Suicide suicide attempt

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					      Teen Suicide:
Strategies for Prevention
       Melissa Schiff, MD, MPH
University of Washington MCH Program
     Harborview Injury Prevention
          and Research Center
           Seattle, Washington

                      Maternal and Child Public
                      Health Leadership
                      Training Program
                      School of Public Health
                      University of Washington
          Story of a Teen Suicide
ML, a 16 year old boy, had
  recently moved to a new
  city and started a new
  school. ML had a hard
  time making new friends
  and had experienced
  some bullying at the new
  school. One Friday night,
  ML took out his father’s
  handgun and shot
  himself in the head.
Using the chat feature, type in what you
 think is the single most common risk factor
 for teen suicide?
          Scope of Suicide Problem
          Risk Factors
Outline   Prevention Strategies
          Treatment for Depression
10 Leading Causes of Death by Age Group,
          United States – 2006
            Teen Suicide Problem
                    Counts     Rates*

Deaths              1718       5.79

Attempts            77,323     260.3

ED evaluations      30,595     103.0

Hospitalizations    19,224     64.7

* Per 100,000
                              CDC, WISQARS
                 Teen Suicide Rates for
                      Region 10
Rate / 100,000

                                 CDC, WISQARS
Suicide rates for ages 10+ years by
        County, 2000-2006

                           CDC, NCIPC
• What do you think is the most common
  method used in fatal suicide attempts?
         A. Hand guns
         B. Falls
         C. Suffocation
         D. Poisoning
   Percentage of Self-Harm Injuries, by Age Group,
Disposition, and Mechanism, United States, 2002-2006

                                          CDC, NCIPC
• Which gender is more likely to have fatal
          A. Male
          B. Female
Suicide Rates* Among Persons Ages 10-24 Years, by
 Race/Ethnicity and Sex, United States, 2002-2006
               Risk Factors
• History of psychiatric disorders (90%),
  especially depression (50%)
  – Hopelessness
  – Impulsiveness, aggression
  – High emotional reactivity
• Alcohol, substance abuse
• Child maltreatment
              Risk Factors
• Threats or actual physical violence – peer
• Sexual orientation
• Parental separation, divorce, discord
• Prior suicide attempt, family history of
              Risk Factors
• Access to lethal suicide methods –
  firearms, ammunition
• Local epidemics of suicide
Percentage* of U.S. High School Students Reporting
Considering, Planning, or Attempting Suicide in the
    Past 12 Months, by Sex, United States, 2007

                               Youth Risk Behavior Survey
YRBSS Data on Youth Suicide
               Teen Suicide
           Prevention Strategies
• Early case finding         • No-suicide contracts
• Community assets           • Peer counseling
  development                • Population-based
• Crisis hotlines              screening
• Early parental pathology   • Restricting dispensing
  detection                    quantities
                             • School awareness
• Emetic products              curriculum
• Treatment compliance       • Substitute less toxic
• Non-pharmacological          medications
  care                       • Surrogate roles models
        How to evaluate if
  prevention strategies effective?

• Injury Prevention & Child Death Review
  teams (WA)
  – Review existing studies
  – Evidence-based suicide prevention strategies
• Suicide Prevention Resource Center
  – Evidence-Based Practices Project
              Teen Suicide
          Prevention Strategies

•   22 strategies reviewed
•   Panel of experts
•   Rate study design
•   Make recommendations on evidence
•   3 strategies recommended
            Teen Suicide
        Prevention Strategies
• 1 strategy appears harmful
Effective Prevention Strategies

  • Skills Training
  • Assessment and Referral Training
  • Media Guidelines
               Skills Training

• Youth at risk of school failure, suicide,
  history of abuse
• Development of skills
  – Interpersonal problem solving skills
  – Coping skills
  – Cognitive skills
• Social support
                Skills Training

• Reduce suicide risk factors
• Outcomes evaluated by randomized controlled
  – Depression
  – Drug abuse
  – Attempted and completed suicides
• Active intervention increased protective factors
           Assessment and
           Referral Training

• 75% family, pediatric physicians treat
  childhood depression
• Few receive adequate training
• Less than half screen for suicide risk
• Providers should be trained in
  assessment and referral for depressed
              Assessment and
              Referral Training

• Training workshops for physicians
  – Depression recognition, treatment
  – Identification of suicidal patients
• Improved treatment for depression; decreased
  suicide rates
• Effects on provider education decrease over
• Additional studies in youth population needed
           Media Guidelines

• “Suicide contagion” - media coverage of
  suicide events
• Austria 1984-1987 - suicide deaths from
  subway trains
• 1987 campaign
• Subway suicides and non-fatal attempts
  declined by 80%
            Media Guidelines

• Increase in suicide related to:
  – Increase in number of suicide stories
  – Particular death reported at length, multiple
  – Front page, broadcast coverage
  – Dramatic headlines
                                Describe Treatment
Avoid romanticizing suicide     Sources, Advances

               Media Guidelines

                              Story Recommendations:
  Present Balanced Life
                                   Trends, Myths,
      Picture + & -
                                    Warning Signs
• Have any of your organizations worked
  with media on suicide reporting?
         A. Yes
         B. No
   Potentially Harmful Strategy

Suicide awareness curriculum at schools
  – Teens to identify peers at-risk
  – Increase awareness, disclosure of suicidal
  – Less mental health referral by peers
  – Negative reactions among those with
    history of suicide attempt
      Treatment of Depression /

• Few studies of interventions to reduce
  suicidal ideation, behaviors
• Medications (SSRIs)
  – Antidepressants reduce suicidal ideation and
  – FDA restrictions on antidepressants for youth
      Treatment of Depression /

• Psychotherapy in teens
  – Interpersonal therapy
  – Cognitive behavioral therapy
  – Reduces depression symptoms
• Limitations of studies of therapy

• Youth suicide rates mostly unchanged
• Well-defined risk factors
• Several suicide prevention strategies proven
• Suicide awareness curriculum harmful
• Additional strategies likely effective – more study

• Gould MS. J Am Acad Child Adolesc
  Psychiatry 2003;42:386-405 (Prevention
  strategy review)
• Mann JJ. JAMA 2005;294:2064-2074
  (Prevention strategy review)
• Williams SB. Pediatrics 2009;123:e716-3
  (Treatment for depression in youth)

• Suicide Prevention Resource Center
          Open Discussion

What Suicide Prevention Strategies do You
           Use in Your Agency?