Download pdf - Suicide Prevention Handouts - MyCASAT · the rate of suicide among AI/AN youth aged 10 to 18 years was 10.37 per 100,000, compared with an overall rate of 3.95 per 100,000.Suicide

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RichShannon

NCC,LMFT,LCADC

[email protected]

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Thistrainingwillconsider:basicstrategiesinaddressingsuicidalthoughtsandbehaviors,techniquesforassessingsuicidalideationandconsiderationsforbestpracticesinrespondingtotheseuniquesituations.Inadditionwewillevaluatehowsuicidemayormaynothaveimpacteduspersonallyandtherolethatplaysinourpractice.

CourseDescription

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Slide3

https://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc-criteria.pdf

InCaseYouDon’tHaveIt

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Atorientationandannuallythereafter,doestheclinicprovide(ataminimum)trainingon(1)riskassessment,suicideprevention,andsuicideresponse;(2)therolesoffamiliesandpeers;and(3)othertrainingsrequiredbythestateoraccreditingagency?

DoestheclinicprovideinstructionsonhowtoaccesscrisisservicesandPsychiatricAdvancedDirectivesusingappropriatemethods,language(s),andliteracylevelsinaccordancewiththepopulations identifiedduringtheneedsassessment?

Doclinicprotocolsandproceduresprovidefortransferofmedicalrecordsofservicesreceived(e.g.,prescriptions),activefollow-upafterdischarge,and,asappropriate,aplanforsuicidepreventionandsafety,andprovisionforpeerservices?

Doestheclinichavepoliciesorproceduresthataredesignedtoreducesuicideriskinplaceforindividualswhoareadmittedtothesefacilitiesasapotentialsuiciderisk?Ifagreementscannotbeestablished,whatistheclinicjustificationforlackofagreement?Ifagreementscannotbeestablished,doestheclinichaveasufficientcontingencyplanforprovisionofservicesorarefurthereffortsrequired?

InRelationtoSuicide

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Doestheclinichaveanestablishedprotocolthatspecifiestheroleoflawenforcementduringtheprovisionofcrisisservices?

Anassessmentofwhethertheconsumerisarisktoselfortoothers,includingsuicideriskfactors

adiagnosticassessment,includingcurrentmentalstatus,mentalhealth(includingdepressionscreening)andsubstanceusedisorders(includingtobacco,alcohol,andotherdrugs);

assessmentofimminentrisk(includingsuiciderisk,dangertoselforothers,urgentorcriticalmedicalconditions,otherimmediaterisksincludingthreatsfromanotherperson);

Targetedcasemanagementshouldincludesupportsforpersonsdeemedathighriskofsuicide,particularlyduringtimesoftransitionssuchasfromanEDorpsychiatrichospitalization

DoestheCQIprocessaddresstrackingofsuicideattemptsandcommittedsuicides?

InRelationtoSuicide

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ProcessingofAttitudes,ExperiencesandPerceptionsFactsandFiguresConsiderationsIncludingAlcohol,DrugsandBeyondAssessmentResponseApplication

Wherearewegoing?

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Rememberthefirstsubstanceabuseclientyouinterviewed?Doyourememberyourinternalreactiontothatinterview?Now,you’realotmorecomfortabletalkingwithclientsabouttheirdrughistory,theircurrentsymptoms,andtheirplansforrecovery.Nothingreducesanxietymorethanpractice.Thesameholdstrueabouttalkingwithyourclientsaboutsuicidalthoughtsandbehaviors.Ifyouneedtoreduceyourinitialdiscomfortonthetopic,practicewithanothercounselororyourclinicalsupervisor.Getfeedbackabouthowyouarecomingacross.Startaskingeveryoneofyourclientsaboutsuicidality.Themoreexperienceyouhave,themorecomfortableyouwillbecome.(TIP50)

Practice,Practice,Practice

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Slide8

Whythismatters…

Processing

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…yourattitudesaboutsuicidearestronglyinfluencedbyyourlifeexperienceswithsuicideandsimilarevents.Needlesstosay,yourresponsestosuicideandtopeoplewhoaresuicidalarehighlysusceptibletoattitudinalinfluence,andtheseattitudesplayacriticalroleinworkwithpeoplewhoaresuicidal.Anempathicattitudecanassistyouinengagingandunderstandingpeopleinasuicidalcrisis.Anegativeattitudecancauseyoutomissopportunitiestoofferhopeandhelportooverreacttopeopleinasuicidalcrisis.(TIP50)

AttitudeConsiderations:

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Objectives:Minimizeanxietyaboutdiscussingsuicide.Exploreattitudetowardsuicideandpotentialforpersonalandprofessionalimpact.Whatismypersonalandfamilyhistorywithsuicidalthoughtsandbehaviors?WhatpersonalexperiencesdoIhavewithsuicideorsuicideattempts,andhowdotheyaffectmyworkwithsuicidalclients?Whatismyemotionalreactiontoclientswhoaresuicidal?HowdoIfeelwhentalkingtoclientsabouttheirsuicidalthoughtsandbehaviors?WhatdidIlearnaboutsuicideinmyformativeyears?HowdoeswhatIlearnedthenaffecthowIrelatetodaytopeoplewhoaresuicidal,andhowdoIfeelaboutclientswhoaresuicidal?WhatbeliefsandattitudesdoIholdtodaythatmightlimitmeinworkingwithpeoplewhoaresuicidal?

ProcessingofAttitudes,ExperiencesandPerceptions

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PositiveAttitudeandBehavior1:Peopleinsubstanceabusetreatmentsettingsoftenneedadditionalservicestoensuretheirsafety.PositiveAttitudeandBehavior2:Allclientsshouldbescreenedforsuicidalthoughtsandbehaviorsasamatterofroutine.PositiveAttitudeandBehavior3:Allexpressionsofsuicidalityindicatesignificantdistressandheightenedvulnerabilitythatrequirefurtherquestioningandaction.

TIP50’s6PositiveAttitudesandBehaviorstoConsider

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PositiveAttitudeandBehavior4:Warningsignsforsuicidecanbeindirect;youneedtodevelopaheightenedsensitivitytothesecues.PositiveAttitudeandBehavior5:Talkingaboutaclient’spastsuicidalbehaviorcanprovideinformationabouttriggersforsuicidalbehavior.PositiveAttitudeandBehavior6:Youshouldgiveclientswhoareatriskofsuicidethetelephonenumberofasuicidehotline;itdoesnoharmandcouldactuallysavealife.

TIP50’s6PositiveAttitudesandBehaviorstoConsider

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Nowthatwehaveprocessedattitudes,experiencesandperceptionswhatisaprofessionalconsiderationforyoumovingforward?

Application

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Objectives:Considerintentionalitywhenworkingwithallclientsanduniqueriskfactorsforspecificpopulations.

Createawarenessofthenumberofsuicidesandtheimpactonsocietyandothers.

FactsandFigures

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Suicideisaleadingcauseofdeathamongpeoplewhoabusealcoholanddrugs(Wilcox,Conner,&Caine,2004).Comparedtothegeneralpopulation,individualstreatedforalcoholabuseordependenceareatabout10timesgreaterrisktoeventuallydiebysuicidecomparedwiththegeneralpopulation,andpeoplewhoinjectdrugsareatabout14timesgreaterriskforeventualsuicide(Wilcoxetal.,2004).Individualswithsubstanceusedisordersarealsoatelevatedriskforsuicidalideationandsuicideattempts(Kessler,Borges,&Walters,1999).

FactsandFigures

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Slide16 Peoplewithsubstanceusedisorderswhoareintreatmentareatespeciallyhighriskofsuicidalbehavior

formanyreasons,including:

Theyentertreatmentatapointwhentheirsubstanceabuseisoutofcontrol,increasingavarietyofriskfactorsforsuicide(Ross,Teesson,Darke,Lynskey,Ali,Ritter,etal.,2005).

Theyentertreatmentwhenanumberofco-occurringlifecrisesmaybeoccurring(e.g.,marital,legal,job)(Rossetal.,2005).

Theyentertreatmentatpeaksindepressivesymptoms(Rossetal.,2005).

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Mentalhealthproblems(e.g.,depression,posttraumaticstressdisorder[PTSD],anxietydisorders,somepersonalitydisorders)associatedwithsuicidalityoftenco-occuramongpeoplewhohavebeentreatedforsubstanceusedisorders.Crisesthatareknowntoincreasesuiciderisksometimesoccurduringtreatment(e.g.,relapseandtreatmenttransitions).

Whatelsemightincreasesuicideriskamongpeoplewithsubstanceusedisorders?

Peoplewithsubstanceusedisorderswhoareintreatmentareatespeciallyhighriskofsuicidalbehavior

formanyreasons,including:

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Suicideisthe10thleadingcauseofdeath,claimingmorethantwiceasmanyliveseachyearasdoeshomicide.1Onaverage,between2001and2009,morethan33,000Americansdiedeachyearasaresultofsuicide,whichismorethan1personevery15minutes.1Morethan8millionadultsreporthavingseriousthoughtsofsuicideinthepastyear,2.5millionreportmakingasuicideplaninthepastyear,and1.1millionreportasuicideattemptinthepastyear.3Almost16percentofstudentsingrades9to12reporthavingseriouslyconsideredsuicide,and7.8percentreporthavingattemptedsuicideoneormoretimesinthepast12months.4

AdditionalFactsandFiguresAboutSuicide

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Despitetheseverypersonalexperiences,mostAmericansaresurprisedtolearnthatbetween2001and2009,anaverageof33,000suicidedeathsoccurredeachyearintheUnitedStates.Suicideisamongthetopfivecausesofdeathforadultsunderage45intheUnitedStates,andin2009,moreAmericansdiedfromsuicidethanfrommotorvehicletraffic-relatedinjuries.(U.S.DeptofHHS)

Afteradecadeofadvancementsinsuicideprevention,weNationalCouncilforSuicidePrevention(NCSP)remainconcernedthatthenationisstillinaperiodofrisingsuiciderates.Therefore,webelievethatthetimingforarevisedNationalStrategyisrightandthatitoffersanimprovedframeworkforachievingourultimategoalofsavinglives.(U.S.DeptofHHS)


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Theeffectofsuicideoncommunitiesacrossournationgoesbeyondthepersonal.Suicideaffectssomeofthemostimportantconcernsofourtime.SuicideamongthosewhoserveinourArmedForcesandamongourveteranshasbeenamatterofnationalconcern.Thelargestnumberofsuicidaldeathseachyearoccursamongmiddle-agedmenandwomen,sappingtheworkforceweneedtogrowoureconomy.Thefactthatsuicidalbehavioroccursamongsomeofourmostmarginalizedcitizensisacalltoactionwemustembrace.(U.S.DeptHHS)


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Slide21

Istheresomethingyoudidn’tknow?

Istheresomethingthatsurprisedyou?

Istheresomethingthatincreasedyourawarenessthatcouldbeusedinprofessionalapplication?

Application

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Objectives:Considerspecificpopulationsidentifiedasbeingathigherriskforsuicide.

Considerspecificlifeeventsthatmaycreateahigherriskforsuicide.

Considerationsincludingalcohol,drugsandbeyond.

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Exceptasnoted,thefollowinginformationonsuiciderisksinspecificpopulationsisfromthe:

2012NationalStrategyforSuicidePrevention:GOALSANDOBJECTIVESFORACTIONAreportoftheU.S.SurgeonGeneralandoftheNationalActionAllianceforSuicidePrevention

Emphasishasbeenadded.

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In2009,thesuiciderateamongAmericanIndians/AlaskaNatives(AI/AN)was11.91per100,000,whichissimilartotheoverallU.S.rateof11.77.However,suicideratesaremuchhigheramongAI/ANyouththanamongyouthoverall. In2009,therateofsuicideamongAI/ANyouthaged10to18yearswas10.37per100,000,comparedwithanoverallrateof3.95per100,000. SuicideisthesecondleadingcauseofdeathamongAI/ANyouthaged10to34years,withyoungNativemenaged20to24havingthehighestrateofsuicideintheAI/ANpopulation:40.79deathsper100,000.Althoughsuicideratesvarywidelyamongindividualtribes,itisestimatedthat14to27percentofAI/ANadolescentshaveattemptedsuicide.

AmericanIndians/AlaskaNatives

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Researchindicatesthatculturalcontinuity, highlevelsofculturalspiritualorientation, andconnectednesstofamilyandfriends areprotectivefactorsforsuicidalbehaviorsamongAI/ANpopulations.Specificriskfactorsparticulartothisgroupincludealcoholandothersubstanceuse, discrimination, limitedmentalhealthservicesaccessanduse, andhistoricaltrauma. FindingsfromtheAdverseChildhoodExperiences(ACE)studysuggestthatthereisastrongandpositivecorrelationbetweenthenumberofadverseeventsinachild’slifeandtheprobabilityfornegativeoutcomesduringadulthood. Inreservationsettings,AI/ANyouthhaveconsiderableexposuretosuicideandmaybeatparticularriskforcontagion.MuchoftheresearchavailableonAI/ANracialandethnicdisparitiesdoesnotincludeurban(non-reservation)areas,whereamajority(78percent)ofNativepeopleintheUnitedStateslive. Comparedwithotherracialandethnicgroups,fewresourcesaredevotedtothehealthneedsoftheurbanAI/ANpopulation, andmanyhaveexperiencedlossesofcommunity,language,andethnicidentity.

AmericanIndians/AlaskaNatives

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Slide26Theimpactofsuicidecanbeprofoundandsometimesdevastatingforthosewhoareleftbehind.Eachyear,morethan13millionpeopleintheUnitedStatesreportthattheyhaveknownsomeonewhodiedbysuicidethatyear. Conservativeestimatessuggestthattherearetypicallyatleastfiveorsixfamilymemberswhoareaffectedwhenafamilymembertakeshisorherlife,andperhapsasmanyas30to60peopleinthelargersocialnetworkwhoalsomaybeaffected.Moreover,exposuretosuicidecarriesrisksforelevatedratesofguilt,depression,andotherpsychiatricsymptoms,complicatedgrief,andsocial isolation.Alarmingly,thereisalsocompellingevidencethatindividualsbereavedbysuicide(alsoreferredtoas“survivorsofsuicideloss”)mayhaveanincreasedriskforsuicidecompletionthemselves.Therefore,toparaphraseEdwinShneidman,helpingthosewhohavebeenbereavedbysuicideisadirectformofsuicidepreventionwithapopulationknowntobeatrisk.

IndividualsBereavedbySuicide

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Suicideisoftenthesinglemostcommoncauseofdeathinsecurejusticesettings.Morethan400suicidesoccurannuallyinlocaljailsataratethreetimesgreaterthanamongthegeneralpopulation,andsuicideisthethirdleadingcauseofdeathinprisons. Youthinvolvedinthejuvenilejusticeandchildwelfaresystemshaveahighprevalenceofmanyriskfactorsforsuicide.Althoughstatisticsonprevalenceareunavailable,juvenilesinconfinementhavelifehistoriesthatputthemathighersuiciderisk,includingexperiencessuchasmentaldisordersandsubstanceabuse;physical,sexual,andemotionalabuse;andcurrentandpriorself-injuriousbehavior. Youthinfostercaresharemanyofthesetraumaticexperiences.Inonestudy,childreninfostercarewerealmostthreetimesmorelikelytohaveconsideredsuicideandalmostfourtimesmorelikelytohaveattemptedsuicidethanthosewhohadneverbeeninfostercare. Suicideamongyouthincontactwiththejuvenilejusticesystemoccursatarateaboutfourtimesgreaterthantherateamongyouthinthegeneralpopulation. Researchsuggeststhatyouthengageinmorethan17,000incidentseachyearinjuvenilefacilities,thatmorethanhalfofalldetainedyouthreportedcurrentsuicidalideation,andthatone-thirdalsohadahistoryofsuicidalbehaviors.

IndividualsinJusticeandChildWelfareSettings

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ResearchofNSSIandDSHpopulationsshowsarelativelystrongrelationshipbetweenself-injuryandsuicidalbehaviors.AnAustralianstudyfoundthatapproximately30percentofpatientspresentingwithself-poisoningtoanemergencydepartment(ED)reportedpreviousepisodesofself-harm.OfpatientswhopresentedtotheEDonmorethanoneoccasion,3percentdiedbysuicidewithin5yearsand4percentwithin10years.Inafollow-upstudyofdeliberateself-harmconductedintheUnitedKingdom,deathbysuicidewas17timesmorefrequentthanexpectedinthosewhohadpreviouslypresentedtoageneralhospitalwithdeliberateself-harm. InanotherU.K.follow-upstudyofdeliberateself-harm,therewasanapproximately30-foldincreaseinriskofsuicidecomparedwiththegeneralpopulation.Suiciderateswerehighestwithinthefirst6monthsafterthefirstself-harmepisode.Asystematicreviewoftheinternationalliteratureonfatalandnonfatalrepetitionofself-harmfoundthatafter1year,nonfatalrepetitionofself-harmbehaviorswasapproximately15percent. Thereviewfoundthatsuicideriskwashundredsoftimeshigheramongself-harmpatientsthaninthegeneralpopulation.

IndividualsWhoEngageinNonsuicidalSelf-Injury

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Slide29

Aprevioussuicideattemptisaknownpredictorofsuicidedeath.Astudyofindividualswhohadsurvivedaserioussuicideattempt,conductedinNewZealand,foundthatalmosthalfmadeanotherattemptorsubsequentlydiedbysuicidewithin5years.Manyindividualsdonotreceiveongoingtreatmentormentalhealthcareafteranattempt,althoughtheymaycontinuetoexperiencesuicidalthoughts. Inaddition,astudyconductedintheUnitedKingdomfoundthatmanypeoplewhodiebysuicidedosowithin30daysofhavingbeendischargedfromahospitalforapreviousattempt,oftenbeforeanappointmentforservices.

IndividualsWhoHaveAttemptedSuicide

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Slide30

Morethan60percentofsuicidaldeathsoccuramongindividualswithmooddisorders.Suicideriskisparticularlyhighamongindividualswithbipolardisorders,whichisstronglyassociatedwithsuicidethoughtsandbehaviors.Overtheirlifetime,thevastmajority(80percent)ofpatientswithbipolardisordershaveeithersuicidalideationorideationplussuicideattempts.Inclinicalsamples,14to59percentofthepatientshavesuicideideation,and25to56percentattemptsuicideatleastonceintheirlifetime.Approximately15to19percentofpatientswithbipolardisordersdiefromsuicide.Thesuiciderateamongpatientswithbipolardisordersisestimatedtobemorethan25timeshigherthantherateinthegeneralpopulation.Severalfactorscanincreasetheriskforsuicideamongpatientswhohavemooddisorders.Thesefactorsincludearecentsuicideattemptandaseveremajordepressiveepisode,oftenaccompaniedbyfeelingsofhopelessnessandguilt,abeliefthatthatarefewreasonsforliving,thoughtsofsuicide,agitation,insomnia,appetiteandweightloss,andpsychoticfeatures. Suicidalbehaviorsamongmooddisorderpatientsoccuralmostexclusivelyduringanacute,severe,majordepressiveepisode.

IndividualswithMentalDisorders:MoodDisorders

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Slide31

Thepresenceofanyanxietydisorderissignificantlyassociatedwithsuicidalideationandsuicideattempts.Anxietydisorderscommonlyoccuralongwithothermentalorphysicalillnesses,includingalcoholorsubstanceabuse,whichmaymaskanxietysymptomsormakethemworse.Thepresenceofanyanxietydisorderincombinationwithamooddisorderisassociatedwithahigherlikelihoodofsuicideattemptsincomparisonwithamooddisorderalone.Amongadultsinthegeneralpopulation(i.e.,notintheArmedForcesorveterans),panicdisorderandPTSDhavebeenfoundtobemorestronglyassociatedwithsuicideattemptswhenthereisaco-occurringpersonalitydisorder.

IndividualswithMentalDisorders:AnxietyDisorder

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Slide32

Ithasbeenestimatedthatbetween3and10percentofpatientswithBPDdiebysuicide. Recurrentsuicideattempts,self-injury,andimpulsiveaggressiveactsareoftenassociatedwithBPDandoftenresultinemergencyandinpatienttreatment.SuicidesinBPDoftenoccurlateinthecourseoftheillnessandfollowlongcoursesofunsuccessfultreatment.

IndividualswithMentalDisorders:BorderlinePersonalityDisorder

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Slide33

Theriskforsuicideinindividualssufferingfromschizophreniaisparticularlyhighintheearlystagesoftheillness(first3–5yearsofonset).Ameta-analysisofmorethan60studiesfoundthatalmost5percentofschizophrenicpatientswilldiebysuicideduringtheirlifetimes,usuallyneartheonsetoftheillness. Survivingtheinitialperiodofheightenedriskresultsinalesser,althoughstillconsiderable,riskofdeathbysuicide.Thegreatestindicatorofsuicideriskamongpeoplewithschizophreniaisactivepsychoticillness(e.g.,delusions)combinedwithsymptomsofdepression.Greaterinsightintothepsychoticillnessitself,theneedfortreatment,andtheconsequencesofthedisorderarestronglyrelatedtosuiciderisk. Increasedriskforsuicideisalsoassociatedwithhigherlevelsofeducationandhighersocioeconomicstatus.Alcoholabusehasbeenreportedinstudiesexaminingsuicideattempts.

IndividualswithMentalDisorders:Schizophrenia

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Slide34

StudiesoverthelastfourdecadessuggestthatLGBTindividualsmayhaveanelevatedriskforsuicideideationandattempts.Attentiontothisdisparityhasbeenlimited,inpartbecauseneithertheU.S.deathcertificatenortheNVDRSidentifydecedents’sexualorientationorgenderidentity.Thus,itisnotknownwhetherLGBTpeoplediebysuicideathigherratesthancomparableheterosexualpeople.

Lesbian,Gay,Bisexual,andTransgenderPopulations

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Slide35

Acrossmanydifferentcountries,astrongandconsistentrelationshipbetweensexualorientationandnonfatalsuicidalbehaviorhasbeenobserved. Ameta-analysisof25internationalpopulation-basedstudiesfoundthelifetimeprevalenceofsuicideattemptsingayandbisexualmaleadolescentsandadultswasfourtimesthatofcomparableheterosexualmales. Lifetimesuicideattemptratesamonglesbianandbisexualfemaleswerealmosttwicethoseofheterosexualfemales.Lesbian,gay,andbisexual(LGB)adolescentsandadultswerealsofoundtobealmosttwiceaslikelyasheterosexualstoreportasuicideattemptinthepastyear.Alatermeta-analysisofadolescentstudies concludedthatLGByouthwerethreetimesmorelikelytoreportalifetimesuicideattemptthanheterosexualyouth,andfourtimesaslikelytomakeamedicallyseriousattempt.Acrossstudies,12to19percentofLGBadultsreportmakingasuicideattempt,comparedwithlessthan5percentofallU.S.adults;andatleast30percentofLGBadolescentsreportattempts,comparedwith8to10percentofalladolescents.Todate,population-basedstudieshavenotidentifiedtransgenderparticipants,butnumerousnonrandomsurveysshowhighratesofsuicidalbehaviorinthatpopulation,with41percentofadultrespondentstothe2009NationalTransgenderDiscriminationSurveyreportinglifetimesuicideattempts.


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Slide36

Moststudieshavefoundsuicideattemptratestobehigheringay/bisexualmalesthaninlesbian/bisexualwomen,whichistheoppositeofthegenderpatternfoundinthegeneralpopulation.Asintheoverallpopulation,thereissomeevidencethatthefrequencyofsuicideattemptsmaydecreaseasLGBadolescentsmoveintoadulthood,althoughpatternsofsuicideattemptsacrossthelifespanofsexualminoritypeoplehavenotbeenconclusivelystudied.WithinLGBsamples,especiallyhighsuicideattemptrateshavebeenreportedamongAfricanAmerican,Latino,NativeAmerican,andAsianAmericansubgroups.


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Slide37

ThesuiciderateforactivedutymilitarypersonnelhashistoricallybeensignificantlylowerthantherateforacomparablepopulationofAmericans.However,boththenumbersandratesofsuicidehavebeenincreasingoverthepastdecade.In2001,theU.S.DepartmentofDefense(DoD)recorded160totalsuicidesforarateof10.3per100,000.Suicideratesbegantoincreasein2006,drivenprimarilybyasteadyupwardtrendinthenumberofsuicidesintheArmyandMarineCorps.In2009,theDoDidentified309totalactivedutysuicides,forarateof18.3per100,000.ThenumberofsuicideshasbeenontheriseintheReserveComponent(RC)aswell.In2009,therewere104suicidesofservicememberswhowereintheRCandnotonactivedutyatthetimeoftheevent. In2010,thisnumberincreasedto180,withtheArmyNationalGuardhavingthelargestincreaseinthetotalnumberofsuicidesfrom48in2009to101in2010.

MembersoftheArmedForcesandVeterans

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Slide38

Forcalendaryear2010,servicememberswhowerewhiteandundertheageof25,juniorenlisted(E1–E4),orhighschooleducatedwereatincreasedriskforsuiciderelativetocomparisongroupsinthegeneralpopulation.Servicemembersmostfrequentlyusedfirearmsasthemeansforsuicide.Drugoverdosewasthemostfrequentmethodforsuicideattempts,andthemisuseofprescriptionmedicationwasmorefrequentthanillegaldrugs.Mostservicememberswerenotknowntohavecommunicatedtheirpotentialforself-harmwithotherspriortosuicideorattemptedsuicide.Themajorityofservicememberswhodiedbysuicidedidnothaveaknownhistoryofamentalorsubstanceusedisorder.Finally,theoverwhelmingmajorityofsuicidesoccurredinanondeployedsetting,andmorethanhalfofthosewhodiedbysuicidedidnothaveahistoryofdeployment.


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Slide39

TheCentersforDiseaseControlandPrevention(CDC)estimatesthatveteransaccountforapproximately20percentofthedeathsfromsuicideinAmerica. ThereiscontroversyinthescientificliteratureaboutwhethersuicideratesarehigheramongveteransthanamongotherAmericansaftercontrollingforsex,age,andminoritystatus. However,ratesappeartobeincreasedamongtwoimportantgroups:veteranswhohaverecentlyreturnedfromserviceinAfghanistanandIraq, andthosewhoreceivehealthcareservicesfromtheVeteransHealthAdministration(VHA), thehealthcaresystemoperatedbytheU.S.DepartmentofVeteransAffairs(VA).Inthemostrecentyearsforwhichdataareavailable,suicideratesformaleVHApatientswereapproximately1.4timesgreaterthanforotherAmericanmen.ForfemaleVHApatients,rateswereapproximatelytwiceashighasamongAmericanwomen.Bothincreasesreflectthehigherratesofmedicalandmentalhealthconditions,disability,andotherriskfactorsforsuicidethatoccuramongVHApatients.InVHA,asinDoD,firearmsrepresentedthemostcommonmeansforsuicideandoverdosesrepresentedthemostcommonmeansforattempts. ApproximatelyhalfofallsuicidesinVHAoccurredamongpatientsknowntohavementalhealthconditions. Anincreaseinthesuiciderateamongreturningveteransfirstappearedin2006, andratescontinuetobemonitoredclosely.TheratesasobservedechotheincreasethatoccurredforthefirstfewyearsafterveteransreturnedfromserviceinVietnam.


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Slide40

Whilesuiciderateshavetendedtodecreaseorremainstableformostagegroupsinthepasttwodecades,suicidesinmiddleadulthoodhaveincreased.Menintheiradultyears,fromtheirearly20sthroughtheir50s,accountforthebulkofsuicidesandthemajorityofyearsoflifelostduetosuicide. Yettherehasbeenlittleresearchonthisdemographicgroup,whencomparedwiththenumberofstudiesconductedwithadolescentsandolderadults.

MeninMidlife

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Slide41

Althoughresearchexploringtherecentsurgeinsuicideinmidlifeislacking,existingstudiessuggestthatthefactorsthatmayincreasetheriskforsuicidalbehaviorsinthisgrouparesimilartothoseamongotheragegroupsandinbothsexes:mentalillnessthatcanbediscernedfromretrospectiveanalyses(particularlymooddisorders),substanceusedisorders(particularlyalcoholabuse),andaccesstolethalmeans. However,thesefactorsarelikelytobeexacerbatedbyotherrisk-relatedcharacteristicsthatoccurmorefrequentlyamongmales,suchastheunderreportingofmentalhealthproblems, areluctancetoseekhelp,engagementininterpersonalviolence, distressfromeconomichardship(e.g.,unemployment),anddissolutionofintimaterelationships.

MeninMidlife

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Slide42

Oldermen,inparticularthosewhoarewhite,havedisproportionatelyhighratesofdeathbysuicide.In2009,therateofdeathbysuicideamongolderwhitemenwas30.15per100,000—almostthreetimestherateamongthegeneralpopulation(11.77per100,000).Severalfactorscanincreasetheriskforsuicidalbehaviorsamongoldermen,includingthepresenceofamentaldisorder.Researchsuggeststhatolderadultswhodiebysuicidearemorelikelytomeetcriteriaforaffectivedisorders(especiallymajordepressivedisorder)thanyoungeradults.Otherimportantriskfactorsincludephysicalillnessandfunctionaldecline.Finally,anextensivebodyofliteratureindicatesthatsocialdisconnectionincreasesriskfordeathbysuicideinoldermen.

OlderMen

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Slide43

Suicideinlatelifeisqualitativelydifferentthaninyoungeradults.Olderadultsaremorelikelythanyoungeradultstodiebysuicideasaresultoftheirfirstsuicideattempt,inpartbecauseolderadultsaremorelikelythanyoungeradultstousehighlylethalmeanstoattemptsuicide. Anotherimportantdifferenceisthatolderadultsarelesslikelythanyoungeradultseithertohavereportedsuicidalideationortohavesoughtmentalhealthtreatmentpriortotheirdeaths. Interestingly,however,researchsuggeststhatmostolderadultswhodiebysuicideareseenbyprimarycarephysiciansinthelastthreemonthsoflife.Althoughmanysuicidepreventioneffortshavetargetedyouth,olderadultshavealsobecomeafocusofsuicideprevention.Since2001,manynationalandregionalconferenceshavefeaturedthetopic,andmanystateshavebroadenedorareintheprocessofbroadeningtheirsuicidepreventionstrategiestoincludeolderadults.Somestates(e.g.,OregonandMaine)haveseparateplansforthisagegroup.MentalhealthparityforMedicareisnowbeingphasedinsothatseniorsintheUnitedStateswillhavethesamecopay(20percent)formentalhealthcareasforphysicalhealthcare.

OlderMen

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Slide44

Severalphysicalillnessesareassociatedwithanincreasedriskforsuicidalbehaviors. Thefactorsthatmayhelpexplainthisincreasedriskvarybymedicalconditionbutcanincludechronicpain,cognitivechangesthatmakeitdifficulttomakedecisionsandsolveproblems,andthechallengesandemotionaltollthatcanbeassociatedwithlong-termconditionsandlimitations.

IndividualsWithMedicalConditions

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Slide45

Cancerisoneofthemostcommonphysicalillnessesassociatedwithelevatedsuiciderisk.TheNationalCancerInstitutehasidentifiedcancersofthemouth,throat,andlungasriskfactorsforsuicidalbehaviors.Whilesuiciderisktendstobehighestinthefirstfewmonthsafterdiagnosis,riskremainselevatedinthefirst5years. Fearassociatedwithhowthediseaseisperceivedandmanaged,ratherthanthefearofdeathitself,isafrequentprecipitatorofsuicidalbehaviors. Theconsequencesorsideeffectsoftreatmentcanalsoresultinpsychologicalproblems. Fatigueand/orexhaustion,someofthemostfrequentlyreportedsideeffectsofcancertreatments,canbeariskfactorforsuicidalbehaviors. Inaddition,depressionandanxietyarecommonincancerpatients.About63to85percentofindividualswithcancerwhodiebysuicidemeetcriteriaforseveredepression,anxiety,andthoughtdisorder. Itisnotalwaysclearwhetherthesetypesofmentaldisordersaretriggeredbythedisease,occurasaconsequenceofthedisease,orareanadverseeffectofthetreatmentitself.


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Slide46

Overallthereisstrongevidencethatpsychologicalandsocialfactors(e.g.comorbiddepression,hopelessness,lossofdignity,andtheimpactofspiritualbeliefs),ratherthanthephysicalones(e.g.functionalstatusandlevelofpaincontrol),arethechiefdeterminantsofthedesiretohastendeath.(MaytalandStern2006)


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Slide47

DegenerativeDiseasesoftheCentralNervousSystemTheprevalenceofsuicideisbelievedtobetwotofourtimesgreaterinindividualswithHuntingtondiseasethanamongthegeneralpopulation.Thelifetimehistoryofsuicideattemptsrangesfrom4.8to17.7percent.MajordepressivedisordermaybepresentinuptohalfofpatientswithHuntington’sdiseaseandisthoughttobeaconsequenceofthediseaseitself,ratherthanapsychologicalreactiontohavingaseriousillness. Inaddition,anxietydisorders,obsessive-compulsivedisorders,psychosis,mania,aggression,irritability,impulsivity,andpersonalitychangeshaveallbeenreportedinpatientswiththedisease.


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Slide48

MultipleSclerosis:Studiesconfirmanincreasedriskofsuicideamongpatientswithmultiplesclerosis. Lifetimeprevalenceratesofdepressionrangefrom37to54percent,andtheprevalencerateofdepressionisalmostthreetimesthelifetimeprevalencereportedinthegeneralpopulation.Generalizedanxietydisorder,panicdisorder,andbipolaraffectivedisorder(manicepisodes)arealsopresentmorefrequentlyinthesepatients.


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Slide49

Parkinson’sdiseaseisoftenassociatedwithoneormorepsychiatricorcognitivedisorders,suchasdepression,psychosis,anddementia.Mostoftheobservationssupportthehypothesisthatdepressionisaprimaryconsequenceofbraindysfunction,althoughsituationalfactorsmaycontributetomoodchangestosomeextent. Suicideandsuicideattemptsareuncommondespitethefactthattheratesofsuicidalideationareelevated.Depressionseemstobethemostimportantpredictorofsuicideideation.


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Slide50

TraumaticInjuriesoftheCentralNervousSystem:Suicideandsuicideattemptsoccurmorefrequentlyinthosewithspinalcordinjuries(SCI)thaninthegeneralpopulation.PeoplewithSCIarefivetimesaslikelytoexperiencedepressioncomparedwiththegeneralpopulation,andtheratesofdepressionfollowingatraumaticspinalcordinjurymaybeashighas45percent.Othershavefoundthat10to13percentofSCIpatientssufferfromanxiety andhighlevelsofpost-traumaticstressdisorder.TraumaticBrainInjury:Peoplewithmoderatetoseveretraumaticbraininjury(TBI)mayhavewidespreadcognitiveimpairmentthatcanaffectattention,memory,executivefunctioning,languageandcommunication,visual-spatialskills,andprocessingspeed. TBIsurvivorsmayalsohaveperceptualdeficitsandmotordeficits.Executivebraindysfunctionisacontributingfactorrelatedtosuicidalbehaviors. Areviewoftheliteraturefoundthatonthewhole,thereisanincreasedriskofdeathbysuicide(threetofourtimesgreaterforthosewithsevereTBI),ahigherfrequencyofattempts,andclinicallysignificantsuicidalideationin21to22percentoftheTBIpopulation.


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Slide51

Ingeneral,patientswithmigrainearetwotofourtimesmorelikelytodevelopdepression,twotosixtimesmorelikelytodevelopgeneralanxietydisorder,fivetimesmorelikelytodevelopobsessive-compulsivedisorder,anduptoseventimesmorelikelytodeveloppanicdisorderthanthegeneralpopulation.Furthermore,depressedpatientsareaboutthreetimesmorelikelytodevelopmigraineintheirlifetime.Migrainewithanauraisbelievedtohaveastrongerassociationwithpsychiatricconditionsthanmigrainewithoutanaura.Therelationshipbetweenmigraineanddepressionandanxietyappearstobebidirectional,witheachincreasingtheriskoftheothercondition.Theriskofsuicideideationandattemptsishigheramongmigrainepatients,especiallyinthosewhohavemigrainewithaura.


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Slide52

HIV/AIDSMoststudiesamongindividualslivingwithHIVreportlifetimeprevalenceofsuicideattemptsthatrange from22to50percent.IndividualswithAIDSwere44timesmorelikelytoattemptsuicidethanthose withoutAIDS.WhilemoststudiesreportthatpersonslivingwithHIV/AIDShavemuchhighersuicideratesthanthegeneralpopulationorthosewithotherlife-threateningillnesses,studieshavereportednosignificantdifferencesinsuicideratesbetweenHIV-infectedindividualsandothergroupsatriskforsuicide,suchasinjectiondrugusersandpsychiatricpatients.Hence,HIVstatusmaynotbethemostrelevantfactorrelatedtosuicide,butratherthatothersuicideriskfactorsthatarecommonamongHIV-infectedindividualsplayamoreimportantrole.StudieshaveshownthatsuicideattemptsandsuicideideationamongpeoplewithHIVoccurmostofteninthosewhohaveapreviouspsychiatrichistoryandothersocialandenvironmentalriskfactorsforsuicide.Mood,anxiety,substanceabuse,andpersonalitydisordersareprevalentamongthosewithHIV.


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Slide53

ChronicKidneyDiseaseThefollowingpsychiatricdisordershavebeenfrequentlyobservedinpatientswithsevereend-stagekidneydiseasewhorequirehemodialysis:affectivedisorders,dementiaanddelirium,drug-relateddisorders(e.g.,alcoholdependence),schizophreniaandotherpsychoses,andpersonalitydisorders. Theprevalenceofdepressivedisordersinhemodialysispatientsisestimatedat20to30percent,witharateof10percentformajordepression.Hemodialysispatientswithmajordepressivedisordercommonlydemonstrateasenseofhopelessness,aswellaslackofpleasureandenergy,andotherdepressivesymptoms.Thissubsetofpatientshasbeennotedtobethemostlikelytorequestwithdrawalfromhemodialysis.


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Slide54

ArthritisArthriticdisordersoftenco-occurwithotherphysicalconditions,especiallychronicpainconditionsincludingbackpain,migraine,andotherchronicheadaches. Theassociationbetweenarthritisandproblemssuchasanxiety,substanceuse,andpersonalitydisordershasbeendemonstratedinlarge,population-basedstudies. Therelationshipbetweenarthritisandsuicidalbehaviormaybelargelyexplainedbycomorbidmentalhealthdisordersaloneorincombinationwithotherfactorssuchaslevelofpainand/ordisabilitythatareassociatedwithalowerqualityoflife.


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Slide55

AsthmaAdolescentswithasthmaaremorelikelytoreportdepressivesymptoms,panicattacks,suicideideationandbehavior,andsubstanceabusewhencomparedwiththosewithoutasthma. Itisnotclearwhethertheassociationbetweenasthmaanddepressiveandanxietydisorders,aswellaswithsuicidalideationandbehavior,resultsfromasharedunderlyingprocessorfromsharedriskfactors.


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Slide56

About8.5percentofU.S.adultsareestimatedtohaveanalcoholusedisorder,whichincludesalcoholdependenceandalcoholabuse.Aboutone-fourthofallthesuicidesintheUnitedStatesareestimatedtooccuramongindividualswithalcoholusedisorders.Acute(e.g.,bingedrinkingepisodes)andchronicuseofalcoholareassociatedwithsuicidalbehaviors.Amongindividualswithalcoholusedisorders,suicidefrequentlytakesplacewithinthecontextofamajordepressionandinterpersonalstressors.Aggression,impulsivity,hopelessness,andpartner-relationshipdisruptionsarealsoriskfactors. Studieshaveshownthatdepressionispresentin45percent tomorethan70percent ofthosewithalcoholandsubstanceusedisorderswhodiebysuicide.Althoughlessisknownabouttherelationshipbetweensuicideriskandotherdruguse,thenumberofsubstancesusedseemstobemorepredictiveofsuicidethanthetypesofsubstancesused. Findingsfromafewinitialstudiessuggestthattreatmentofdrugabusemayhelpreducetheriskforfuturesuicidalbehaviors.

SubstanceUseDisorders

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Slide57

SUDsandchronicsubstanceusecanleadtoconsequencesandlossesthatcontributetosuicideriskfactors.Individualsintreatmentforsubstanceusedisordersand/ortransitioningbetweenlevelsofcaremaybeespeciallyvulnerable.Alargenumberofpeopleintreatmenthaveco-occurringmentaldisordersthatincreasesuiciderisk,particularlymooddisorders.Atthetimetheseindividualsentertreatment,theirsubstanceabusemaybeoutofcontrol,theymaybeexperiencinganumberoflifecrises,andtheymaybeatpeaksindepressivesymptoms.Inaddition,mentaldisordersassociatedwithsuicidalbehaviors,suchasmooddisorders,PTSD,anxietydisorders,andsomepersonalitydisorders,oftenco-occuramongpeoplewhohavebeentreatedforsubstanceusedisorders.Crisesthatareknowntoincreasesuiciderisk,suchasrelapseandtreatmenttransitions,mayoccurduringtreatment.Accordingtoonestudy,comparedwiththegeneralpopulation,individualstreatedforalcoholabuseordependencehavea10timesgreaterriskofeventuallydyingbysuicide. Amongthosewhoinjectdrugs,theriskisabout14timesgreaterthaninthegeneralpopulation.


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Slide58

Alcoholanddrugabusearesecondonlytodepressionandothermooddisordersasthemostfrequentriskfactorsforsuicide.AccordingtodatafromtheNationalViolentDeathReportingSystem(NVDRS),in2008alcoholwasafactorinapproximatelyone-thirdofsuicidesreportedin16states.Opiates,includingheroinandprescriptionpainkillers,werepresentin25.5percentofsuicidedeaths,antidepressantsin20.2percent,cocainein10.5percent,marijuanain11.3percent,andamphetaminesin3.4percent.Suicideisaleadingcauseofdeathamongpeoplewithsubstanceusedisorders(SUDs).Substanceusemayincreasetheriskforsuicidebyintensifyingdepressivethoughtsorfeelingsofhopelessnesswhileatthesametimereducinginhibitionstohurtingoneself. Alcoholandsomedrugscancausea“transientdepression,”heightenimpulsivity,andcloudjudgmentaboutlong-termconsequencesofone’sactions.


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Slide59

Researchconsistentlyshowsahighprevalenceofsuicidalthoughtsandsuicideattemptsamongpersonswithsubstanceabuseproblemswhoareintreatment(Ilgen,Harris,Moos,&Tiet,2007)andasignificantprevalenceofdeath-by-suicideamongthosewhohaveatonetimebeeninsubstanceabusetreatmentwhencomparedwiththosewhodonothaveadiagnosisofsubstanceusedisorder(Wilcoxetal.,2004).


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Slide60

Asaresult,substanceabusetreatmentprovidersmustbepreparedtogatherinformationroutinelyfrom,refer,andparticipateinthetreatmentofclientsatriskforsuicidalbehavior.Suicidalthoughtsandbehaviorsarealsoasignificantindicatorofotherco-occurringdisorders(suchasmajordepression,bipolardisorder,PTSD,schizophrenia,andsomepersonalitydisorders)thatwillneedtobeexplored,diagnosed,andaddressedtoimproveoutcomesofsubstanceabusetreatment.


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Slide61

Objectives:Review/introducecommonassessmenttools.

Assessment

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Slide62

Thereisnosubstitutefordirectquestioning.Cliniciansmustbewillingtoaddresssuicidedirectly,confidentlyandwithintentionalityinassessmentandresponse.Allwhileusingtherapeuticskillsincludingempathyandcare.

Intentionality

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Slide63

∗ Clientsinsubstanceabusetreatmentshouldbescreenedforsuicidalthoughtsandbehaviorsroutinelyatintakeandatspecificpointsinthecourseoftreatment.Screeningforclientswithhighriskfactorsshouldoccurregularlythroughouttreatment.

∗ Counselorsshouldbepreparedtodevelopandimplementatreatmentplantoaddresssuicidalityandcoordinatetheplanwithotherproviders.

ExpertRecommendations

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Slide64

∗ Ifareferralismade,counselorsshouldcheckthatreferralappointmentsarekeptandcontinuetomonitorclientsaftercriseshavepassed,throughongoingcoordinationwithmentalhealthprovidersandotherpractitioners,familymembers,andcommunityresources,asappropriate.

∗ Counselorsshouldacquirebasicknowledgeabouttheroleofwarningsigns,riskfactors,andprotectivefactorsastheyrelatetosuiciderisk.


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Slide65

∗ Counselorsshouldbeempathicandnonjudgmentalwithpeoplewhoexperiencesuicidalthoughtsandbehaviors.

∗ Counselorsshouldunderstandtheimpactoftheirownattitudesandexperienceswithsuicidalityontheircounselingworkwithclients.

∗ Substanceabusecounselorsshouldunderstandtheethicalandlegalprinciplesandpotentialareasofconflictthatexistinworkingwithclientswhohavesuicidalthoughtsandbehaviors.


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Slide66

Practice,practice,practice.

Whatstrategywouldyouusetointroducethetopicofsuicide?

Whatassessmentstrategywouldyouusetoassessforsuicide?

Application

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Slide67

http://www.youtube.com/watch?v=nbTsOAy2M0Q

http://www.samhsa.gov

Resources

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Slide68

http://www.thencsp.org/

http://actionallianceforsuicideprevention.org/

http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/CDCResponse.pdf

Resources

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Slide69

Objectives:Determinebaselineforprofessionalresponsetoanassessedsuicidethreatand/orrisk.

Considerwhatpolicyandproceduresexistatcurrentplaceofpractice.

Developawarenessofnationalandlocalorganizations,hotlinesandresources.

Response

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Slide70

Point1:Almostallofyourclientswhoaresuicidalareambivalentaboutlivingornotliving.Point2:Suicidalcrisescanbeovercome.Point3:Althoughsuicidecannotbepredictedwithcertainty,suicideriskassessmentisavaluableclinicaltool.Point4:Suicidepreventionactionsshouldextendbeyondtheimmediatecrisis.

TIP50TenPointsToKeepYouonTrack

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Slide71

Point5:Suicidecontractsarenotrecommendedandareneversufficient.Point6:Someclientswillbeatriskofsuicide,evenaftergettingcleanandsober.Point7:Suicideattemptsalwaysmustbetakenseriously.Point8:Suicidalindividualsgenerallyshowwarningsigns.


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Slide72

Point9:Itisbesttoaskclientsaboutsuicide,andaskdirectly.Point10:Theoutcomedoesnottellthewholestory.


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Slide73

Researchsuggeststhatevensimpleeffortstochallengeisolationandprovidefollow-upsupporttopeoplelivinginthecommunityafteranattemptcanhaveapowerfulimpactandreducefutureattempts. Aprogramthatusedhand-writtenpostcardswithbriefpersonalmessagesshowedremarkableresultsinreducingreattempthospitaladmissions,revealingthatasmallamountofeffortintheareaofsocialsupportmaybeverypowerful.Inaddition,agrowingnumberofprogramsthatprovidesuicideattempt survivorswithself-helptoolsandsocialsupportshowgreatpromiseinreducingisolationandempoweringpeopletomanagetheirownsuicideriskandmentalhealth.

AfteranAttempt

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Slide74

Atwhatpointandhowwouldyouinterveneifyouassessedforsuiciderisk?

Areyouawareofthepolicyandproceduresatyourcurrentplaceofpracticeinregardtosuicideassessmentandresponse?Ifnothowcouldyoufindout?

Whatresourceswouldyouconsiderprovidingyourclient?

Application

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Slide75

Objectives:Review/introducecommonassessmenttools.

Brainstormotherconsiderations.

Assessment

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Slide76

Social:AvailabilityoflethalmeansofsuicideUnsafemediaportrayalsofsuicideCommunity:FewavailablesourcesofsupportiverelationshipsBarrierstohealthcareRelationship:HighconflictorviolentrelationshipsFamilyhistoryofsuicideIndividual:MentalillnessSubstanceabusePrevioussuicideattempts

RiskFactors

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Slide77

Social:Availabilityofphysicalandmentalhealthcare.RestrictionsonlethalmeansofsuicideCommunity:SafeandsupportiveschoolandcommunityenvironmentsSourcesofcontinuedcareafterpsychiatrichospitalizationRelationship:Connectednesstoindividuals,family,communityandsocialinstitutionsSupportiverelationshipswithhealthcareprovidersIndividual:CopingandproblemsolvingskillsReasonsforlivingMoralobjectionstosuicide

ProtectiveFactors

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Slide78

Thereisnosubstitutefordirectquestioning.Cliniciansmustbewillingtoaddresssuicidedirectly,confidentlyandwithintentionalityinassessmentandresponse.Allwhileusingtherapeuticskillsincludingempathyandcare.

Intentionality

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Slide79

PPriorAttemptsIIntentMMeansPPlan

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Slide80

DDisorderEEnvironmentalStressorsAAccesstoFirearmsDDisinhibitionPPriorAttemptsIIdeationMMalePPlan

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Slide81

IIdeation

SSubstanceAbuse

PPurposelessness

AAnxiety

TTrapped

HHopelessness

WWithdrawal

AAnger

RRecklessness

MMoodChange

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Slide82

“Thereisnogenerallyacceptedandstandardizedinstrumentthatcanaccuratelymeasuresuicidepotential.Suicidescreeningandassessmentscalescanbeusedasaids,butifaclientshowssignsofbeingatriskofsuicide,thesescalesarenotasubstituteforathoroughclinicalinterviewbyaqualifiedmentalhealthclinician,duringwhichclientandcounselorcantalkopenlyaboutsuicidality.Anyclientshowingwarningsignsorriskfactorsforsuicidality shouldbeassessedbyamentalhealthprofessionalspecificallytrainedinconductingsuicidalriskevaluations(APA,2000).”(TIP48)

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Slide83

Practice,practice,practice.

Whatstrategywouldyouusetointroducethetopicofsuicide?

Whatassessmentstrategywouldyouusetoassessforsuicide?

Application

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