Download Understanding Depression and Suicide

Saving Lives:
Understanding Depression And Preventing
Suicide – Prevention Training For Physicians
and Medical Personnel
The Ohio Suicide Prevention Foundation
Developed by Ellen J. Anderson, Ph.D., SPCC, 20032008
“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
Physicians Awareness Training
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Training Goals
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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
Physicians Awareness Training
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Why Do We Need To Improve Suicide
Prevention Efforts?
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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
Physicians Awareness Training
4
Changing Our Approach:
Depression Is An Illness

Suicide has been viewed for countless generations
as:
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A moral failing, a spiritual weakness
An inability to cope with life
“The coward’s way out”
A character flaw
This cultural view of suicide is not validated by our
current understanding of brain chemistry and it’s
interaction with stress, trauma and genetics on
mood and behavior
Physicians Awareness Training
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The Feel of Depression

“I am 6 feet tall. The way I have felt these past
few months, it is as though I am in a very small
room, and the room is filled with water, up to
about 5’ 10”, and my feet are glued to the floor,
and its all I can do to breathe.”
Physicians Awareness
Gatekeeper
Training-Training
Dr. Ellen
Anderson
6
6
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The research evidence is overwhelming- what we think of
as depression is far more than a sad mood. It includes:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
Often, suicidal thoughts
(DSMIVR, 2002)
Physicians Awareness Training
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
20 years of brain research teaches that what we
are seeing is the behavioral result of:
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Changes in the physical structure of the brain
Destruction or shutting down of brain cells in
the hippocampus and amygdala (5HTP axis)
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 General’s Call To Action, 1999, Stoff & Mann,
1997, The Neurobiology of Suicide)
Physicians Awareness Training
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Faulty Wiring?

Literally, damage to certain nerve cells in our brains
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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)
Physicians Awareness Training
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Faulty 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)
Physicians Awareness Training
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Where It Hits Us
Physicians Awareness Training
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One 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
Physicians Awareness Training
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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)
Physicians Awareness Training
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Renewed dendrites increase the number of
neuronal connections
 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)
Physicians Awareness Training
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Why Don’t We Seek Treatment?
We don’t know we are experiencing a brain
disorder – we don’t 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

Physicians Awareness Training
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No 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

Physicians Awareness Training
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Therapy? Are You Kidding? I Don’t
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
 They’ll just blame it on my mother or some
other stupid thing

Physicians Awareness Training
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How Does Psychotherapy Help?
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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)
Physicians Awareness Training
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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 (evidencebased)
 Consider EMDR for patients with trauma
experiences
 Look for therapists with specific training – Ask!

Physicians Awareness Training
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
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
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Physicians Awareness Training
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Suicide Prevention Efforts

First national effort established at NIMH in 1969
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Surgeon General issued a call to action to prevent
suicide in 1999
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In 2001, a National Strategy for Suicide Prevention
Committee developed future goals and objectives
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An Ohio Suicide Prevention Plan was developed in
May, 2002, and grants for local coalitions were given
out in November of 2002
Physicians Awareness Training
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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
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An increase in suicide prevention programs in schools
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The rapid development of suicidology as a
multidisciplinary sub-specialty
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Establishment of centers for the study and prevention of
suicide
Physicians Awareness Training
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Framework For Prevention
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Public health approach to prevention in contrast to
clinical approaches used in the past
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The prevailing model is the Universal, Selective, and
Indicated model (WHO, 2002)
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Focuses attention on defined populations, from
everyone, to specific at-risk groups, to specific high-risk
individuals
Physicians Awareness Training
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Is Suicide Really a Problem?
89 people complete suicide every day
 32,637 people in 2005 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 General’s Report on Suicide, 1999)
Physicians Awareness Training
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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 58,000 troops, and 220,000 people
to suicide
Physicians Awareness Training
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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
 In 2005, 267 children aged 10-14 completed
 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
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(Surgeon General’s call to Action, 1999)
Physicians Awareness Training
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Comparative Rates Of U.S. Suicides-2004
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Rates per 100,000 population
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National average
White males
Hispanic males
African-American males
Asians
Caucasian females
African American females
Males over 85
- 11.1 per 100,000*
- 18
- 10.3
- 9.1 **
- 5.2
- 4.8
- 1.5
- 67.6
Annual Attempts – 811,000 (estimated)
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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)
Physicians Awareness Training
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Suicide Rate By Age Per 100,000
% Suicide per 100,000
25%
20%
15%
10%
5%
0%
15-24
25-34
35-44
45-54
55-64
Age
65-74
75-84
85+
Older people: 12.7% of 1999 population, but 18.8% of suicides.
(Hovert, 1999)
Physicians Awareness Training
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Suicide 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 significantly
alter the course of other medical conditions
(Empfield, 2003)
Physicians Awareness Training
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PCP’s And Diagnosis Of Depression
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Seniors have often visited a health-care provider before
completing suicide
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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)
Physicians Awareness Training
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Poor Quality Of Mental Health Care
For Elders
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Increased risk for inappropriate medication
treatment (Bartels, et al., 1997, 2002)
> 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)
Physicians Awareness Training
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Depression Associated With Worse
Health Outcomes
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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
Parkinson’s disease
Rheumatoid Arthritis
Physicians Awareness Training
Alzheimer’s disease
(Empfield, 2003)
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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
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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 1992;Ashby1991; Shah 1993, Samuels 1997)
Physicians Awareness Training
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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
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Physicians Awareness Training
(Empfield, 2003)
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Benefits Of Treatment For Depression
In The Elderly
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Depression is one of the few medical conditions in
which treatment can make a rapid and dramatic
difference in an elderly person’s 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
Physicians Awareness Training
(Empfield, 2003)
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What Factors Put
Someone At Risk?
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Many things increase one’s risk for suicide- biological,
psychological, social factors all apply
The single greatest risk factor for suicide completion Having
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a Depressive Disorder
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 selfmedicating
Physicians Awareness Training
(Lester, 1998)
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
Other risk factors include:
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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 – 60% of completed suicides used
firearms
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(Surgeon General’s call to Action, 1999)
Physicians Awareness Training
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
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
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Psychological factors:
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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
Physicians Awareness Training
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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 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 General’s Call To Action, 1999)
Physicians Awareness Training
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Treatment
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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 SSRI’s and a decline in suicide
rates**
(*Baldessarini, et.al, 1999, **NIMH, 2002)
Physicians Awareness Training
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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)
Physicians Awareness Training
41
SSRI’s And Suicide
More Mythology?
Media has sensationalized the idea that “Prozac”
causes suicide in teens
 There is a very low risk that SSRI’s can induce
suicidal agitation in a very few individuals
 Many teens on SSRI’s are, in fact already suicidal,
and meds may not work well enough, or in time
 The FDA has recently banned the use of Paxil for
depression in adolescents, but Prozac has been
approved for use in teens

Physicians Awareness Training
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The American College of Neuropsychopharmacology's Task
Force report from January 21, 2004, which reviewed all
clinical trials, epidemiological studies and toxicology studies
in autopsies did not find evidence for a link between SSRI's
and increased risk of suicide in children and adolescents
In a recent preliminary study of 49 adolescent suicides,
researchers found that 24% had been prescribed
antidepressants, but none had any trace of SSRI's in their
system at the time of their death
There is an increased risk of suicide in depressed individuals
who do not take their medication; which is a factor common
to adolescents
A 2003 World Health Organization study in over fifteen
countries found a significant reduction, averaging about 33%,
in the youth suicide rate that coincided with the introduction
of SSRI's
(Altesman, 2005)
Physicians Awareness Training
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
A review of all the research on this topic was conducted
recently

CONCLUSION: “No increased susceptibility to aggression
or suicidality can be connected with fluoxetine or any other
SSRI. In fact SSRI treatment may reduce aggression toward
self or others”
 “In the absence of any convincing evidence to link SSRI’s
causally to violence and suicide, the recent media reports are
potentially dangerous, unnecessarily increasing the concerns of
depressed patients who are prescribed antidepressants” (Goldberg,
2003)

In November, Newsweek reported that prescriptions
for SSRI’s for teens have dropped by 50% in 03 and
04 – suicide rates have climbed 18% in 03
Physicians Awareness Training
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High Risk Behaviors and Suicide
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Miller and Taylor (2000) analyzed high risk behaviors in
9th-12th graders and found a correlation with suicide
ideation and attempts
High risk health behaviors included
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High Risk Sex (multiple partners, before age 14)
Binge Drinking (5 or more in several hours)
Drug Use
Disturbed eating patterns (boys do not get asked about this)
Smoking
Violence (girls do not get asked about this)
Physicians Awareness Training
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The 17% of youth with more than three problem
behaviors were the youth who acted
They accounted for 60% of medically treated suicidal
acts
Compared to adolescents with zero problem behaviors,
the odds of a medically treated suicide attempt were
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2.3 times greater among respondents with one
8.8 with two
18.3 with three
30.8 with four
50.0 with five
227.3 with six
A count of problem behaviors may offer a reliable way
to identify suicide risk
(Miller & Taylor, 2000)
Physicians Awareness Training
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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 General’s Call To Action, 1999; Empfield, 2003
Physicians Awareness Training
47

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
PCP’s


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 PCP’s*

“Physicians are often reticent to talk with patients about suicide
intent or ideation, and patients seldom spontaneously report it”**
(*Surgeon General’s Call to Action, 1999; **Quinnett, 2000 )
Physicians Awareness Training
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What 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

Physicians Awareness Training
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How Do We Know Suicide
Prevention Coalitions Work?
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In 1996 the U.S. Air Force decided to mount an assault
on it’s 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
Physicians Awareness Training
50
How Can You Help?

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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 General’s Call To Action, 1999)
Physicians Awareness Training
51
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)
Physicians Awareness Training
52
Hopelessness is the most immediate risk factor
for suicide, so instilling hope is essential
 If your patient is on anti-depressant or antianxiety 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

Physicians Awareness Training
53
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 anxiety)
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Learn to Ask the “S” question
Not – you aren’t thinking of suicide are you?
But - Some people who experience the amount of pain you’re
in think about killing themselves. Have you ever thought
about it?
(Lester, 1998)
Physicians Awareness Training
54
Use Of A Structured Interview
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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
Physicians Awareness Training
55
Screening Recommendations

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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 PCP’s 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)
Physicians Awareness Training
56
Possible Depression Scales
Beck Depression Inventory
 Children’s 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

Physicians Awareness Training
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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



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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)
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Intervention
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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!
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Psychiatric Hospitalization
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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)
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The 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 General’s Call to Action to Prevent Suicide, 1999)
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Voluntary Hospitalization
Best choice – less hard on the patient’s sense of
self-worth – a way to buy time (to think it over,
get sleep, etc.)
 Safety is the main message – a good night’s
sleep, a start on medications, talk with doctors,
put things on hold for awhile
 Allows them to save face – I didn’t want to, but
they insisted…
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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
suffering
 ECT cannot be given without patient permission
 Patients rights are guaranteed
 Modern hospitals are not snake pits

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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.

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Local 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
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“Suicide is a
permanent solution
to a
temporary problem”
Edwin Schneidman, MD.
Founder of Suicidology
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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
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A Brief Bibliography
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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. SSRI’s 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.
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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.cf
m
President’s 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
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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 General’s 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-behavioral therapy for depression”. Journal
of Consulting and Clinical Psychology 67: 894-904.
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