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Saving Lives: Understanding Depression And Preventing Suicide Prevention Training For Physicians and


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Title: Saving Lives: Understanding Depression And Preventing Suicide Prevention Training For Physicians and

Saving LivesUnderstanding Depression And
Preventing Suicide Prevention Training For
Physicians and Medical Personnel
  • Sponsored by the Ohio Department of Mental Health
    in Partnership with the ADAMH Board of Franklin
    County and the Ohio Suicide Prevention Team
  • Developed by Ellen J. Anderson, Ph.D., LPCC,

  • 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

Training Goals
  • Learn about local suicide prevention efforts, how
    these efforts connect with your practice and
  • Understand the pivotal role of physicians 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

Why Do We Need To Improve Suicide Prevention
  • 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

Changing Our Approach Depression Is An Illness
  • Suicide has been viewed for countless generations
  • 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

  • The research evidence is overwhelming- what we
    think of as depression is far more than a sad
    mood. It includes
  • Sad mood
  • Loss of interest in pleasurable things, lack of
  • Weight gain/loss
  • Sleep problems
  • Sense of tiredness, exhaustion
  • Irritability
  • Confusion, loss of concentration, poor memory
  • Negative thinking
  • Withdrawal from friends and family
  • Sometimes, suicidal thoughts
  • (DSMIVR, 2002)

  • 20 years of brain research teaches that what we
    are seeing is the behavioral result of
  • Internal changes in the physical structure of the
  • 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
  • (Braun, 2000 Surgeon Generals
    Call To Action, 1999, Stoff Mann, 1997, The
    Neurobiology of Suicide)

Faulty Wiring?
  • Literally, damage to certain nerve cells in our
    brains - the result of too many stress hormones
    cortisol, adrenaline and testosterone the
    hormones activated by our Autonomic Nervous
    System to protect us in times of danger
  • A situation of chronic stress causes a
    dysregulation or imbalance in the functioning of
    the ANS, so that a high level of activation
    occurs with very little stimulus
  • We then see patterns of dysregulation in muscle
    tension, imbalances in blood flow patterns
    leading to certain illnesses such as asthma, IBS
    and depression
  • (Braun, 1999)

Faulty Wiring?
  • Every time something upsets us it causes an
    activation in the ANS without a way to detach
    and go back to a baseline of rest, stresses
    accumulate and keep us in a state of high arousal
  • Stress alone is not the problem, but our
    interpretation of the event
  • 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)

Where It Hits Us
One of Many (Billions of) Neurons
  • Neurons are the basic units of information
  • Synapses formed by connections are where the
    storage and transfer of information takes place
  • Stress hormones damage dendrites and axons,
    causing them to shrink away from other
  • As fewer and fewer connections are made, more and
    more symptoms of depression appear

  • 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
  • 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)

  • 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)

How Does Psychotherapy Help?
  • Medications may relieve immediate suffering and
    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)

What 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
  • Doctors should make referrals to a cognitive or
    interpersonal therapists

  • Yet most people do not understand the physical
    aspects of mental illness, as you have no doubt
    found in talking with your patients
  • Because suicide is strongly linked with certain
    mental illnesses, and because 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
    consequences of untreated depression

Suicide 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
  • An Ohio Suicide Prevention Plan was developed in
    May, 2002, and grants for local coalitions were
    given out in November of 2002

Development 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
  • The rapid development of suicidology as a
    multidisciplinary sub-specialty
  • Establishment of centers for the study and
    prevention of suicide

Framework 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

Is Suicide Really a Problem?
  • 81 people complete suicide every day
  • 31,655 people in 2002 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)

The 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

Who 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)

  • Comparative Rates Of U.S. Suicides-2002
  • Rates per 100,000 population
  • National average - 11 per 100,000
  • White males - 19.9
  • African-American males - 9.1
  • Asians - 5.2
  • Caucasian females - 4.8
  • African American females - 1.5
  • Males over 85 - 67.6
  • Annual Attempts 790,000 (estimated)
  • 150-1 completion for the young - 4-1 for the
  • (AAS website),(Significant increases have
    occurred among African Americans in the past 10
    years - Toussaint, 2002)

Suicide Rate By Age Per 100,000
Older people 12.7 of 1999 population, but 18.8
of suicides. (Hovert, 1999)
Suicide Rates Among The Elderly
  • The elderly have the highest suicide rate of any
  • 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
  • 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
  • (Empfield, 2003)

PCPs And Diagnosis Of Depression
  • The elderly 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
  • 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)

Poor 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)

Depression 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
  • Rheumatoid Arthritis
    (Empfield, 2003)

  • 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)

Rates 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)

Benefits Of Treatment For Depression In The
  • 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)

What Factors Put Someone At Risk?
  • Many things increase ones risk for suicide-
    biological, psychological, social factors all
  • The single greatest risk factor for suicide
    completion - having a depressive illness.
  • 90 of reported US suicides are experiencing
  • 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)

  • 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
  • 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)

  • 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
  • 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

Protective 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
  • 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)

  • Treatment of suicidality has improved
    dramatically in the last 20 years
  • Evidence is clear that lithium treatment of
    bi-polar disorder significantly reduces suicide
  • A correlation has been noted between an increase
    in prescription rates for SSRIs and a decline in
    suicide rates
  • (Baldessarini,, 1999, NIMH, 2002)

  • 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
  • Medication combined with psychotherapy is the
    current standard of care for clinical depression
  • (Beck, 1996, Quinnett, 2000, Macintosh, 1996)

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,

  • Currently, no psychological test, clinical
    technique or biological marker is sensitive
    enough to accurately and consistently predict
  • 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 )

What Is Your County Doing?
  • Suicide prevention coalitions have been developed
    over the past two 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

How 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
  • 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

How Can You Help?
  • Physicians are the front line of defense against
    this insidious killer - assess your patients
    for suicidal ideation when depressive symptoms
  • Specifically ask your patients if they are
    experiencing suicidal ideation They may not
    volunteer the information
  • Train your 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)

Comfort 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)

  • Hopelessness is the most immediate risk factor
    for suicide, so instilling hope is essential
  • If you place a patient 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 in your

What 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
  • 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)

Symptoms And Observables
  • 1. Depressed or irritable moodlook for
  • Directly and indirectly says "I hate my life"
  • Easily irritated
  • Rebellious behavior (Youth)
  • Seldom looks happy
  • Frequent crying spells
  • Wears somber clothes
  • Listens to music or has themes in writing with
    depressive or violent undertones (Youth)
  • Hangs around friends who appear depressed or
    irritable (Youth)

  • 2. Marked decrease in interest or pleasure in
    activitieslook for
  • Stops activities that used to be pleasurable
    (quits golf, choir)
  • Withdraws or spends much time alone
  • Declining hygiene
  • Avoids friends and family
  • 3. Psychomotor agitation or slowing look for
  • Agitated, always moving around
  • Sits in front of the TV, moves and speaks slowly,
    with little animation
  • 4. Significant change in appetite or weightlook
  • Becomes a picky eater
  • Snacks frequently and eats when stressed
  • Quite thin or overweight
  • 5. Significant changes in sleeping habits look
  • Takes more than an hour to fall asleep
  • Multiple awakenings
  • Wakes in early morning hours and cant return to
  • Sleeps more than normal
  • (Oregon SHDP)

  • 6. Fatigue or loss of energylook for
  • Too tired to do housework, play or work
  • Comes home from work exhausted and naps
  • Too tired to cope with conflict
  • 7. Feelings of worthlessness or inappropriate
    guiltlook for
  • Describes self as "bad" or "stupid"
  • Has no hope or goals for the future
  • Always trying to please others
  • Blames self for causing divorce or a death, when
    not to blame
  • 8. Decreased concentration or indecisiveness
  • look for
  • Often responds "I dont know"
  • Takes much longer to get work done
  • Drop in grades (Youth)
  • Headaches, stomachaches
  • Many somatic complaints
  • Poor eye contact
  • (Oregon SHDP)

Use Of A Structured Interview
  • Many patients will not overtly acknowledge common
    symptoms of depression, focusing more on vague
  • 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

Screening Recommendations
  • The U.S. Preventive Services Task Force reviewed
    new evidence that patients fare best when
    physicians 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
  • Physicians should have systems in place to assure
    accurate diagnosis, effective treatment, and
    follow-up if patients are to benefit from
  • 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
    physicians make appropriate choices of screening
    (Sharp and Lipsky, 2002)

Possible 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 -
  • Zung Depression Inventory

Learning 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
  • Refer Getting the person to professional help
  • Your staff can learn this method in a very short
  • (Quinnett, 2000)

  • Once a patient has told someone they are thinking
    of suicide, you need someone to do a thorough
    suicide assessment
  • In your area, what mental health facilities are
    available, what crisis hotlines can you access?
  • 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

Psychiatric Hospitalization
  • The actual prediction of suicide is, essentially,
  • 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 physicians know risk
    factors for suicide
  • (MacIntosh, 1993)

The Top Ten Risk Factors When Thinking Of
  • 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)

Voluntary 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

Sharing 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
  • ECT cannot be given without patient permission
  • Patients rights are guaranteed
  • Modern hospitals are not snake pits

Know 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.

Local Professional Resources
  • Your Hospital Emergency Room
  • Your Local Mental Health Agencies
  • Your Local Mental Health Board
  • School Guidance Counselors
  • Local Crisis Hotlines
  • National Crisis Hotlines
  • School nurses
  • 911
  • Local Police/Sheriff
  • Local Clergy

  • Suicide is a
  • permanent solution
  • to a
  • temporary problem
  • Edwin Schneidman, MD.
  • Founder of Suicidology

A 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
  • Goldberg, I. SSRIs and Suicide Results of a
    MELINE Search. At ttp//
  • Jacobs, D., Ed. (1999). The Harvard Medical
    School Guide to Suicide Assessment and
    Interventions. Jossey-Bass.

  • 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//
  • Presidents New Freedom Council on Mental Health,
  • 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,

  • Smith, Range Ulner. Belief in Afterlife as a
    buffer in suicide and other bereavement. Omega
    Journal of Death and Dying, 1991-92, (24)3
  • Stoff, D.M. Mann, J.J. (Eds.), (1997). The
    Neurobiology of Suicide. American Academy of
  • Schneidman, E.S. (1996). The Suicidal Mind.
    Oxford University Press.
  • Styron, W. (1992). Darkness Visible. Vintage
  •  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.