Richard McKeon, Ph.D., MPH Acting Branch Chief, Suicide Prevention SAMHSA

1. Suicide and Substance Abuse: Challenge and Opportunity Richard McKeon, Ph.D., MPH Acting Branch Chief, Suicide Prevention SAMHSA

2. Behavioral Health isEssential to Health Prevention Works Treatment is Effective People Recover

3. SAMHSA 3 • Substance Abuse and Mental Health Services Administration • Center for Mental Health Services • Center for Substance Abuse Treatment • Center for Substance Abuse Prevention • Center for Behavioral Health Statistics and Quality

4. SAMHSA’s Strategic Priorities 4 • 8 strategic priorities • Prevention of Substance Abuse and Mental Illness--includes suicide prevention • Military Families--(Active Duty, Guard, Reserve, Veteran) • Health Care Reform • Trauma and Justice

5. SAMHSA Strategic Initiatives • Housing and Homelessness • Health Information Technology for Behavioral Health Providers • Data, Quality, and Outcomes • Public Awareness and Support

6. Components of Presentation • Policy Issues • Selected Research Findings • Challenges • Resources

7. Leading causes of death for selected age groups – United States, 2005 Age groups in years Source: CDC vital statistics

8. Burden of injury Deaths Hospitalizations Emergency Dept visits Events reported on surveys Unreported events

9. NSDUH • 8.4 million adults (3.7% of the population) thought seriously about suicide in the past year • 2.3 million made a suicide plan • 1.1 million made a suicide attempt • 61.2% reported receiving medical attention for their attempt • 43.9% stayed overnight or longer in a hospital

10. “Suicide is a serious public health challenge that has not received the attention and degree of national priority it deserves.” - The President’s New Freedom Commission on Mental Health, 2003

11. Suicide and Public Policy 1997-U.S. Congress -S.Res 84 and H.Res 212 1999-Surgeon General’s Call to Action to Prevent Suicide 2001-National Strategy for Suicide Prevention 2002-Institute of Medicine Report-Reducing Suicide: A National Imperative 2004-Garrett Lee Smith Memorial Act 2007-Joshua Omvig Veterans Suicide Prevention Act 2009-DOD Suicide Prevention Task Force required by Congress 2010-Launch of National Action Alliance for Suicide Prevention

12. National Action Alliance for Suicide Prevention NSSP represents a comprehensive public health approach to suicide prevention Everything we know about suicide prevention suggests that reducing suicide rates requires a sustained, comprehensive approach NSSP has 11 goals and 68 objectives No single agency can oversee its implementation

13. National Action Alliance for Suicide Prevention Implementation requires a broad public- private partnership Action Alliance launched September 10, 2010, at a press conference by HHS Secretary Sebelius, and Defense Secretary Gates Mission is also to update the National Strategy

14. National Action Alliance for Suicide Prevention Private sector co-chair is former U.S. Senator Gordon Smith Public Sector Co-chair is Secretary of the Army John McHugh

15. National Action Alliance for Suicide Prevention Members of the Alliance include: Robert Jesse, Principal Deputy Under Secretary for Health for VHA Gordon Mansfield-former VA Deputy Sec and current Wounded Warriors Board Member Derek Blumke-Student Veterans of America

16. National Action Alliance for Suicide Prevention Education, Justice, NIMH, CDC, SAMHSA, HRSA, AOA, Indian Health Service, BIA State mental health and state substance abuse commissioners Private representatives from MCOs, health care and accrediting organizations, philanthropies, faith communities and others

17. NSSP GOAL 7:Develop and Promote Effective Clinicaland Professional Practices

18. Objective 7.1: Increase the proportion of patients treated for self-destructive behavior in hospital emergency departments that pursue the proposed mental health follow-up plan. Many of these patients have abused substances NSSP

19. NSSP Objective 7.2: Develop guidelines for assessment of suicidal risk among persons receiving care in primary health care settings, emergency departments, and specialty mental health and substance abuse treatment centers

20. Objective 7.4: Develop guidelines for aftercare treatment programs for individuals exhibiting suicidal behavior (including those discharged from inpatient facilities). NSSP

21. NSSP Objective 7.8: Develop guidelines for providing education to family members and significant others of persons receiving care for the treatment of mental health and substance abuse disorders with risk of suicide. Implement the guidelines in facilities (including general and mental hospitals, mental health clinics, and substance abuse treatment centers).

22. Suicide and Substance Abuse Substance abuse is second only to depression in its association with suicide Comorbidity increases the risk even further Suicide mortality can be impacted by changes in alcohol control policy Drinking age increase associated with decreased mortality Example of Russia in the 1980s Binge drinking vs. per capita consumption

23. Juvenile Justice Data-Utah 63% of youth suicide completers had contact with the Juvenile Court System (n=95 of 151). 54% of the 95 subjects involved with Juvenile Court had a referral(s) for substance possession, use, or abuse (n=51 of 95). Source: Gray, D, et al (2002). Utah Youth Suicide Study, Phase I: Government Agency Contact Before Death. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 427-434.

24. Health/Behavior information for suicide decedents aged 20-64 years by sex Source: NVDRS, 2008 ^ Categories are not mutually exclusive *Significant difference at p<0.05

25. Toxicology Findings Alcohol: Tested in 72% of decedents 32% were positive for alcohol 62% had a BAC >.08mg/DL Other substances/medications Antidepressants (tested in 40%, present in 25%) Opiates (tested in 48%, present in 19%) Cocaine (tested in 48%, present in 9%) Marijuana (tested in 36% , present in 8%) Amphetamines (tested in 42%, present in 5%) Other drug (tested in 43%, present in 49%) Source: Karch D.L., et al. Surveillance for Violent Deaths- National Violent Death Reporting System, 16 States, 2005 MMWR April 2008

26. Link Between Substance Abuse and Suicide Compared with the general population, individuals treated for alcohol abuse and dependence are at about 10x greater risk for suicide (Wilcox et al.,2004) Those who inject drugs are at about 14x greater risk for suicide (Wilcox et al., 2004) Acute, alcohol intoxication present in about 30-40% of suicides and suicide attempts

27. Links between Substance Abuse and Suicide Alcohol’s acute effects include disinhibition, intense focus on the current situation with little appreciation for consequences, and promoting depressed mood, all of which may increase risk for suicidal behavior (Hufford, 2001) Intense, short lived depression is prevalent among those who seek treatment for cocaine and methamphetamines as well as alcohol. Indian Health Service has Methamphetamine/Suicide Prevention grants

28. Challenges in Working with Suicidal Substance Abusers Challenges in the Emergency Department and post discharge Challenges on the Telephone Challenges with Families

29. Challenges in the Emergency Department Suicidal substance abusers may receive fragmented care in the ED Medical staff frequently see suicide as a mental health issue and want MH to take charge MH typically wants the patient medically cleared i.e., BAL has dropped before an evaluation Inpatient Psychiatry may see the patient as a substance abuser who needs detox/rehab Detox/rehab sees as needing mental health because suicidal

30. Challenges in the Emergency Department As a result, the intoxicated patient may be held for hours or overnight, and when evaluated by MH may no longer be suicidal and may be released. Several significant problems with this. The absence of suicidal ideation or suicidal intent when sober is a poor predictor of suicide risk when intoxicated. Family members who could be valuable informants are unlikely to be present when the evaluation finally takes place. Follow up post discharge is likely to be poor.

31. Importance of ED as a setting for suicide prevention Data from the South Carolina National Violent Death Reporting System, which links to a comprehensive health services data base, found that almost 10% of the suicides in the state had been discharged from an ED within 60 days. Some likely suicide attempts but substance abuse may also be a significant contributor.

32. Emergency Department • Fleischmann et. al. (2008) • Randomized controlled trial; 1867 Suicide attempt survivors from five countries (all outside US) • Brief (1 hour) intervention as close to attempt as possible • 9 F/U contacts (phone calls or visits) over 18 months

33. Follow-up Can Reduce Suicide WHO Study, 2008: Over 800 attempters from 8 hospitals around the world Received brief ED psycho-ed session before discharge, + 9 post-discharge contacts (telephone and face-2-face) for 18 months 9x fewer suicides than control group

34. Suicide and Substance Abuse in the Emergency Department But the challenge is also an opportunity NIMH (ED SAFE) and VA (Safe Vets) both researching this important area Important area for collaboration as many of these veterans are likely being brought to community EDs rather than VA facilities

35. Emergency Department Look for signs of acute suicide risk

36. Emergency Department • Brief Interventions • Motivational interviewing • Safety planning; support planning • Means restriction • Follow up contacts

37. Emergency Department

38. Suicide after Inpatient discharge British National Clinical Survey (Appleby), which reviewed all deaths by suicide over a five year period, found the period after inpatient discharge to be one of high risk, with the greatest number of suicides occurring within one week of discharge. Dramatic changes in nature of inpatient care. Emphasis on present suicidal ideation to determine suicide risk.

39. U.S. Research In a study of almost 900,000 veterans who received treatment for depression between 1999-2004, suicide rates were highest in the 12 weeks following inpatient discharge (Valenstein et al., 2008) Researchers conclusions; “To have the greatest impact on suicide, health systems should prioritize prevention efforts following psychiatric hospitalizations.” We should think of discharge from substance abuse treatment similarly

40. COSTLY GAPS: CONTINUITY OF CARE U.S. E.D. visits, 1992-2001: More attempts (49% increase), fewer admissions for attempts (35% less) (Larkin et al., 2008) Fewer outpatient resources, longer waits: 76% of ED directors report lack of community referrals (Baraff et al., 2006) About 50% of suicide attempters fail to attend treatment post-discharge (Tondo et al., 2006) Over 1/3 re-attempt or die by suicide within 18 months post discharge (Beautrais, 2003) This is an intense challenge but also a real opportunity for us to do better

41. Motto 1976: 389 patients refusing outpatient assigned to “no “contact” (up to 24 letters over 5 years) Contact group sig. fewer suicides than no-contact group (particularly first 2 yrs) Carter et al, 2005: Postcards to 378 attempters, varying monthly intervals, 12 mos. after discharge Approx 50% reduction in attempts

42. ED Telephone Follow-up with Attempt Survivors: StudyVaiva et al, BMJ, 2006 605 attempt survivors, discharged from 13 EDs in France Telephone follow-up at one month vs. three months vs. TAU Follow-up method: empathy, reassurance, explanation, suggestion, crisis intervention as needed

43. ED Telephone Follow-up with Attempt Survivors: StudyVaiva et al, BMJ, 2006 Significant reductions in re-attempts at 1 month No significant effects at 3 months 48 re-attempted before 1st month (suggest 15-21 days) Patients more open to phone contact than attending outpatient treatment

44. Telephone “Check-in” Service Reduces Suicides Elderly “tele-check” phone service in Italy significantly decreased suicide among elderly women - 6 times lower than general population. (De Leo et al., 1995, 2002) Over 12,000 callers in 3 year period Provided 2x weekly support and needs assessment; 24 hour “alarm service”

45. Follow up study of serious suicide attempts

46. Mortality Following Serious Suicide Attempt Most deaths in the 5-year follow-up period (62.5% of suicides; 59% of all deaths) occurred within 18 months of the index attempt. However, deaths (from suicide and all causes) continued throughout the entire 5-year period. Clearly, there was a significant change of method in suicide attempt of those who died in the 5-year follow-up period: 75% changed from the method used at the index attempt (usually O/D) to a more lethal method (CO, hanging) that resulted in their death.

47. Further suicide attempts, including those which resulted in death, in the 5-year follow-up period (%) Attempt Suicide Attempt or suicide 0.7 6 mo. 18.6 21.9 18 mo. 27.9 4.0 33.5 30 mo. 32.2 4.6 37.9 60 mo. 37.0 6.7 44.5

48. 10-year record review of all admissions for suicide attempt, regardless of severity

49. What is needed Collectively, these findings and observations suggest: The need to acknowledge long-term risks of those who make serious suicide attempts, and to develop appropriate long-term treatment and management plans. The need for high quality follow-up, treatment, management and surveillance of all who make suicide attempts rather than focussing on those clinically deemed to be at risk. The need for substantial improvements in the psychiatric and psychosocial care and support of individuals who have made serious suicide attempts.

50. What is needed Relatively simple interventions appear to be useful: Sending letters to people who had been discharged from inpatient psychiatric units or medical units following admission for self-poisoning showed reduced suicide attempts and suicides (Carter et al., 2005; Motto & Bostrom, 2001) Employing a counsellor to coordinate assessment and long-term treatment led to fewer suicide attempts (Aoun 1999) At minimum, there is a high risk period that needs to be the focus of attention 30 days, 60 days, 18 months