Saving Lives: Understanding Depression And Preventing Suicide – Prevention Training For Physicians and Medical Personnel

1. 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., LPCC, 2004-2006

2. “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

3. Training Goals • 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

4. Why Do We Need To Improve Suicide Prevention Efforts? • 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

5. Changing Our Approach: Depression Is An Illness • Suicide has been viewed for countless generations as: • 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

6. The research evidence is overwhelming- what we think of as depression is far more than a sad mood. It includes: • 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 • Sometimes, suicidal thoughts (DSMIVR, 2002) Physicians Awareness Training

7. 20 years of brain research teaches that what we are seeing is the behavioral result of: • Internalchanges in the physical structure of the brain • Destruction or shutting down of brain cells in the hippocampus and amygdala • 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

8. Faulty Wiring? • Literally, damage to certain nerve cells in our brains • 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

9. 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

10. Where It Hits Us Physicians Awareness Training

11. 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

12. 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

13. Renewed dendrites: • increase the number of neuronal connections • allow our nerve cells to begin connecting again • 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

14. 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

15. 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

16. 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

17. How Does Psychotherapy Help? • 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

18. 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 (evidence-based) • Doctors should make referrals to a cognitive or interpersonal therapists Physicians Awareness Training

19. 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 Physicians Awareness Training

20. Suicide Prevention Efforts • First national effort established at NIMH in 1969 • Surgeon General issued a call to action to prevent suicide in 1999 • In 2001, a National Strategy for Suicide Prevention Committee developed future goals and objectives • 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

21. 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 • An increase in suicide prevention programs in schools • The rapid development of suicidology as a multidisciplinary sub-specialty • Establishment of centers for the study and prevention of suicide Physicians Awareness Training

22. Framework For Prevention • Public health approach to prevention in contrast to clinical approaches used in the past • The prevailing model is the Universal, Selective, and Indicated model (WHO, 2002) • Focuses attention on defined populations, from everyone, to specific at-risk groups, to specific high-risk individuals Physicians Awareness Training

23. Is Suicide Really a Problem? • 89 people complete suicide every day • 32,439 people in 2004 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

24. 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 55,000 troops, and 220,000 people to suicide Physicians Awareness Training

25. 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 • 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 (Surgeon General’s call to Action, 1999) Physicians Awareness Training

26. Comparative Rates Of U.S. Suicides-2004 • Rates per 100,000 population • National average - 11.1 per 100,000* • White males - 18 • Hispanic males - 10.3 • African-American males - 9.1 ** • Asians - 5.2 • Caucasian females - 4.8 • African American females - 1.5 • Males over 85 - 67.6 • Annual Attempts – 811,000 (estimated) • 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

27. Suicide Rate By Age Per 100,000 Older people: 12.7% of 1999 population, but 18.8% of suicides.(Hovert, 1999) Physicians Awareness Training

28. 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 alter the course of other medical conditions (Empfield, 2003) Physicians Awareness Training

29. PCP’s And Diagnosis Of Depression • Seniors have often visited a health-care provider before completing suicide • 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

30. Poor Quality Of Mental Health Care For Elders • 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

31. Depression Associated With Worse Health Outcomes • 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 increasesthe risk for depression particularly in: • Ischemic heart disease (e.g. MI, CABG) Stroke Cancer Chronic lung disease Alzheimer’s disease Parkinson’s disease Rheumatoid Arthritis (Empfield, 2003) Physicians Awareness Training

32. 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 • 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

33. 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 (Empfield, 2003) Physicians Awareness Training

34. Benefits Of Treatment For Depression In The Elderly • 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 (Empfield, 2003) Physicians Awareness Training

35. What Factors Put Someone At Risk? • Many things increase one’s risk for suicide- biological, psychological, social factors all apply • The single greatest risk factor for suicide completion - having a depressive illness. • 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 self-medicating (Lester, 1998) Physicians Awareness Training

36. Other risk factors include: • 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 – 70% of completed suicides used firearms (Surgeon General’s call to Action, 1999) Physicians Awareness Training

37. 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 • Psychological factors: • 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

38. 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

39. Treatment • 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

40. 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. 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

42. 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

43. 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

44. How Do We Know Suicide Prevention Coalitions Work? • 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

45. How Can You Help? • 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

46. 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

47. Hopelessness is the most immediate risk factor for suicide, so instilling hope is essential • If your patient is on anti-depressant or anti-anxiety 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

48. 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) • 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

49. Use Of A Structured Interview • 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

50. Screening Recommendations • 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