Community-Based Suicide Prevention

Phoenix Area Integrated Behavioral Health

Objectives

• consider suicide as a form of interpersonal violence interrelated with homicide, domestic violence, assault• review evidence on suicide as a community

illness as well as an individual one• develop a prevention approach that blends

“off the shelf” programs with strengths-based interventions specific to your community

suicide: connection to other violence

• US Air Force suicide prevention program was implemented 1996-7• system-wide set of initiatives to change

social norms • in the first 5 years, suicide decreased by 33%• homicide decreased 51% • ‘severe’ family violence decreased 54%• accidental death decreased 18%

Knox K et al. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force. BMJ 2003; 327:1376-80

Arizona 2013 American Indian Trauma Report

compared to all other racial/ethnic groups, Arizona American Indians living on or off tribal lands have: • two times higher rates of any traumatic

injury • three times higher rates of suicide• nine times higher rates of homicide

also see: Addressing Trauma in American Indian and Alaska Native Youth Aug 24,2016Mathematica Policy Research https://aspe.hhs.gov/system/files/pdf/207941/AIANYouthTIC.PDF

Arizona 2013 American Indian Trauma Report – released April 15, 2016

compared to all other racial/ethnic groups, Arizona American Indians living on or off tribal lands have: • 35% more traumas involving alcohol use• 22% less safety restraint use in motor

vehicle crashes

Race-specific trauma rate per 100,000 Arizona residents

Factors associated with higher suicide risk

• depression, anxiety • anhedonia, poor concentration, insomnia, panic

• unemployment• unmarried status (especially for men)• past history of suicide attempts• family history of suicide

Some differences in risk factors for Native people

• alcohol intoxication twice as likely at time of death• AI/AN males: 50% (all US males 25%)• AI/AN females: 40% (all US females 20%)

• age of highest risk • Caucasian males: ages 85 and older• AI/AN males: ages 18-24

Kaplan M et al. Economic contraction, alcohol intoxication and suicide: analysis of the National Violent Death Reporting System Inj Prev 2015;21:35–41.

question

• There is a wide variation in suicide rates among AI/AN communities. Is it explained by differences in reported rates of psychiatric illness and substance abuse?

AI/AN community suicide rate study

• in an analysis of risk factors, protective factors, and individual characteristics from studies on suicide in AI/AN communities, • community-level factors (NOT individual

factors such as diagnosis) were found to explain the largest proportion of the variance in suicide outcomes

Allen J et al. A protective factors model for alcohol abuse and suicide prevention among Alaska Native youth. Am J Community Psychol. 2014;54(1-2):125-139

Community factors associated with higher risk

• severity of historical trauma• lack of cultural continuity as measured by

adequacy of:• self-government, land claims processing• police and fire services• health and education services• cultural facilities

Evans-Campbell T. The historical trauma response among natives and its relationship with substance abuse: a Lakota illustration. J. Psychoactive Drugs 2003 Jan-Mar; 35 (1): 7-13

Alcantra C and Gone J. Reviewing Suicide in Native American Communities: Situating Risk and Protective Factors within a Transactional-Ecological Framework. Death Studies, 31: 457-477, 2007

Some community factors associated with lower suicide risk (Yup’ik teens)

• opportunities for participation and contribution • parents who nurture and regulate children’s

friendships• family and friends perceived as competent

to help solve problems • members engage in self-reflection, develop a

personal life narrative Allen J et al. A protective factors model for alcohol abuse and suicide prevention among

Alaska Native youth. Am J Community Psychol. Sep 2014 V54 pp125-139

Suicide screening tools: outpatient

• PHQ-9 (depression screen)• developed for use in primary care settings • 9 questions • easily scored, with treatment recommendations

(see citation below)

• PHQ-2 is an abbreviated version

http://www.cqaimh.org/pdf/tool_phq9.pdf

Suicide screening tools: home health

Bruce M et al. Depression Care for Patients at Home (Depression CAREPATH): Home Care Depression Management Protocol. Home Healthc Nurse. 2011 Sep; 29(8): 480–489

Suicide screening tools: outpatient toolkit for adolescents

• Guidelines for Adolescent Depression in Primary Care (GLAD-PC) Toolkit

http://www.thereachinstitute.org/images/GLAD-PCToolkit_V2_2010.pdf

Suicide screening: emergency departments

• a study comparing treatment as usual (TAU), primary suicide screening, and primary suicide screening plus intervention • *screening was a combination of PHQ-2 and C-

SSRS questions

Miller I et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570

Suicide screening: emergency departments

• intervention included secondary screening, development of safety plan with ED nurse, and follow up phone calls over a 52-week period• up to 7 brief (10 to 20 min) phone calls • phone calls used ‘Coping Long-term with Active

Suicide Protocol’ (CLASP-ED) protocol • calls made by psychologists, psychology fellows

and a licensed counselor

Miller I et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570

*http://emnet-usa.org/ED-SAFE/materials/K_PtSafetyScreen.pdf

Suicide screening: emergency departments

• outcome variable was suicide attempts• no meaningful reduction in attempts

between TAU and screening groups • intervention group had a 30% reduction in

suicide attempts• frequent ED users are at higher risk of

suicide

Miller I et al. Suicide Prevention in an Emergency Department Population: The ED-SAFE Study. JAMA Psychiatry. 2017;74(6):563-570

Suicide crisis (cluster, epidemic)

• increased incidence of suicide, evidence of “contagion” within a group or community• requires a different level of intervention

• similar to “code green” in a hospital setting• coordinated with community leadership• all helpers unified (school, clinic, chapter, elders,

traditional medicine practitioners, clergy)• with clarity of roles and direction

• ability to move with events

Suicide crisis response

• provide safety, grief counseling• plan for secondary issues (anniversary)

• identify those at risk, link them to care• deliver care where people are• ‘farm out’ clinicians to improve access

• respect beliefs, maintain privacy • bring the community out !!• contact, culture, beliefs

Sharing information in a suicide crisis

WHO recommendations:

• inform without sensational headlines• keep it off the front page• cover it once

• don’t give details of method, location, note• when possible avoid photos/video of family

reaction, funeral

Sharing information in a suicide crisis

• in news/media coverage, focus on the public health aspect of suicide, not the personal details • highlight advice from prevention specialists,

not first responders

• say, “died by suicide”, or “killed him/herself”• not “successful” or “unsuccessful” attempt

Sharing information in a suicide crisis

• explain that most people give warning signs• suicide is preventable

• provide information on how to get help

www.who.int/mental_health/prevention/suicide/resource_media.pdf

question

• Caucasian males over 85 are at highest risk for suicide• AI/AN males between 18 and 24 are at

highest risk• what community factors might this suggest?

Wexler et al. Advancing Suicide Prevention Research With Rural American Indian and Alaska Native Populations .American Journal of Public Health May 2015, Vol 105, No. 5

Elements of a suicide prevention plan

• ‘evidence-based’ skills curricula, provider training, interventions• address risk/protective factors in the individual

• ‘community-based’ interventions • only these can address the unique risk and

protective factors of your community, responsible for much of the difference in suicide rates

Evidence-based interventions

• consider curriculum-based, “off-the-shelf” programs• good for primary prevention and screening• inexpensive to deliver

• invest in training for providers in evidence-based treatments• dialectical behavioral therapy (DBT), cognitive

therapy for suicide prevention (CT-SP), problem-solving therapy (PST), etc.

• follow best practices in choosing levels of care, managing transitions, etc.

Curriculum example: Zuni Life Skills

• school-based• 3 times a week over a 30 week school year• focused on: • building self-esteem, identifying emotions and

stress, increasing communication and problem-solving skills, recognizing and eliminating self-destructive thinking and behavior (pessimism, anger reactivity), receiving suicide information, receiving suicide intervention training, setting personal and community goals

Evidence-based suicide prevention options

• Applied Suicide Intervention Skills Training (ASIST) • like CPR for suicide

• Dialectical Behavioral Therapy (DBT)• Cognitive Therapy for Suicide Prevention

(CT-SP)• Problem-Solving Therapy (PST)• others

Zero Suicide initiative

• paradigm for a health-care system or community• lead (commitment)• train (providers in evidence-based therapies)• identify (those at risk) • engage (in treatment plan) • treat• transition (prevent falling through the cracks

during level-of-care transitions) • improve (data-driven quality improvement)

http://zerosuicide.sprc.org/toolkit

Developing community-based interventions

• some good manuals are available to help design your program• “ A Community-Based Suicide Prevention Planning

Manual for Designing a Program Just Right For Your Community” *

• don’t reinvent the wheel • learn what is being done in other AI/AN communities• “Healthy Indian Country Initiative Promising Prevention

Practices Resource Guide” **

*Idaho State University**http://www.nihb.org/docs/04072010/2398_NIHB%20HICI%20Book_web.pdf

Developing community-based interventions

• planners should be representative of the community• not just one agency• not just health care• not just human services employees • elders, artists, spiritual leaders, youth

representatives

*Idaho State University*http://www.nihb.org/docs/04072010/2398_NIHB%20HICI%20Book_web.pdf

Summary

• a suicide prevention plan should address both individual and community factors• individual risk factors can be improved with

“off-the-shelf” education and treatments • community factors are unique and require a

creative, collaborative effort • use community strengths to offset risks

• larger issues of PTSD and interpersonal violence

Nancy Holt, Sun Tunnels, Utah