Title: Saving Lives: Understanding Depression And Preventing Suicide Prevention Training For Physicians and
1Saving LivesUnderstanding Depression And
Preventing Suicide Prevention Training For
Physicians and Medical Personnel
- The Ohio Suicide Prevention Foundation
- Developed by Ellen J. Anderson, Ph.D., LPCC,
2004-2006
2-
- Still the effort seems unhurried. Every 17
minutes in America, someone commits suicide.
Where is the public concern and outrage? - Kay Redfield Jamison
- Author of Night Falls Fast Understanding Suicide
3Training Goals
- Learn about local suicide prevention efforts, how
these efforts connect with your practice and
patients - Understand the pivotal role of medical personnel
in the treatment of depressed patients and in
reducing suicide risk - Increase awareness of suicide risk
characteristics in patients who may not present
as depressed/suicidal - Learn a brief suicide risk assessment model
- Learn to ask the S question
4Why Do We Need To Improve Suicide Prevention
Efforts?
- Suicide is the last taboo
- We can talk about sex, alcoholism, cancer, but
not suicide - People need to understand the impact of
depression and other mental illnesses, and how
they lead to suicide - Suicide is a preventable death
- Integrating medical staff into the efforts of
suicide prevention coalitions to reduce deaths,
increase awareness, and reduce stigma seems
critical to local, state, and national efforts to
change our approach to this age-old problem
5Changing Our Approach Depression Is An Illness
- Suicide has been viewed for countless generations
as - A moral failing, a spiritual weakness
- An inability to cope with life
- The cowards way out
- A character flaw
- This cultural view of suicide is not validated by
our current understanding of brain chemistry and
its interaction with stress, trauma and genetics
on mood and behavior
6- The research evidence is overwhelming- what we
think of as depression is far more than a sad
mood. It includes - Weight gain/loss
- Sleep problems
- Sense of tiredness, exhaustion
- Sad mood
- Loss of interest in pleasurable things, lack of
motivation - Irritability
- Confusion, loss of concentration, poor memory
- Negative thinking
- Withdrawal from friends and family
- Sometimes, suicidal thoughts
- (DSMIVR, 2002)
7- 20 years of brain research teaches that what we
are seeing is the behavioral result of - Internal changes in the physical structure of the
brain - Destruction or shutting down of brain cells in
the hippocampus and amygdala - Decrease in neurotransmitters
- increased agitation in the limbic system
- Depressed people suffer from a physical illness
within the brain what we might consider faulty
wiring - (Braun, 2000 Surgeon Generals
Call To Action, 1999, Stoff Mann, 1997, The
Neurobiology of Suicide)
8Faulty Wiring?
- Literally, damage to certain nerve cells in our
brains - The result of too many stress hormones
cortisol, adrenaline and testosterone - Hormones activated by our Autonomic Nervous
System to protect us in times of danger - Chronic stress causes changes in the functioning
of the ANS, so that a high level of activation
occurs with little stimulus - Causes changes in muscle tension, imbalances in
blood flow patterns leading to illnesses such as
asthma, IBS, back pain and depression - (Goleman, 1997, Braun, 1999)
9Faulty Wiring?
- Without a way to return to rest, hormones
accumulate, doing damage to brain cells - Stress alone is not the problem, but how we
interpret the event, thought or feeling - People with genetic predispositions, placed in a
highly stressful environment will experience
damage to brain cells from stress hormones - This leads to the cluster of thinking and
emotional changes we call depression
(Goleman, 1997 Braun, 1999)
10Where It Hits Us
11One of Many Neurons
- Neurons make up the brain and cause us to think,
feel, and act - Neurons must connect to one another (through
dendrites and axons) - Stress hormones damage dendrites and axons,
causing them to shrink away from other
connectors - As fewer connections are made, more and more
symptoms of depression appear
12- As damage occurs, thinking changes in the
predictable ways identified in our 10 criteria - Thought constriction can lead to the idea that
suicide is the only option - How do antidepressants affect this brain
damage? - May counter the effects of stress hormones
- We know now that antidepressants stimulate genes
within the neurons (turn on growth genes) which
encourage the growth of new dendrites - (Braun, 1999)
13- Renewed dendrites
- increase the number of neuronal connections
- allow our nerve cells to begin connecting again
- The more connections, the more information flow,
the more flexibility and resilience the brain
will have - Why does increasing the amount of serotonin, as
many anti-depressants do, take so long to reduce
the symptoms of depression? - It takes 4-6 weeks to re-grow dendrites axons
- (Braun, 1999)
14Why Dont We Seek Treatment?
- We dont know we are experiencing a brain
disorder we dont recognize the symptoms - When we talk to doctors, we are vague about
symptoms - We believe the things we are thinking and feeling
are our fault, our failure, our weakness, not an
illness - We fear being stigmatized at work, at church, at
school
15No Happy Pills For Me
- The stigma around depression leads to refusal of
treatment - Taking medication is viewed as a failure by the
same people who cheerfully take their blood
pressure or cholesterol meds - Medication is seen as altering personality,
taking something away, rather than as repairing
damage done to the brain by stress hormones
16Therapy? Are You Kidding? I Dont Need All That
Woo-Woo Stuff!
- How can patients seek treatment for something
they believe is a personal failure? - Acknowledging the need for help is not popular in
our culture (Strong Silent type, Cowboy) - People who seek therapy may be viewed as weak
- Therapists are viewed as crazy
- Theyll just blame it on my mother or some other
stupid thing
17How Does Psychotherapy Help?
- Medications may improve brain function, but do
not change how we interpret stress - Psychotherapy, especially cognitive or
interpersonal therapy, helps people change the
(negative) patterns of thinking that lead to
depressed and suicidal thoughts - Research shows that cognitive psychotherapy is as
effective as medication in reducing depression
and suicidal thinking - Changing our beliefs and thought patterns alters
our response to stress we are not as reactive
or as affected by stress at the physical level
(Lester, 2004)
18What Therapy?
- The standard of care is medication and
psychotherapy combined - At this point, only cognitive behavioral and
interpersonal psychotherapies are considered to
be effective with clinical depression
(evidence-based) - Doctors should make referrals to a cognitive or
interpersonal therapists
19- Yet most people do not understand the physical
aspects of mental illness, as you have no doubt
found in talking with your patients - Suicide is strongly linked with certain mental
illnesses, and most people do not understand this
connection - Your county Suicide Prevention Coalition is
attempting to Reduce the stigma attached to
mental illness, increase help-seeking behavior,
and increase awareness of the consequences of
untreated depression
20Suicide Prevention Efforts
- First national effort established at NIMH in 1969
- Surgeon General issued a call to action to
prevent suicide in 1999 - In 2001, a National Strategy for Suicide
Prevention Committee developed future goals and
objectives - An Ohio Suicide Prevention Plan was developed in
May, 2002, and grants for local coalitions were
given out in November of 2002
21Development Of Prevention Efforts
- Over the past 20 years, we have acquired valuable
information on risk and protective factors,
methods for preventing suicidal behavior, and
improved research methods - An increase in suicide prevention programs in
schools - The rapid development of suicidology as a
multidisciplinary sub-specialty - Establishment of centers for the study and
prevention of suicide
22Framework For Prevention
- Public health approach to prevention in contrast
to clinical approaches used in the past - The prevailing model is the Universal, Selective,
and Indicated model (WHO, 2002) - Focuses attention on defined populations, from
everyone, to specific at-risk groups, to specific
high-risk individuals
23Is Suicide Really a Problem?
- 89 people complete suicide every day
- 32,439 people in 2004 in the US
- Over 1,000,000 suicides worldwide (reported)
- This data refers to completed suicides that are
documented by medical examiners it is estimated
that 2-3 times as many actually complete suicide - (Surgeon Generals Report on Suicide, 1999)
24The Unnoticed Death
- For every 2 homicides, 3 people complete suicide
yearly data that has been constant for 100 years - During the Viet Nam War from 1964-1972, we lost
55,000 troops, and 220,000 people to suicide
25Who Is At Risk?
- Most people assume young people
- are more likely to complete suicide,
- It is the 3rd largest killer of youth ages 15-24
- Adult males from 35-55 actually complete suicide
at a far greater rate than youth - The elderly are at significant risk among those
over 75, 1 out of 4 attempts end in death because
the elderly tend to use more lethal means - (Surgeon Generals call to Action, 1999)
26- Comparative Rates Of U.S. Suicides-2004
- Rates per 100,000 population
- National average - 11.1 per
100,000 - White males - 18
- Hispanic males - 10.3
- African-American males - 9.1
- Asians - 5.2
- Caucasian females - 4.8
- African American females - 1.5
- Males over 85 - 67.6
- Annual Attempts 811,000 (estimated)
- 150-1 completion for the young - 4-1 for the
elderly - (AAS website),(Significant increases have
occurred among African Americans in the past 10
years - Toussaint, 2002)
27Suicide Rate By Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hovert, 1999)
28Suicide Rates Among The Elderly
- The elderly have the highest suicide rate of any
group. - Depression in late life affects six million
people, one out of six patients in a general
medical practice - However, only one of those six patients is
diagnosed and treated appropriately - The majority of these people have seen their
primary care physician within the last month of
life - There is evidence that the majority of elderly
suicide victims die in the midst of their first
episode of major depression - Depression is not a normal consequence of aging
and can alter the course of other medical
conditions - (Empfield, 2003)
29PCPs And Diagnosis Of Depression
- Seniors have often visited a health-care provider
before completing suicide - 20 of elderly (over 65 years) who complete
suicide visited a physician within 24 hours - 41 within a week
- 75 within one month
- Patients may not use the words depression or
sadness - Because of the stigma that is still attached to
this diagnosis, somatic symptoms may become the
focus of complaint - There may be much denial and minimizing of
affective symptoms - (Empfield, 2003)
30Poor Quality Of Mental Health Care For Elders
- Increased risk for inappropriate medication
treatment (Bartels, et al., 1997, 2002) - gt 1 in 5 older persons given an inappropriate
prescription (Zhan, 2001) - The elderly are less likely to be treated with
psychotherapy (Bartels, et al., 1997) - Lower quality of general health care is
associated with increased mortality - (Druss, 2001)
31Depression Associated With Worse Health Outcomes
- Depression is common among older patients with
certain medical disorders - Associated with worse health outcomes
- Greater use and costs of medications
- Greater use of health services
- Medical illness greatly increases the risk for
depression particularly in - Ischemic heart disease (e.g. MI, CABG)
- Stroke Cancer Chronic lung disease
Alzheimers disease Parkinsons
disease - Rheumatoid Arthritis
(Empfield, 2003)
32- In Cancer, depression leads to
- Increased Hospitalization
- Poorer physical function
- Poorer quality of life
- Poorer pain control
- Increased mortality rates for
- Hip fractures
- Long Term Care Residents
- Myocardial Infarction
- In heart attack patients, depression is a
significant predictor of death at 6 months - ( Frasure-Smith 1993, 1995 Mossey 1990 Penninx
et al. 2001 Katz 1989, - Rovner 1991, Parmelee 1992Ashby1991 Shah 1993,
Samuels 1997)
33Rates Of Depression Among Elders With Illness
- Cognitively intact nursing home patients shown to
have symptoms consistent with depressive
disorders 60 - Chronically ill outpatients in a primary care
practice - 25 - Hospitalized patients - 20
- In nursing homes, regardless of physical health,
major depression increases the likelihood of
mortality by 59 in one year - (Empfield, 2003)
34Benefits Of Treatment For Depression In The
Elderly
- Depression is one of the few medical conditions
in which treatment can make a rapid and dramatic
difference in an elderly persons level of
function and quality of life - Treatment may help patients accept medical
treatment that they otherwise might refuse
because of feelings of hopelessness or futility - Treatment also helps enhance or recover coping
skills needed to deal with the inevitable losses
associated with chronic medical illness - (Empfield, 2003)
35What Factors Put Someone At Risk?
- Many things increase ones risk for suicide-
biological, psychological, social factors all
apply - The single greatest risk factor for suicide
completion - having a depressive illness. - 90 of reported US suicides are experiencing
depression - The 2nd biggest factor - having an alcohol or
drug problem. However, many people with alcohol
and drug problems are significantly depressed,
and are self-medicating - (Lester, 1998)
36- Other risk factors include
- Previous suicide attempts
- A family history of suicide - increases our risk
by 6 times - A significant loss by death, divorce, separation,
moving, or breaking up with a loved one. Shock or
pain, even long term lower level stress, can
affect the structure of the brain, especially the
limbic system - 30 years of research confirms the relationship
between hopelessness and suicide, across
diagnoses - Impulsivity, particularly among youth, is
increasingly linked to suicidal behavior - Access to firearms 70 of completed suicides
used firearms - (Surgeon Generals call to Action, 1999)
37- Biological factors
- Biological changes are associated with
- both completed and attempted suicide
- Changes include abnormal functioning of
- the Hypothalamic-Pituitary-Adrenal axis,
- a major component of the way we adapt to
stress - Psychological factors
- Changes in thinking (constricted thought) leading
to the belief that suicide is the only answer
negative automatic thoughts that lead to sadness,
hopelessness, loss of pleasure, inability to see
a future, low self-esteem - Suicidality, although clearly overlapping the
symptoms of associated MH disorders, does not
appear to respond to treatment in exactly the
same way - In some cases, depressive symptoms can be reduced
by medication without a reduction in suicidal
thinking
38Protective Factors
- Stigma reduction programs, especially
- among youth, increase help-seeking behavior
- Resiliency and coping skills to reduce risk can
be taught (Dialectical Behavioral Training) - Spirituality improves defenses against suicidal
thinking - Social support those with close relationships
cope better with various stresses, including
bereavement, job loss, and illness - Social disapproval of suicide reduces rates
- (Berman Jobes, 1996 Beck, 1985 Rush et al,
1992, Surgeon Generals Call To Action, 1999)
39Treatment
- Treatment of suicidality has improved
dramatically in the last 20 years - Evidence is clear that lithium treatment of
bi-polar disorder significantly reduces suicide
rates - A correlation has been noted between an increase
in prescription rates for SSRIs and a decline in
suicide rates - (Baldessarini, et.al, 1999, NIMH, 2002)
40- However, medication alone is insufficient to
reduce suicidal ideation - Psychotherapy can reduce suicidality by helping
people learn to interpret the stresses in their
lives more effectively, reducing the level of
stress hormones in the body - Psychotherapy provides a necessary therapeutic
relationship that reduces risk through increased
hope and support - Cognitive-behavioral approaches that include
problem-solving training reduce suicidal ideation
and attempts more effectively than other
approaches - Medication combined with psychotherapy is the
current standard of care for clinical depression - (Beck, 1996, Quinnett, 2000, Macintosh, 1996)
41 Barriers To Treatment
- Fragmentation of services and cost of care are
the most frequently cited barriers to treatment - About 67 of people with significant mental
disorders do not receive treatment - Psychological autopsy studies reveal that less
than 14 of completers were receiving adequate
treatment, and fewer than 17 were being treated
with psychiatric medications - However, 50-70 had contact with health services
in the weeks before their death - Surgeon Generals Call To Action, 1999 Empfield,
2003
42- Currently, no psychological test, clinical
technique or biological marker is sensitive
enough to accurately and consistently predict
suicide - Primary care has become a critical setting for
detection of the two most common factors
depression and alcoholism - Depression is the second most common chronic
disorder seen by PCPs - According to the AMA, a diagnostic interview for
depression is comparable in sensitivity to
laboratory tests commonly used in diagnosis, but
currently, less than 50 of adults with
diagnosable depression are accurately diagnosed
by PCPs - Physicians are often reticent to talk with
patients about suicide intent or ideation, and
patients seldom spontaneously report it - (Surgeon Generals Call to Action, 1999
Quinnett, 2000 )
43What Is Your County Doing?
- Suicide prevention coalitions have been developed
over the past 3 years across the state with
grants from Ohio Dept. of Mental Health - In many counties, the Mental Health Board is
spearheading this process, with help - from all areas of the community,
- including health care providers, mental
- health professionals, suicide survivors,
- clergy, school personnel, human resource
- personnel, police/sheriff dept, health
- department, and many others
44How Do We Know Suicide Prevention Coalitions Work?
- In 1996 the U.S. Air Force decided to mount an
assault on its high suicide rate - They targeted help-seeking behavior, stigma, and
awareness - After 5 years of a major collaborative effort
within the service, suicide rates dropped 78 - Comparable rates in the other 4 armed services
remained the same
45How Can You Help?
- Medical personnel are the front line of defense
against this insidious killer - assess your
patients for suicidal ideation when depressive
symptoms arise - Specifically ask your patients if they are
experiencing suicidal ideation They may not
volunteer the information - Train staff in depression awareness, and in
asking the S question - We must gain confidence in asking people if they
are thinking about dying - (Surgeon Generals Call To Action, 1999)
46Comfort And Competence Lead To Hopefulness
- A study by Dr. Paul Quinett, a long-time
researcher and clinician in suicide, indicates
that patients who felt their clinician was
comfortable asking questions about their suicidal
thoughts and feelings reported much higher levels
of hope about the future - The best outcome of asking the S question is
immediate relief for the patient - (Quinnett, 2001)
47- Hopelessness is the most immediate risk factor
for suicide, so instilling hope is essential - If your patient is on anti-depressant or
anti-anxiety medication, refer them to a
psychologist or counselor who can work with them
on the maintaining causes of depression - Consider using a risk assessment format to ensure
you ask the right questions
48What To Ask?
- Except for psychiatrists, routine
- questioning about suicidal ideation
- is not the current standard of care
- If you have a patient with depressive symptoms or
other mental health disorders (especially
anxiety) - Learn to Ask the S question
- Not you arent thinking of suicide are you?
- But - Some people who experience the amount of
pain youre in think about killing themselves.
Have you ever thought about it? - (Lester, 1998)
49Use Of A Structured Interview
- Many patients will not overtly acknowledge common
symptoms of depression, focusing more on vague
pain - You may wish to develop or purchase a guided
clinical interview for use with suicidal clients - A structured form assesses current risk, sets up
a management plan, and ensures that all the right
questions are asked - Most take just a few minutes to complete, and
people are surprisingly honest
50Screening Recommendations
- The U.S. Preventive Services Task Force reviewed
new evidence that patients fare best when medical
professionals recognize the symptoms of
depression and make sure they receive appropriate
treatment - The USPSTF issued new depression screening
recommendations in May, 2002, asking PCPs to
routinely screen adult patients for depression - Medical professionals should have systems in
place to assure accurate diagnosis, effective
treatment, and follow-up if patients are to
benefit from screening - The journal of AAFP offers the article Screening
for Depression across the Lifespan A review of
Measures of Use in Primary Care settings to help
medical professionals make appropriate choices of
screening tool
(Sharp and Lipsky, 2002)
51Possible Depression Scales
- Beck Depression Inventory
- Childrens Depression Inventory
- CES-DC (Center for Epidemiological Studies
Depression Scale) - Edinburgh Post-Natal Depression Scale
- Geriatric Depression Scale
- QPRT - Question, Persuade, Refer or Treat -QPR
Institute - www.qprinstitute.com - Zung Depression Inventory
52Learning QPR Or, How To Ask The S Question
- It is essential, if we are to reduce the number
of suicide deaths in our country, that community
members/gatekeepers learn QPR - First identified by Dr. Paul Quinnett as an
analogue to CPR, QPR consists of - Question asking the S question
- Persuade Getting the person to talk, and to seek
help - Refer Getting the person to professional help
- Medical staff can learn this method in a very
short time - (Quinnett, 2000)
53Intervention
- Once a patient has told someone they are thinking
of suicide, you need a thorough suicide
assessment - In your area, what mental health facilities with
emergency services are available? - Sending a suicidal patient alone to the emergency
room could be a mistake - Most mental health agencies have crisis workers
who can come to your office to interview your
patient suicidal people should never be left
alone!
54Psychiatric Hospitalization
- The actual prediction of suicide is, essentially,
impossible - The base rates are too low, and risk level
changes from day to day - Statistically, you could almost always bet that
no given individual will complete suicide - Other risks are managed by understanding what
risk factors exist, and limiting as many of them
as possible, like wearing sunscreen - It is imperative that medical professionals know
risk factors for suicide - (MacIntosh, 1993)
55The Top Ten Risk Factors When Thinking Of
Hospitalization
- Previous Suicide attempt(s)
- Mental disorders (especially depression, bipolar)
- Co-occurring mental and AL/SA disorders
- Family history of suicide
- Hopelessness (should this be first?)
- Impulsive/aggressive tendencies
- Barriers to accessing mental health treatment
- Relational, social, work or financial loss
- physical illness (esp. with chronic pain)
- Easy access to lethal methods, especially guns
- (Surgeon Generals Call to Action to Prevent
Suicide, 1999)
56Voluntary Hospitalization
- Best choice less hard on the patients sense of
self-worth a way to buy time (to think it over,
get sleep, etc.) - Safety is the main message a good nights
sleep, a start on medications, talk with doctors,
put things on hold for awhile - Allows them to save face I didnt want to, but
they insisted
57Sharing Knowledge Of Hospitals
- Ease the transition by addressing their fears
- Facts hospital stays tend to be short
- Staff are well-trained and know about suicidal
suffering - ECT cannot be given without patient permission
- Patients rights are guaranteed
- Modern hospitals are not snake pits
58Know Your Local Resources And Agencies
- Where to hospitalize
- Who do you call
- Have your risk assessment information ready
- Help to overcome barriers to hospitalization such
as child care, pets, transportation, calls to
work, etc.
59Local Professional Resources
- Your Local Mental Health Agencies
- Your Local Mental Health Board
- School Guidance Counselors
- Your Hospital Emergency Room
- Local Crisis Hotlines
- National Crisis Hotlines
- School nurses
- 911
- Local Police/Sheriff
- Local Clergy
60- Suicide is a
- permanent solution
- to a
- temporary problem
- Edwin Schneidman, MD.
- Founder of Suicidology
61- The Ohio Suicide Prevention Foundation
- The Ohio State University, Center on Education
and Training for Employment - 1900 Kenny Road, Room 2072
- Columbus, OH 43210
- 614-292-8585
62A Brief Bibliography
- Anderson, E. The Personal and Professional
Impact of Client Suicide on Mental Health
Professionals. Unpublished Doctoral dissertation,
U. of Toledo, 1999 - Berman, A. L. Jobes, D. A. (1996) Adolescent
Suicide Assessment and Intervention. - Blumenthal, S.J. Kupfer, D.J. (Eds) (1990).
Suicide Over the Life Cycle Risk Factors,
Assessment, and Treatment of Suicidal Patients.
American Psychiatric Press. - Empfield, Maureen MD( 2002) PSYCHIATRY FOR THE
PRIMARY CARE PHYSICIAN Section 2. URL - Goldberg, I. SSRIs and Suicide Results of a
MELINE Search. At ttp//www.psycom.net/depression
.central.ssri-suicide.html - Jacobs, D., Ed. (1999). The Harvard Medical
School Guide to Suicide Assessment and
Interventions. Jossey-Bass.
63- Jamison, K.R., (1999). Night Falls Fast
Understanding Suicide. Alfred Knopf - Lester, D. (1998). Making Sense of Suicide An
In-Depth Look at Why People Kill Themselves.
American Psychiatric Press - Oregon Health Department, Prevention. Notes on
Depression and Suicide ttp//www.dhs.state.or.us/
publickhealth/ipe/depression/notes.cfm - Presidents New Freedom Council on Mental Health,
2003 - Quinnett, P.G. (2000). Counseling Suicidal
People. QPR Institute, Spokane, WA - Shea, C., 2000. A Practical Interviewing Strategy
for the Elicitation of Suicidal Ideation. Journal
of Clinical Psychiatry (supplement 20) 59 58-72,
1998
64- Smith, Range Ulner. Belief in Afterlife as a
buffer in suicide and other bereavement. Omega
Journal of Death and Dying, 1991-92, (24)3
217-225. - Stoff, D.M. Mann, J.J. (Eds.), (1997). The
Neurobiology of Suicide. American Academy of
Science - Schneidman, E.S. (1996). The Suicidal Mind.
Oxford University Press. - Styron, W. (1992). Darkness Visible. Vintage
Books - Surgeon Generals Call to Action (1999).
Department of Health and Human Services, U.S.
Public Health Service. - Tang, T.Z. De Rubeis, R.J. ((1999). Sudden
Gains and critical sessions in cognitive-behaviora
l therapy for depression. Journal of Consulting
and Clinical Psychology 67 894-904.