Suicide

1
Suicide

• There is but one truly serious philosophical
  problem, and that is suicide. Judging whether
  life is or is not worth living amounts to
  answering the fundamental question of
  philosophy.
• Albert Camus, The Myth of Sisyphus (1942)

2
Outline

• What suicide is and how it is studied
• What it isnt myths and opinions vs. facts
• Epidemiology, especially pediatric
• Warning signs
• Prevention, intervention, and postvention
• Suicide and your clinical skills assessment,
  intervention, and risk

3
Facing the facts

• 900,000 per year, worldwide about 1 of deaths
• 1 death by suicide every 40 seconds
• 10-20 million suicide attempts per year 18
  ratio of attempters vs. completers
• 395,000 emergency department visits per year are
  self-inflicted injuries
• 3rd leading cause of death among 15-24 year olds
  (following accidents and homicide)
• 2nd leading cause among 25-34 year olds
• 8 per 100,000 among US college students

4
Suicidolgy, epidemiologyCDC, WHO, NASP, IASP

• Methods of suicide
• Table 1 also indicates the most common methods
  of suicide in the participating countries. In
  Australia, Japan, New Zealand, Pakistan, and
  Thailand, hanging dominates as the most common
  method of suicide. In China, Hong Kong SAR, and
  Singapore, jumping (typically from apartment
  buildings) is the most frequent method used (Ung,
  2003 Yip,1996). In countries with larger rural
  populations, such as China, India and the
  Republic of Korea, poisoning (usually by
  pesticides) is common (Bose et al., 2006 Shin et
  al., 2004). Some new methods are also emerging,
  such as carbon monoxide poisoning by
  intentionally burning charcoal in a confined
  space. In China, Hong Kong SAR charcoal-burning
  accounted for a single suicide in 1997 but it is
  currently among the top three most common methods
  of suicide (Chan et al., 2005 Chung et al.,
  2001 Yip et al., 2007) (italics added).

5
Suicide Trends Among Youths and Young Adults Aged
10--24 Years --- United States, 1990--2004 In
2004, suicide was the third leading cause of
death among youths and young adults aged 10--24
years in the United States, accounting for 4,599
deaths (1,2). From 2003 to 2004, the rate
increased by 8.0, from 6.78 to 7.32 (2), the
largest single-year increase during 1990--2004.
CDC analyzed data recorded during 1990--2004, the
most recent data available. Results indicated
that, from 2003 to 2004, suicide rates for three
sex-age groups (i.e., females aged 10--14 years
and 15--19 years and males aged 15--19 years)
departed upward significantly from otherwise
declining trends. Suicides both by
hanging/suffocation and poisoning among females
aged 10--14 years and 15--19 years increased from
2003 to 2004 and were significantly in excess of
trends in both groups. The results suggest that
increases in suicide and changes in suicidal
behavior might have occurred among youths in
certain sex-age groups, especially females aged
10--19 years. Closer examination of these trends
is warranted at federal and state levels. Where
indicated, health authorities and program
directors should consider focusing
suicide-prevention activities on these groups to
help prevent suicide rates from increasing
further. http//www.cdc.gov/mmwr/preview/mmwrhtml/
mm5635a2.htm
6
Suicidology Important caveats

• Many actual suicides fail to be classified as
  such.
• Suicide rates vary by country, gender, and age.
• Studies of suicide are hampered by low base rates
  and after-the-fact data.
• It is a social construction. Societies view
  suicides very differently!

7
More epidemiology

• 41 Male to female ratio worldwide
• Firearms, poison, suffocation and/or hanging
• Access to firearms is the 1 predictor among
  pediatric suicides in the US
• Teens and elderly are most at risk worldwide
• Physician suicide rate is four times the national
  average.

8
What it is

• Medical one of 4 modes of death (NASH)
• Legal the deliberate taking of ones life in
  common law, formerly considered a crime, but no
  longer
• Historical/cultural ever evolving (e.g. early
  Christian martyrs vs. the contemporary Vatican
  stance.
• the fruit of illogical action resulting from
  funnel thinking, which prevents a person from
  perceiving alternatives to self-destruction
  (Hef)
• alienations last word (Gomezil)
• the most tragic decision of a man who found
  nobody to hold out a hand to him (Kielanowski)
• a conscious act of self-induced annihilation,
  best understood as a multidimensional malaise in
  a needful individual (Schneidman)

9
Definition(s)

• The act of causing ones own death.
• Positive taking ones own life with purpose and
  intention.
• Negative not doing what is necessary to escape
  death (not leaving a burning building stopping
  insulin treatments).
• Direct having the intention of causing ones own
  death, either as an end, or as a means to an end
  (to avoid ruin or disgrace, or escape
  condemnation).
• Indirect (and not usually called suicide) death
  is not necessarily desired, but one commits an
  act which courts death, as in tending someone
  with SARS knowing that one may succumb to the
  same illness.

10
What suicide is NOT

• A disease
• An immorality
• A biological anomaly
• A neurological dysfunction
• It is unlikely that any one theory will ever
  explain phenomena as complex and varied as acts
  of human self-destruction. (Leenars, 1995)

11
Facts vs. Myths

• Myth People who talk about suicide wont really
  do it.
• Fact 8 of 10 suicides have given a definite
  warning.

12
Facts vs. Myths

• Myth Suicide happens without warning.
• Fact Almost all suicidal people give many
  warnings.

13
Facts vs. Myths

• Myth Suicidal persons are fully intent on dying.
• Fact Most are undecided and ambivalent.

14
Facts vs. Myths

• Myth Once a person is suicidal she/he is
  suicidal forever.
• Fact Individuals who wish to kill themselves are
  suicidal for only a limited period of time.

15
More facts and myths

• Myth Improvement following suicide crisis means
  the risk is over.
• Fact Most suicides occur within 3 months of
  improvement when the person has more energy to
  carry through.
• Myth Suicides strike more among the rich (or
  poor).
• Fact Suicide is very democratic and represented
  proportionally among all levels of society.

16
Facts vs. Myths

• Myth All suicide individuals are mentally ill,
  and suicide is always the act of a severely
  depressed or psychotic person.
• Fact Studies of hundreds of suicide notes
  indicate that although the person was in
  unbearable pain, he or she was not necessarily
  mentally ill. About 15-20 percent of suicides do
  NOT have a mental illness.

17
Probably the most dangerous myth

• Asking about suicide or suicidality will increase
  the risk of suicide.
• Fact Assessing suicidal thoughts and behaviors
  prevents suicide by identifying individuals at
  risk and by inviting people who are in pain to
  communicate.

18
Unbearable psychological pain

• Depression
• Masked depression
• Hostility, anxiety, guilt, shame, hopelessness
• Overwhelming, painful EMOTION, not depression per
  se
• Constricted thinking as a result of emotional pain

19
Cognitive constriction

• Rigid
• Narrow focus (tunnel vision)
• Concreteness
• Dysfunction in emotions, logic, perceptions
• Inability to adjust
• Aggression, confusion, humiliation

20
PSYCHIATRIC SYMPTOMS ASSOCIATED WITH SUICIDE

• Hopelessness
• Impulsivity / Aggression
• Anxiety
• Command hallucinations

21
Interpersonal difficulties

• Rejection
• Aggression
• Identification with a lost loved one
• Shame and humiliation that is deemed unfair,
  especially public shame (losing ones license to
  practice failing out of school)

22
Biology of suicide

• Learning disabilities right brain dysfunction
• Physical illness and disabilities
• Biomarkers corticosteroids, thyrotropin
  releasing hormone, norepiepi ratio
• Small samples sizes, problems with data
  collection, confounding variables

23
Family background of suicide

• Lack of generational boundaries
• Inflexible family system (secretiveness, denial,
  poor communication, patterns of authoritarian
  discipline
• Symbiotic parent-child relationship
• Long term family disorganization
• Adolescents who feel a lack of control over their
  environment

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25
SUICIDE A MULTI-FACTORIAL EVENT
Psychiatric IllnessCo-morbidity
Neurobiology
Personality Disorder/Traits
Impulsiveness
Substance Use/Abuse
Hopelessness
Severe Medical Illness
Suicide
Family History
Access To Weapons
Psychodynamics/ Psychological Vulnerability
Life Stressors
Suicidal Behavior
Jacobs, 2003
26
Suicidal Behavior in Children and Youth An
Overview

• Suicide is the third-leading cause of death among
  children and adolescents in the U.S.
• Suicide rate among children and youth has
  increased over 300 since the 1950s
• A child or adolescent commits suicide in the U.S.
  approximately every 2 hours
• Suicide rates are highest among high school
  students, although there have been recent
  increases among middle school students

27
Suicidal Behavior in Children and Youth An
Overview

• More children and adolescents die annually from
  suicide than from cancer, heart disease, AIDS,
  birth defects, and other medical conditions
  combined
• Survey research suggests approximately 20 of
  high school students experience serious suicidal
  thoughts in a given year, and that about 4-8
  make actual attempts
• Over 2000 children and adolescents commit suicide
  annually
• These statistics likely underestimate actual
  figures, although the degree to which this occurs
  is uncertain
• (National Association of School Psychologists)

28
Suicidal Behavior in Children and Adolescents

• In any given year in a typical high school class
  of 30 students
• 6 will seriously consider suicide
• 2 to 3 will attempt suicide
• 1 will make an attempt sufficiently harmful to
  require medical attention

29
Suicidal Behavior in Children and Adolescents
Demographics

• Gender
• Adolescent females attempt suicide at a rate of
  21/ 31 compared to adolescent males
• Adolescent males commit suicide at a rate of
  nearly 51 compared to adolescent females
• Age
• Rates of suicidal behavior increase as children
  get older, hitting peak in early 20s

30
Suicidal Behavior in Children and Adolescents
Demographics

• Race
• White males currently at highest risk
• Other high risk groups Native-American youth
  African-American males
• Limited data available on other groups
• Geography
• Highest suicide rates in Western states and
  Alaska
• Lowest suicide rates in Northeastern states
• Higher suicide rates in rural than in urban areas

31
Suicidal Behavior in Children and Adolescents
Demographics

• When
• Slightly more suicides occur during Spring
• Month with least amount of suicides December
• Suicide rates lower just before and during
  holidays
• Where
• Most adolescent suicides occur at home, where
  primary means for suicide (typically firearms)
  are available

32
Suicidal Behavior in Children and Adolescents
Demographics

• How
• Firearms are most popular method among both males
  and females who commit suicide in U.S.
• Worldwide, hanging is the most frequently used
  method of youth suicide, and the second most
  popular method among U.S youth.
• Risk of suicidal behavior is a function of intent
  and lethality youths with high level of intent
  who use methods of high lethality (e.g.,
  firearms) present the greatest risk.

33
Suicide Ideation, Attempts, and Completion

• Three different types of suicidal behaviors
  (ideators, attempters, and completers) reflect
  different types of individuals
• Typical youth suicide attempter Adolescent
  female who ingests pills in front of her family
  during an argument
• Typical youth suicide completer Adolescent male
  who is a victim of a gunshot wound

34
Attempters vs. Completers

• An overlapping group
• 81 ratio overall
• In young people, 501 ratio
• Parasuicide
• Distinguishing among the two a slippery slope
• Perturbation and lethality are rated high,
  medium, or low, on a 1-9 scale
• Lethality is what kills.
• ALL ATTEMPTS SHOULD BE TAKEN AS A SERIOUS
  COMMUNICATION.
• Words like blackmail, manipulation, and attention
  seeking are perjorative and only reveal our own
  attitudes and fears.
• A third group contemplators, very little
  research on them

35
Common Myths About Youth Suicide

• Adolescents who talk about suicide are just
  looking for attention
• Listening to certain types of music (e.g., heavy
  metal) or engaging in certain activities (e.g.,
  watching particular movies) causes people to
  become suicidal
• Preventing access to lethal means will not
  prevent suicide - students will simply choose
  another method
• Most dangerous myth Talking about suicide will
  encourage suicidal behavior

36
Prevention

• Schools and communities.
• EDUCATION and knowledge vs. fear and judgments.
• Secondary prevention identification and
  intervention.
• Tertiary prevention siblings, children of people
  who complete suicide.
• Pediatricians and postpartum depression or
  postpartum psychosis.

37

• ASSESSMENT AND INTERVENTION

38
Protective Factors in General Population

• Children in the home, except among those with
  postpartum psychosis
• Pregnancy
• Deterrent religious beliefs
• Life satisfaction
• Reality testing ability
• Positive coping skills
• Positive social support
• Positive therapeutic relationship

39
Child/Adolescent Risk Factors in Youth Suicide

• Previous suicide attempt
• Current suicidal ideation, intent, and plan
• Psychiatric Disorders and Problems
• Depression
• Hopelessness
• Conduct problems
• Drug and/or alcohol abuse
• Impulse control problems (e.g., shoplifting
  gambling eating disorders self-injury)

40
Child/Adolescent Risk Factors in Youth Suicide

• Gay or lesbian sexual orientation
• Unwillingness to seek help because of perceived
  stigma
• Feelings of isolation or being cut off from
  others
• Ineffective coping
• Inadequate problem-solving skills, low emotional
  intelligence
• Cultural and/or religious beliefs (e.g., belief
  that suicide is a noble or acceptable solution to
  a personal dilemma)

41
Environmental/Situational/Family Risk Factors in
Youth Suicide

• Access to lethal methods, especially firearms
• Exposure to suicide and/or family history of
  suicide
• Loss (e.g., death divorce relationships)
• Victimization/exposure to violence (e.g.,
  bullying)
• School crisis (e.g., disciplinary academic)
• Family crisis (e.g., abuse domestic violence
  running away child-parental conflict)
• Influence (either through personal contact or
  media representations) of significant people who
  died by suicide
• Barriers to accessing mental health treatment.

42
Environmental/Situational/Family Risk Factors in
Youth Suicide

• Experiences of disappointment or rejection
• Feelings of stress brought about by perceived
  achievement needs
• Unwanted pregnancy, abortion
• Infection with HIV or other sexually transmitted
  diseases
• Serious injury that may change the individuals
  life course (e.g., Traumatic Brain Injury)
• Severe or terminal physical illness
• Death of a loved one
• Separation from family or friends.

43
Suicide Clusters (Copycat suicides)

• Defined as more suicides or suicide attempts than
  expected, close together in time and location.
• Teens most susceptible to contagion.
• Appears to represent 1-5 of all suicides.
• Centers for Disease Control (CDC) estimates that
  100-200 teens die in clusters annually.
• Media reporting may contribute to clusters

44
Youth Suicide ClustersCommunity Characteristics

• Lack of integration and belonging
• Rapid community growth and large schools
• High rates of substance abuse
• Emphasis on material possession
• Lack of mental health services and little
  awareness of problem of youth suicide
• No 24-hour crisis hotlines
• Lack of networking and coordination among
  community agencies

45
Warning Signs for Youth Suicide

• Suicide threats
• Suicide plan/method/access
• Making final arrangements
• Sudden changes in behavior, friends, or
  personality
• Changes in physical habits and appearance
• Preoccupation with death and suicide themes
• Increased inability to concentrate or think
  clearly
• Loss of interest in previously pleasurable
  activities
• Symptoms of depression
• Increased use and abuse of alcohol and/or drugs

46
Suicide Risk Assessment Questions to Ask

• Hows your mood?
• Have you ever thought about suicide?
• Have you ever tried to hurt yourself?
• Do you have a plan to harm yourself now?
• What is your plan?
• Have you told anyone about your plan?

47
Suicide Risk AssessmentIssues to Cover

• What do you think others say if you were dead?
• Have you made any final arrangements?
• Who are your support system (e.g. parents,
  caregivers, other adults, friends, etc.)
• Are there reasons why you wouldnt?

48
Suicide Risk Assessment Interviewing Children
and Youth

• Calmly gather information.
• Be direct and unambiguous in asking questions.
• Assess lethality of method and identify a course
  of action.
• Use effective listening skills by reflecting
  feelings, remaining non-judgmental, and not
  minimizing the problem.
• Communicate caring, support, and trust while
  providing encouragement for coping strategies.
• Be hopeful emphasize the individuals abilities
  to solve problems.
• Determine if he/she has a thorough understanding
  of the finality of death (suicide is a permanent
  solution to a temporary problem).

49
No-Suicide or Safety Contracts

• Widely used and recommended, but there is
  increasing controversy regarding their use
• In reality, they are neither contractual nor
  ensure genuine safety
• They tend to emphasize what students wont do
  rather than what they will do
• May be viewed by students as coercive, since
  failure to sign may force hospitalization
• May give clinicians a false sense of security
• Better approach Encourage students to commit to
  treatment rather than merely promising safety

50
Suicide Risk AssessmentQuestions for Teachers

• Have you noticed any major changes in your
  students schoolwork recently?
• Have you noticed any behavioral, emotional, or
  attitudinal changes?
• Has the student experienced any trouble in
  school? What kind of trouble?
• Does the student appear depressed and/or hostile
  and angry? If so, what clues does the student
  give?
• Has the student either verbally, behaviorally, or
  symbolically (in an essay or story) threatened
  suicide or expressed statements associated with
  self-destruction or death?

51
Suicide Risk AssessmentQuestions for
Parents/Caregivers

• Has any serious change occurred in your childs
  or familys life recently?
• (If yes) How did your child respond?
• Has your child had any accidents or illnesses
  without a recognizable physical basis?
• Has your child experienced a loss lately?
• Has your child experienced difficulty in any
  areas of his/her life?
• Has your child been very self-critical, or does
  he/she seem to think that you or teachers have
  been very critical lately?

52
Suicide Risk AssessmentQuestions for
Parents/Caregivers

• Has your child made any unusual statements to you
  or others about death or dying? Any unusual
  questions or jokes about death or dying?
• Have there been any changes youve noticed in
  your childs mood or behavior over the last few
  months?
• Has your child ever threatened or attempted
  suicide before, or attempted to harm
  himself/herself?
• Have any of your childs friends or family,
  including yourselves, ever threatened or
  attempted suicide?
• How have these last few months been for you? How
  have you reacted to your child (e.g., with anger,
  despair, empathy)?

53
Special Issues in Suicide Risk Assessment
Self-Injury

• Self-injury (also known as self-mutilation)
  involves the intentional self-destruction of body
  tissue without deliberate suicidal intent
• Most typical form of self-injury is cutting
• Self-injury appears to provide rapid but
  temporary relief from stress and tension, a sense
  of security or control, and/or decreases in
  distressing thoughts or feelings
• Although youth who engage in self-injury are at
  increased risk for suicidal behavior, self-injury
  and suicide are two different types of problems
  and are not synonymous

54
Special Issues in Suicide Risk Assessment
Self-Injury

• Making an accurate distinction between suicidal
  behavior and self-injury is critical, because
  despite some similarities in appearance they
  serve different functions
• An individual attempting suicide is trying to end
  his/her life, whereas the individual engaging in
  self-injury is typically trying to maintain it
• In contrast to suicide completion, self-injury
  appears to be more prevalent in girls than boys
• Self-injury typically begins in early adolescence
  and may persist for years if not adequately
  treated
• The number of children and youth engaging in
  self-injury is likely underestimated and
  increasing

55
Immediate Interventions for Suicidal Youth

• Assess severity of suicidal risk
• Remove access to methods
• Notify parents/caregivers and others as needed
• Supervise at all times
• Suicide-proof the environment
• Seek support and collaboration from colleagues
• Mobilize a support team for the individual
• Document all actions

56
What NOT to do

• Dont leave the person alone or send him away
•  
• Dont overreact dont be shocked by anything he
  (she) says. Listen and express willingness to
  help
• Dont rush establish contact and get the person
  to someone who can help you are not trying to
  completely resolve the crisis
•  
• Dont minimize the persons concerns this is
  not worth killing yourself over.   Remember to
  acknowledge I see this is very upsetting to you
  and I want to get help for you.
•  
• Dont argue whether suicide is right or wrong.
•  
• Dont preach or moralize you have everything to
  live for.  The issue is the problem or bind the
  person feels he (she) is in, not life and death
  per se.
•  
•   

57
What NOT to do, contd.

• Dont discount or make light of the suicidal
  threat  you dont really want to kill
  yourself. 
• Dont challenge or get into a power struggle. 
  You will do everything you can to get help right
  now, but ultimately he (she) has control over his
  decision.
•  
• Dont think the person just needs reassurance. 
  You can reassure that you will get help.
•  
• Dont promise to keep the conversation
  confidential.  There is limited confidentiality
  in life-threatening situations.
•  
• Remember that all persons who are at risk for
  suicide need help.  It is always better to
  overreact (in terms of taking action) than to
  fail to take action.  It is better to have
  someone angry with you or embarrassed than dead.

58
Suicide Postvention

• Schools and communities are frequently not
  prepared for suicide, yet few events have greater
  impact on parents, staff, and other youth.
• In schools, primary goal of postvention is to
  prevent further suicidal behavior and possible
  contagion effects.
• Among clinicians, primary goal is to offer
  support to family members.

59
Suicide PostventionRecommended Dos and
Donts

• Do plan in advance of any crisis
• Do select and train a crisis team
• Do verify that a suicide occurred
• Do disseminate information to faculty, students,
  and parents be truthful but avoid unnecessary
  detail
• Do report information to students in small groups
  (classrooms) using fact sheets and uniform
  statements
• Do not release information about the suicide in a
  mass assembly or over a loud speaker
• Do have extra counselors available on site for
  students and staff

60
Suicide PostventionRecommended Dos and
Donts

• Do not dismiss school or stop classes
• Do not dedicate a memorial, fly flag at
  half-mast, or have a moment of silence for
  deceased develop living memorials instead (e.g.,
  student assistance programs)
• Do allow students, with parental permission, to
  attend the funeral
• Do not make special arrangements to send all
  students from a class or school to the funeral
• Do contact the family and offer any assistance
• Do collaborate with media, law enforcement, and
  community agencies

61
Suicide PostventionMedia Guidelines

• Do not sensationalize with front page coverage
  and/or details of suicide method
• Avoid phrases like successful suicide, failed
  attempt
• Do not print pictures of deceased
• Do not report the suicide as simplistic or
  romantic
• Do emphasize that no one person or thing is to
  blame
• Do provide information on suicide prevention
• Do provide information about where students can
  go for help, including both school and community
  resources
• Do emphasize that suicide is a preventable
  problem, and that we all have a role in it

62
Your Clinical Skills

• Assessment Knowledge of the risk factors
• 1. Biological
• 2. Family
• 3. Psychological
• 4. Personal
• 5. Contextual
• 6. MSE

63
Biological risk factors

• Family history of psychiatric disorders
• Low serotonin, poor impulse control

64
Family Risk Factors

• Family history of suicide
• Death of parent
• Early separation from parent
• Hostile family relationships
• Chaotic family environment

65
Psychological risk factors

• Substance abuse
• Impulsivity
• Affect regulation problems
• Perfectionism
• Social inhibition
• Sexual identity issue
• Psychiatric disorder
• (especially MDD, BPD, Psychosis, Substance Abuse)

66
Personal risk factors

• Age (Adolescent, elderly)
• Ethnicity (White, male)
• Marital status (single)
• Live alone
• Previous attempt
• Poor health
• History of abuse
• Recent loss
• Access to means, presence of firearms

67
The Specific Suicide Inquiry

• Ask About
• Suicidal ideation
• Suicide plans
• Give Added Consideration to
• Suicide attempts (actual and aborted)
• First episode of suicidality (Kessler 1999)
• Hopelessness
• Ambivalence a chance to intervene
• Psychological pain history
• (Jacobs, 1998)

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Mental status exam

• Mood, affect (hate of self or other, aloneness,
  fear, fatigue, hopelessness, helplessness)
• Suicide preoccupation ideation, intent, plan,
  access, fantasies about death
• Reality testing
• Capacity for differentiation
• Cognitive constriction

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THERE IS NO SINGLE DEFINITIVE PREDICTIVE BEHAVIOR

• Previous attempts
• Verbal statements
• Cognitive constriction
• High perturbation
• Sudden behavioral changes
• Life threatening behaviors
• Access to means

70
Adolescent warning signs

• Withdrawal from friends and family members
• Trouble in romantic relationships
• Difficulty getting along with others
• Changes in the quality of schoolwork or lower
  grades
• Rebellious behaviors
• Unusual gift-giving or giving away own
  possessions
• Appearing bored or distracted
• Writing or drawing pictures about death
• Running away from home
• Changes in eating habits
• Dramatic personality changes
• Changes in appearance (for the worse)
• Sleep disturbances
• Drug or alcohol abuse
• Talk of suicide, even in a joking way
• Having a history of previous suicide attempts

71
Negligence, forseeability, and the legal issues
of pediatric suicide

• Schools
• Primary Care Providers
• Mental Health Clinicians Psychologists, Clinical
  social workers, licensed counselors,
  psychiatrists, and to a lesser extent, clergy

72
Suicidal Behavior and SchoolsLegal Issues

• School districts have been found liable for not
  offering suicide prevention programs, for
  providing inadequate supervision of at-risk
  students, and for failing to notify parents when
  their children were suicidal
• Schools not responsible ultimately, but must
  demonstrate they made appropriate, good faith
  efforts to prevent suicide from occurring

73
Suicidal behavior and physicians Legal issues

• Most common PCP did not make a referral to
  mental health providers or (in a few cases) for
  psychiatric hospitalization
• Second most common PCP did not assess for
  suicidal thoughts, or documentation of assessment
  was not present or insufficient.

74
Legal issues for mental health specialists

• Majority of lawsuits pertained to inpatient
  suicide, or recently released inpatient
• Failure to diagnose misdiagnosis or failing to
  predict
• Abandonment
• Precautions for all health care providers
• DOCUMENTATION

75
When to document suicide assessment

• At first assessment or admission.
• With occurrence of any suicidal behavior or
  ideation.
• Whenever there is any noteworthy clinical change.
• For inpatients
• Before increasing privileges/giving passes
• Before discharge

76
Firearms and the assessment of lethality

• If present - document instructions
• If absent - document as pertinent negative

77

• All adolescents with symptoms of depression
  should be asked about suicidal ideation, and an
  estimation of the degree of suicidal intent
  should be made. No data indicate that inquiry
  about suicide
• precipitates the behavior. In fact, adolescents
  often are relieved that someone has heard their
  cry for help. For most adolescents, this cry for
  help represents an attempt to resolve a difficult
  conflict, escape an intolerable living situation,
  make someone understand
• their desperate feelings, or make someone feel
  sorry or guilty. Suicidal thoughts or comments
  should never be dismissed as unimportant.
  Adolescents must be told by pediatricians that
  their plea for assistance has been heard and that
  they will be helped.
• American Academy of Pediatrics
• http//aappolicy.aappublications.org/cgi/reprint/p
  ediatrics105/4/871.pdf

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Examples of Adolescents at Low, Moderate, and
High Risk for Suicide Low risk Took 5 ibuprofen
tablets after argument with girlfriend.
Impulsive told mother 15 minutes after taking
pills No serious problems at home or
school Occasionally feels down but has no
history of depression or serious emotional
problems Has a number of good friends Wants
help resolving problems and is no longer
considering suicide after interview
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Moderate risk Suicidal ideation precipitated by
recurrent fighting with parents and failing
grades in school Wants to get back at
parents Cut both wrists while at home alone
called friend 30 minutes later Parents
separated, changed school this semester, history
of attention-deficit hyperactivity
disorder Symptoms of depression for the last 2
months, difficulty controlling temper Binge
drinking on the weekends Answers all the
questions during the interview, agrees to see a
therapist if parents get counseling, will contact
the interviewer if suicidal thoughts return
80
High risk Thrown out of house by parents for
smoking marijuana at school, girlfriend broke up
with him last night, best friend killed in
auto crash last month Wants to be dead sees no
purpose in living Took fathers gun is going to
shoot himself where no one can find me Gets
drunk every weekend and uses marijuana
daily Hates parents and school has run away
from home twice and has not gone to school for 6
weeks Hospitalized in the past because he lost
it Does not want to answer many of the
questions during the interview and hates shrinks
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Pediatricians should

• Be informed, know the risk factors
• Ask questions about depression and suicidal
  thoughts during routine exams throughout
  adolescence
• Ask about firearms in the home and discuss safety
  with parents
• Recognize the signs, refer to mental health
  clinicians, and follow up
• Know the community resources
• Be a relentless patient advocate with insurance
  companies.
• American Academy of Pediatrics
• http//aappolicy.aappublications.org/cgi/reprint/p
  ediatrics105/4/871.pdf

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References

• Berman, A.L., Jobes, D.A., Silverman, M.M.
  (2006). Adolescent suicide Assessment and
  intervention, 2nd edition. Washington, DC APA.
• Brock, S.E. (2002). School suicide postvention.
  In S.E. Brock, P.J. Lazarus, and S.R. Jimerson
  (Eds.), Best practices in school crisis
  prevention and intervention (pp. 553-576).
  Bethesda, MD NASP
• Jacobs, D. Suicide Assessment. University of
  Michigan Colloquium series, 2003.
• Kalafat, J., Lazarus, P.J. (2002). Suicide
  prevention in schools. In S.E. Brock, P.J.
  Lazarus, S.R. Jimerson (Eds.), Best practices
  in school crisis prevention and intervention (pp.
  211-223). Bethesda, MD NASP.
• Lenaars, A. (1995). Suicide. Wass, H.,
  Neimeryer, R. (Eds), Dying Facing the Facts,
  Washington, DC, Taylor and Francis.
• Lieberman, R., Poland, S. (2006).
  Self-mutilation. In G. Bear K. Minke (Eds.),
  Childrens needs III. (pp. 965-975). Bethesda,
  MD NASP.
• Miller, D.N., McConaughy, S.H. (2005).
  Assessing risk for suicide. In S.H. McConaughy
  Clinical interviews for children and adolescents
  (pp. 184-199). New York Guilford.
• Stillion, J. (1996). Survivors of Suicide. In
  Doka, K. (Ed.), Living with grief after sudden
  loss (41-51). NY Hospice Foundation of America.
• American Academy of Pediatrics, Policy
  statements. Online at http//aappolicy.aappublicat
  ions.org/cgi/reprint/pediatrics105/4/871.pdf

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Web-Based Resources

• National Association of School Psychologists
• www.nasponline.org
• American Association of Suicidology
• www.suicidology.org
• American Foundation for Suicide Prevention
• www.afsp.org
• Centers for Disease Control
• www.cdc.gov