suicide prevention in the - hope4utah€¦ · perhaps a third of all suicide decedents accessed...

Suicide Prevention in the United States

RichardMcKeon,Ph.D.Chief,SuicidePreven7onBranch

Preventing suicide

A global imperative

National Strategy for Suicide Prevention

Copyright©2010-2015Educa7onDevelopmentCenter,Inc.AllRightsReserved

SavingLives:Impactofthe2012Na8onalStrategy

forSuicidePreven8on

AmericanAssocia8onofSuicidology

2015AnnualMee7ng


NotableFindings

§  39statesandtheDistrictofColumbiahaveusedorarecurrentlyusingtheNSSPinrevisingandupda7ngtheirstateplan.

§  Someac7vityisoccurringforeveryobjec7ve.§  Magnitudeofeffortandpoten7alforhavingmeasurable

impactisvariable.§  Absenceofstate,tribal,andcommunityinfrastructure

hamperssuccessfulsuicidepreven7onefforts.§  Effortstointegrateandcoordinatesuicidepreven7on

effortsacrosssectorsareemergingbestprac7cesbutarenotstandardprac7ce.


NotableAccomplishments

§  Goal6§  NewHampshire’sFirearmsSafetyCoali7on(includesfirearmsdealers,gunrightsadvocates,mentalhealthandpublichealthprofessionals)

§  Thismodelisbeingadoptedbyotherstates.§  Goals8&9

§  Texaslaunched“SuicideSafeCare”ini7a7veinstate’spublicbehavioralhealthcaresystem.

§  Goals1&5§  ColoradoSuicidePreven7onCommission


Recommenda8ons

§  RegularmonitoringofNSSPimplementa7onandcoordina7on

§  State,tribal,andcommunity(college)-levelsuicidepreven7oninfrastructure

§  Federal,state,communityspecifica7onofroles§  Regionalcollabora7ononsuicidepreven7on§  Transla7onofNSSPtocommunity-friendlytool.§  Specifica7onofcomponentsandrolesforcommunity

suicidepreven7on,andneedforcoordinatedeffort.

The Garrett Lee Smith (GLS) Suicide Prevention National Outcomes Evaluation is supported through contract no. HHSS283201200007I/HHSS28342002T (reference no. 283-12-0702) awarded to ICF International by the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS).

THE IMPACT OF GLS SUICIDE PREVENTION PROGRAM ON YOUTH SUICIDAL BEHAVIOR

Lucas Godoy Garraza (ICF International); Christine Walrath (ICF International); David Goldston (Duke CSSPI); Hailey Reid (ICF

International), Richard McKeon (SAMHSA)

GLS implementation GLS + 1 year GLS + 2 years GLS implementation GLS + 1 year GLS + 2 years Solidlinesrepresentthees.matedoutcometrajectoryfollowingGLStrainingimplementa.on.Dashedlinesrepresentthees.matedoutcometrajectoryduringthesameperiodhadGLSnotbeenimplemented.90%and50%confidenceintervalsaroundthetrajectoryarerepresentedbydarkgrayandlightgray,respec.vely.

Results: Difference in Suicide Mortality co

unt p

er 1

00,0

00

6 7

8 9

10

11

12

Training year (T) T + 1 year T + 2 years Training year (T) T + 1 year T + 2 years

suicide 10-24

coun

t per

100

,000

14

16

18

20

22

24

suicide 25+

10

Results: Difference in Nonfatal Attempts

*Solidlinesrepresentthees.matedtrajectoryoftheoutcomefollowingGLSimplementa.on.Dashedlinesrepresentthees.matedtrajectoryoftheoutcomeduringthesameperiodhadGLSnotbeenimplemented.90%and50%confidenceintervalsaroundthedifferenceinthetrajectoriesarerepresentedbydarkgrayandlightgray,respec.vely.

11

Implications

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–  Results suggest there is an important reduction on youth suicide and attempts following the implementation of GLS.

§  More than 400 deaths were avoided between 2007-10. (There were 776 county-years where GLS trainings were implemented during 2006-2009 and 41K youth 10-24 on average per county, i.e. 776*41K*-1.33/100,000).

§  More than 100,000 attempts among youth 16-23 were avoided during approximately the same period. (There were 776 county-years where GLS trainings were implemented during 2006-2009 and 29K youth 16-23 on average per county, i.e. 776*29K*-4.9/1,000).

Implications (Cont.)

13

•  Continuous reductions require sustained public efforts

•  GLS may have been more effective in rural communities

•  Gatekeeper trainings should be part of comprehensive suicide prevention strategy

Comprehensive Suicide Prevention

•  Requires two strong elements •  Strong, multi-pronged community effort •  Strong multi-pronged healthcare effort •  Attention to transitions across a range

of settings •  Should be data driven, coordinated by

a public-private partnership, and sustained by a strong state infrastructure.

State, Tribal Infrastructure

•  Need a foundation for suicide prevention •  State suicide prevention coordinator with

sufficient authority to convene participants from across state government including Departments of Heath, Mental Health, Substance Abuse, Children and Youth, Veterans, Justice , Education, etc.

•  Ability to work with a strong coalition

Community Suicide Prevention

•  Schools/colleges •  Justice settings (adult and youth-Utah

Youth Suicide Study) •  Workplace •  Faith Communities •  Foster care •  Veterans/military/National Guard •  Social Media

Implica7onsforVeterans

•  HowdowereachthemajorityofveteranswhodiebysuicidewhoarenotinVA?

•  Requireamobilizedcommunityinwhichworkplaces,faithcommuni7es,colleges,jus7cesystems,EmergencyDepartmentsworktopreventsuicide

•  Whatarethesystemsthatveteranswhodiebysuicidearetouchingbeforetheirdeath?

Community Suicide Prevention

•  CDC Suicide Prevention Technical Package

•  Previous technical packages on child abuse and sexual violence

•  Action Alliance Comprehensive Community Suicide Prevention workgroup

International Community Efforts

•  SAMHSA/PHAC/MHC-webinar series •  IIMHL community suicide prevention

meetings •  European Alliance Against Depression •  World Health Organization Community

Engagement Toolkit •  New South Wales implementation and

evaluation

Healthcare Settings

•  Mental health (Zero Suicide) •  Substance Abuse (TIP 50, county

coalitions) •  Emergency Departments and Crisis

Services •  Primary Care-Institute for Family

Health, Pa GLS

Develop a competent, confident, and caring workforce

Create a leadership-driven, safety-oriented culture

Pathway to Care

•  Identify and assess risk •  Screen •  Assess

•  Evidence-based care •  Safety Plan •  Restrict Lethal Means •  Treat Suicidality and MI

•  Continuous support as needed

Electronic Health Record

Continuous Quality

Improvement

The Elements of Zero Suicide in a Health Care Organization

Risk following completion of PHQ9 (sample size = 1.2 million)

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And that answer leads to…

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Implementation

Response to PHQ item 9

strongly predicts

suicide risk. Exploration

Experimentation

Implementation: Standard work for suicide risk assessment and safety planning in mental health clinics

•  Abbreviated version of Columbia Suicide Severity Rating Scale

•  Training for all mental health clinicians •  EHR prompts for standard work •  Defined care pathway for high risk patients

•  Safety plan recorded in EHR and noted on problem list •  Acute care pathway

•  Continuous monitoring of: •  Adherence to standard work •  Suicide attempt and suicide death rates

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Education Development Center Inc. ©2015 All Rights Reserved.

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Resource: Using the C-SSRS

Accessat:www.zerosuicide.com

ALLBehaviorsArePrevalentandPredictive

.6% .8% .2% .2%

9 8 . 6 %

No Behavior: 28,303 Actual Attempt: 70

Interrupted Attempt: 178 Aborted Attempt: 223

Preparatory Behavior: 71

.2%

n = 28,699 administrations

Mundtetal.,2011

472Interrupted,AbortedandPreparatory(87%)vs.70ActualAttempts(13%)

*Only1.7%hadanyworrisomeanswer*Only.9%with~50,000administrations

EachbehaviorisEQUALLY

PREDICTIVEtoanattempt

Multiplebehaviors=greaterrisk


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Resource: Safety Planning Intervention

Accessat:www.zerosuicide.com

Critical Data Sources

•  Now required in GLS and NSSP grants •  Child Fatality Review •  Utah Juvenile Justice •  Foster Care? •  Public Behavioral Health-Kentucky,

Vermont, New York, Ohio •  Medicaid-Ohio , Utah

You can’t fix what you can’t measure….

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Perhapsathirdofallsuicidedecedentsaccessedcarepriortodeath,butfewU.S.healthcaresystemstracksuicideoutcomes.

Ahmedani BK et al (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, online Feb 25. DOI: 10.1007/s11606-014-2767-3.

Karch, DL, Logan, J, McDaniel, D, Parks, S, Patel, N, & Centers for Disease Control and Prevention (CDC). (2012). Surveillance

for violent deaths—national violent death reporting system, 16 states, 2009. Morbidity and Mortality Weekly Report. Surveillance

Summaries (Washington, DC: 2002), 61(6), 1-43.

Of those with contact with health care, 45%

had a psychiatric diagnoses

Deconstructing Suicide Deaths in the U.S.

ü= Already Modeled

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ü

Adult ED visits related to Suicidal Ideation-2006-2013

•  Rate increased 12% annually, 15% in West and Midwest

•  By 2013, 903,400 ED visits related to suicidal ideation, 1% of all adult ED visits

•  72% were admitted to the same hospital or transferred to another facility

Components of Comprehensive Crisis Systems

•  Mobile crisis response teams •  Crisis stabilization beds •  Hotlines (data, technology, dispatch,

monitor) •  Crisis chat and text, warmlines •  Crisis respite •  Psych emergency/walk in •  Post crisis follow up engagement and

support •  Peers

National Suicide Prevention Lifeline

•  158 crisis centers across the nation •  1.5 million calls answered last year •  24 hour crisis chat service •  Access point for Veterans Crisis Line/

Military Crisis Line •  Joint Commission recommendation •  Calls In Utah answered by UNI

(University Neuropsychiatric Institute)

4405 4419

5416

5942

6941

8315

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2010 2011 2012 2013 2014 2015

UtahCallVolume


36

Lifeline’s Imminent Risk Policy (2011)


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Helper Interventions with Imminent Risk Callers (N= 491) TYPE OF INTERVENTION SPECIFIC INTERVENTION N %

Active Engagement (Collaborative)

Person at Imminent Risk Agreed to…..

Less Invasive

Take action on his/her own behalf to immediately reduce risk (e.g., collaborate on safety plan; not incl. self-transport)

214 43.6%

Receive follow-up from center 142 28.9%Involve a 3rd party to keep him/her safe (not for transport) 125 25.5%Get rid of means 65 13.2%Be evaluated by a mobile crisis/outreach team 22 4.5%Transport him/herself to a hospital or walk-in clinic 21 4.3%Have center contact the VA 20 4.1%Be transported to the hospital by a 3rd party 15 3.1%Any less invasive Active Engagement 334 68.0%

More Invasive Have center send emergency services (police, sheriff, EMS) 94 19.1%Any Active Engagement 375 76.4%

Active Rescue (Non-collaborative)

Without Consent of Person at Imminent Risk, Helper…..

Less Invasive

Involved a 3rd party (not for transport) 8 1.6%Sent a mobile crisis/outreach team 5 1.0%Contacted the VA 4 0.8%Involved a 3rd party for transport to hospital 1 0.2%Any less invasive Active Rescue 18 3.7%

More Invasive Sent emergency services (police, sheriff, EMS) 121 24.6% Any Active Rescue 136 27.7%

Imminent Risk Reduced Enough so Rescue was Not Needed 192 39.1%

Improving Care Transitions

•  There are lethal gaps in many systems. •  Period after IPU and ED discharge is

one of high risk, particularly the first 30 days.

•  Rates of follow up care are poor. •  Intervention during this time has been

shown to save lives and reduce suicidal behavior.

Mortality After Recent Suicide Attempts

•  SAMHSA NSDUH data •  Significant post non-fatal attempt

suicide mortality-3.2 % •  Higher among men then women •  45 and older with less then a high

school education -16% •  40.6% had any outpatient mental health

treatment, 15.8% had 1-4 visits,

Improving Post Discharge Safety

•  ED SAFE RCT demonstrated reduction in suicidal behavior for suicidal people discharged from ED’s doing telephonic follow up.

•  White Mountain Apache/JHU Center for American Indian Health almost 40% reduction in suicides from 2006-2012-centerpiece is tribally mandated reporting and follow up

7

Clients’PerceptionsofCare:CohortII(preliminary)

“To what extent did the follow-up call(s) stop you from killing yourself?”

Callers (n= 283)

Hosp. Clients (n= 70)

Total (n= 353)

(17 callers, 2 hosp. clients had missing data)

•  A lot 60.8% 51.4% 58.9%

•  A little 22.6% 14.3% 21.0%

•  Not at all 16.6% 32.9% 19.8%

•  It made things worse

0.0% 1.4% 0.3%

Major International Efforts Have Reduced Suicides

•  Taiwan-nationwide effort to intervene with those who have attempted suicide, 50,000+

•  63.5% reduction in suicide attempts among those who accepted the program. Those who refused but then persuaded 22% reduction.

•  English National Strategy- 24 hours crisis care strongly associated with reduction in suicides.

•  Proactive outreach and discharge f/u 7 days

EMERGENCY DEPARTMENT F/U

•  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

0

0.5

1

1.5

2

2.5

3

Died of Any Cause Died by Suicide

Perc

ent o

f Pat

ient

s

Results at 18 Month F/U

Usual Care Brief Intervention

Preventing Suicide Is Everyone’s Business

•  To those who have lost their lives by suicide, •  To those who struggle with thoughts of suicide, •  To those who have made an attempt on their lives, •  To those caring for someone who struggles, •  To those left behind after a death by suicide, •  To those in recovery, and •  To all those who work tirelessly to prevent suicide

and suicide attempts in our nation. •  We believe that we can and we will make a

difference. –Dedica7onfromthe2012Na7onalStrategyforSuicidePreven7on

RichardMcKeon,Ph.D.,M.P.H.BranchChief,SuicidePreven8on,[email protected]

suicide prevention in the - hope4utah€¦ · perhaps a third of all suicide decedents accessed...

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