Community-Based Suicide Prevention€¦ · •severity of historical trauma •lack of cultural...

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%

KnoxKetal.Riskofsuicideandrelatedadverseoutcomesafterexposuretoasuicidepreventionprogramme intheUSAirForce. BMJ2003;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

alsosee:AddressingTraumainAmericanIndianandAlaskaNativeYouthAug24,2016MathematicaPolicyResearchhttps://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

KaplanMetal.Economiccontraction,alcoholintoxicationandsuicide:analysisoftheNationalViolentDeathReportingSystemInj 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-levelfactors(NOT individual

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

AllenJetal.AprotectivefactorsmodelforalcoholabuseandsuicidepreventionamongAlaskaNativeyouth.AmJCommunityPsychol.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-CampbellT. Thehistoricaltraumaresponseamongnativesanditsrelationshipwithsubstanceabuse:aLakotaillustration.J.PsychoactiveDrugs2003Jan-Mar;35(1):7-13

Alcantra CandGoneJ.ReviewingSuicideinNativeAmericanCommunities:SituatingRiskandProtectiveFactorswithinaTransactional-EcologicalFramework.DeathStudies,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 • membersengageinself-reflection,developapersonallifenarrative

AllenJ etal.AprotectivefactorsmodelforalcoholabuseandsuicidepreventionamongAlaskaNativeyouth.AmJCommunityPsychol.Sep2014V54 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

BruceMetal.DepressionCareforPatientsatHome(DepressionCAREPATH):HomeCareDepressionManagementProtocol.HomeHealthc Nurse.2011Sep;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

MillerIetal.SuicidePreventioninanEmergencyDepartmentPopulation:TheED-SAFEStudy.JAMAPsychiatry.2017;74(6):563-570


• 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


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


• 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


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


• 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


• 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?

Wexleretal.AdvancingSuicidePreventionResearchWithRuralAmericanIndianandAlaskaNativePopulations.AmericanJournalofPublicHealthMay2015,Vol105,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

NancyHolt,SunTunnels,Utah

Community-Based Suicide Prevention€¦ · •severity of historical trauma •lack of cultural...

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