schools • High rates of substance abuse • Emphasis on material possession • Lack of mental health services and little awareness of problem of youth suicide • No 24-hour crisis hotlines • Lack of networking and coordination among community agencies

45. Warning Signs for Youth Suicide • Suicide threats • Suicide plan/method/access • Making final arrangements • Sudden changes in behavior, friends, or personality • Changes in physical habits and appearance • Preoccupation with death and suicide themes • Increased inability to concentrate or think clearly • Loss of interest in previously pleasurable activities • Symptoms of depression • Increased use and abuse of alcohol and/or drugs

46. Suicide Risk Assessment: Questions to Ask • How’s your mood? • Have you ever thought about suicide? • Have you ever tried to hurt yourself? • Do you have a plan to harm yourself now? • What is your plan? • Have you told anyone about your plan?

47. Suicide Risk Assessment:Issues to Cover • What do you think others say if you were dead? • Have you made any final arrangements? • Who are your support system (e.g. parents, caregivers, other adults, friends, etc.) • Are there reasons why you wouldn’t?

48. Suicide Risk Assessment: Interviewing Children and Youth • Calmly gather information. • Be direct and unambiguous in asking questions. • Assess lethality of method and identify a course of action. • Use effective listening skills by reflecting feelings, remaining non-judgmental, and not minimizing the problem. • Communicate caring, support, and trust while providing encouragement for coping strategies. • Be hopeful; emphasize the individual’s abilities to solve problems. • Determine if he/she has a thorough understanding of the finality of death (suicide is a permanent solution to a temporary problem).

49. “No-Suicide” or “Safety” Contracts • Widely used and recommended, but there is increasing controversy regarding their use • In reality, they are neither contractual nor ensure genuine safety • They tend to emphasize what students won’t do rather than what they will do • May be viewed by students as coercive, since failure to sign may force hospitalization • May give clinicians a false sense of security • Better approach: Encourage students to commit to treatment rather than merely promising “safety”

50. Suicide Risk Assessment:Questions for Teachers • Have you noticed any major changes in your student’s schoolwork recently? • Have you noticed any behavioral, emotional, or attitudinal changes? • Has the student experienced any trouble in school? What kind of trouble? • Does the student appear depressed and/or hostile and angry? If so, what clues does the student give? • Has the student either verbally, behaviorally, or symbolically (in an essay or story) threatened suicide or expressed statements associated with self-destruction or death?