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Richard McKeon, Ph.D., MPH


Suicide and Substance Abuse: Challenge and Opportunity Richard McKeon, Ph.D., MPH Acting Branch Chief, Suicide Prevention SAMHSA Effect of telephone contact on ... – PowerPoint PPT presentation

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Title: Richard McKeon, Ph.D., MPH


Suicide and Substance Abuse Challenge and
  • Richard McKeon, Ph.D., MPH
  • Acting Branch Chief, Suicide Prevention

Behavioral Health is Essential to Health
  • Prevention Works
  • Treatment is Effective
  • People Recover

  • Substance Abuse and Mental Health Services
  • Center for Mental Health Services
  • Center for Substance Abuse Treatment
  • Center for Substance Abuse Prevention
  • Center for Behavioral Health Statistics and

SAMHSAs Strategic Priorities
  • 8 strategic priorities
  • Prevention of Substance Abuse and Mental
    Illness--includes suicide prevention
  • Military Families--(Active Duty, Guard, Reserve,
  • Health Care Reform
  • Trauma and Justice

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

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

Leading causes of death for selected age groups
United States, 2005
Age groups in years
Rank 10-14 years 15-19 years 20-29 years 30-39 years 40-49 years 50-59 years
1 Unintentional Injuries Unintentional Injuries Unintentional Injuries Unintentional Injuries Malignant Neoplasms Malignant Neoplasms
2 Malignant Neoplasms Homicide Homicide Malignant Neoplasms Heart Disease Heart Disease
3 Suicide Suicide Suicide Heart Disease Unintentional Injuries Unintentional Injuries
4 Homicide Malignant Neoplasms Malignant Neoplasms Suicide Suicide Diabetes Mellitus
5 Congenital Malformations Heart Disease Heart Disease Homicide Liver Disease Cerebro- vascular
6 Heart Disease Congenital Malformations HIV HIV HIV Liver Disease
7 Chronic Lower Respiratory Ds Cerebro- vascular Congenital Malformations Diabetes Mellitus Cerebro- vascular Chronic Lower Respiratory Ds
8 Influenza pneumonia Influenza and pneumonia Diabetes mellitus Cerebro- vascular Diabetes Mellitus Suicide
Source CDC vital statistics
Burden of injury
Emergency Dept visits
Events reported on surveys
Unreported events
  • 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

  • Suicide is a serious public health
    challenge that has not received the attention
    and degree of national priority it deserves.

- The Presidents New Freedom Commission on
Mental Health, 2003
Suicide and Public Policy
  • 1997-U.S. Congress -S.Res 84 and H.Res 212
  • 1999-Surgeon Generals Call to Action to Prevent
  • 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

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

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

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

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

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


GOAL 7Develop and Promote Effective
Clinicaland Professional Practices
  • 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

  • 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

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

  • 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).

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
  • Example of Russia in the 1980s
  • Binge drinking vs. per capita consumption

Juvenile Justice Data-Utah
  • 63 of youth suicide completers had contact with
    the Juvenile Court System (n95 of 151).
  • 54 of the 95 subjects involved with Juvenile
    Court had a referral(s) for substance possession,
    use, or abuse (n51 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.

Health/Behavior information for suicide decedents
aged 20-64 years by sex
Source NVDRS, 2008 Categories are not mutually
exclusive Significant difference at plt0.05
Toxicology Findings
  • Alcohol
  • Tested in 72 of decedents
  • 32 were positive for alcohol
  • 62 had a BAC gt.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
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
  • 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

Links between Substance Abuse and Suicide
  • Alcohols 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,
  • 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

Challenges in Working with Suicidal Substance
  • Challenges in the Emergency Department and post
  • Challenges on the Telephone
  • Challenges with Families

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

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.

Importance of ED as a setting for suicide
  • 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.

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

Follow-up Can Reduce Suicide
  • WHO Study, 2008
  • Over 800 attempters from 8 hospitals around the
  • 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

Suicide and Substance Abuse in the Emergency
  • 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

Emergency Department
  • Look for signs of acute suicide risk

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

Emergency Department
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.

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

  • 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

  • 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

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

ED Telephone Follow-up with Attempt Survivors
Study Vaiva 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
  • Patients more open to phone contact than
    attending outpatient treatment

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

Follow up study of serious suicide attempts
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.

Further suicide attempts, including those which
resulted in death, in the 5-year follow-up period
Attempt or suicide
6 mo.
18 mo.
30 mo.
60 mo.
10-year record review of all admissions for
suicide attempt, regardless of severity
What is needed
  • Collectively, these findings and observations
  • The need to acknowledge long-term risks of those
    who make serious suicide attempts, and to develop
    appropriate long-term treatment and management
  • 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

What is needed
  • Relatively simple interventions appear to be
  • 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

To whom should such services be directed?
  • In particular, rather than targeting the
    minority of people who make suicide attempts that
    we deem clinically to be at highest risk of
    making further attempts that result in their
    death, and given our limited ability to predict
    with certainty who those will be, we may do
    better to focus on improving our treatment,
    management and support of all those who make
    suicide attempts.
  • Annette Beautrais

Telephone contact from suicidal, substance
abusing patients
  • Although every day, multiple times per day,
    decisions have to be made regarding the use of
    emergency interventions (i.e., ambulance or
    police), there is almost no research or
    formalized training on how to make these critical
    life and death decisions.
  • Many lives are saved, VA hotline reports
    regularly on the number of emergency rescues
  • The use of emergency interventions can backfire
    in several ways.

Telephone contact from suicidal, substance
abusing patients
  • CDR case
  • Public humiliation
  • Reluctance to communicate re ideation in the
  • Intoxication is going to make the use of
    emergency rescue more likely
  • For example, clinicians will be less likely to
    accept a plan to secure lethal means if the
    caller is intoxicated
  • National Suicide Prevention Lifeline will be
    issuing guidelines for responding to callers at
    imminent risk

National Suicide Prevention Lifeline
  • National toll free number 1-800-273-TALK (8255)
  • Calls routed automatically to the closest of 145
    networked crisis centers
  • Press one if a veteran or active duty military,
    SAMHSA, DVA, DOD collaboration
  • Evaluation studies published June 2007 in Suicide
    and Life Threatening Behavior
  • Dont yet know how many veterans dont press 1

Suicide Callers Rescue Rate
  • Total 12.6
  • With current plan 19.2.
  • Without plan 4.9
  • Took some action 37.9
  • Took no action 10.8
  • Lifeline has introduced Guidelines for
    Intervening with Callers at Imminent Risk
  • Engaged in preparatory behavior or had done
    something to hurt/kill themselves

Emergency Intervention Rate
  • Just one example of using suicide related data to
    manage suicide prevention and intervention
  • There has been very little of this in the past
    nationally bit it affords a tremendous
  • VA is focusing on this
  • Another example is Henry Ford Medical Centers
    Perfect Depression Program
  • Set goal of zero suicides

Veterans Mental Health
Resource Locator
Resource Locator http//www.suicidepreventionlif Informat
ion for Lifeline Crisis Centers and veterans alike
New Frontiers in Crisis Intervention
  • Chat-Veterans chat initiated 2009
  • Texting-Crisis texting services in UK
  • Social Networking Sites-relationship with
  • SAMHSA Summit and White Paper on suicide
    prevention and the new technologies

Chat and Texting
  • How millions now communicate
  • United Kingdom-crisis text service through the
    Samaritans, significant use but almost an hour
    delay in response
  • Rape and Sexual Abuse Crisis Response

Social Networking
  • Lifeline provides crisis response for some social
    networking sites such as Facebook
  • Emergency rescue much more complicated when only
    have email address or on social networking site
  • A generation of online gatekeepers is emerging
  • SAMHSA White Paper due out in 2010

Challenges in Suicide Prevention with Substance
Abuse and Suicide
  • Joiner model
  • Acquired capacity
  • Failed belonging
  • Perceived burdensomeness

Joiner model and substance abuse
  • Substance abuse more likely to lead to the kind
    of provocative, desensitizing experiences that
    lead to the acquired capacity to die by suicide
  • Substance abuse leads to family disruption
  • Family disruption more associated with suicide
    among substance abusers than among any other
    diagnostic group

Joiner model and substance abuse
  • Abstinence should greatly reduce the number of
    new desensitizing experiences
  • Focus on the whole family needs crucial to
    maintain or reestablish connectedness and reduce
    the perception of burden
  • Burden is often real but the burden of suicide is
  • Burden of death virtually always greater than
    that of life

Important Resource
  • Treatment Improvement Protocol 50 (TIP 50)
  • Addressing Suicidal Thoughts and Behaviors in
    Substance Abuse Treatment
  • The patient cannot be the hot potato that no
    one wants
  • Substance abuse programs need to identify and
    build their own capacities and work together with
    specialized mental health services

TIP 50
  • GATE model
  • Gather information
  • Access supervision or consultation
  • Take responsible action (matched to the risk
    level assessed)
  • Extend the action (risk doesnt disappear)

TIP 50
  • Video using veterans as examples funded by VA in
    collaboration with SAMHSA
  • Show video

Suicidal Individual
Failure to seek help hopelessness helplessness
Help-Seeking Behavior
Failure to make contact poor availability or
accessibility of services
Professional contact made assessment of suicide
Failure to detect suicide risk or offer
appropriate intervention
Appropriate intervention
Treatment failure poor response, compliance or
Suicide Prevented
Murphy, BM, Puffett, A. Pathways to suicide
prevention. British Journal of Hospital
Medicine. 199554(1)11-14.
Clinical Training for Mental Health Professionals
  • One day workshop
  • Developed by 9-person expert task force
  • 24 Core Competencies
  • Skill demonstration through video
  • 110 Page Participant Manual with exhaustive
  • 6.5 Hrs CEUs

Categories of Competencies
  • A. Working with individuals at risk for suicide
    attitudes and approach
  • B. Understanding suicide
  • C. Collecting accurate assessment information
  • D. Formulating risk
  • E. Developing a treatment and services plan
  • F. Managing care
  • G. Documenting
  • H. Understanding legal and regulatory issues
    related to suicidality

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NSPL Suicide Risk Assessment Standards
  • 3 Prompt Questions
  • Are you thinking of suicide?
  • Have you thought about suicide in the past two
  • Have you ever attempted to kill yourself?

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Contact informationRichard McKeon, Ph.D.
Acting Branch Chief, Suicide Prevention,