Suicide Prevention in the United States: Challenges, Opportunities, and Innovations. Richard McKeon Ph.D.Chief, Suicide Prevention Branch SAMHSA

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1 Illinois Suicide Prevention Summit Suicide Prevention in the United States: Challenges, Opportunities, and Innovations Richard McKeon Ph.D.Chief, Suicide Prevention Branch SAMHSA 1

2 Disclaimer The views, opinions, and content expressed in this presentation do not necessarily reflect the views, opinions, or policies of the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration (SAMHSA), or the U.S. Department of Health and Human Services. 2

3 National Center for Injury Prevention and Control Division of Violence Prevention CDC Vital Signs:Suicide rising across the U.S. More than a mental health concern June 12, 2018 Deborah M. Stone, ScD, MSW, MPH Behavioral Scientist

4 PROBLEMS : UICIDE RATES INCREASED IN ALMOST EVERY STATE. Suicide rates rose across the US from 1999 to Increase 38-58% Increase 31-37% Increase 19-30% Increase 6-18% Decrease 1% SOURCE: CDC s National Vital Statistics System; CDC Vital Signs, June 2018.

5 45K Nearly 45,000 lives lost to suicide in % Suicide rates went up more than 30% in half of states since RESULTS % % More than half of people who died by suicide did not have a known mental health condition.

6 Percentage increases in state suicide rates Top 10

7 Suicide rates among persons aged years by state -- United States, 2016 (U.S. avg 9.4) DC Rate per 100, Source: CDC vital statistics 7

8 Statistics

9 Leading causes of death for selected age groups United States, 2016 Rank years years years years years years 1 Unintentional Injuries Unintentional Injuries Unintentional Injuries Unintentional Injuries Unintentional Injuries 2 Suicide Suicide Suicide Suicide Malignant Neoplasms Malignant Neoplasms Heart Disease 3 Malignant Neoplasms Homicide Homicide Malignant Neoplasms Heart Disease Unintentional Injuries 4 Homicide Malignant Neoplasms Malignant Neoplasms Heart Disease Suicide Liver Disease 5 Congenital Malformations Heart Disease Heart Disease Homicide Liver Disease Chronic Lower 6 Heart Disease Congenital Malformations Diabetes Mellitus Liver Disease Diabetes Mellitus Diabetes Mellitus 7 Chronic Lower Chronic Lower Ds Congenital Malformations Diabetes Mellitus Cerebro- Vascular Suicide 8 Cerebro- Vascular Source: CDC vital statistics Cerebro- Vascular Complicated Cerebro- Vascular Homicide Cerebro- Vascular 9

10 Rate per 100,000 population Suicide rates among all persons by age and sex--united States, Males Females Age Group in years Source: CDC vital statistics

11 Rate per 100,000 population Self-inflicted injury among all persons by age and sex-- United States, Males Females Age Group in years Source: CDC WISQARS NEISS

12 Identifying Areas of High Need and/or Opportunity 44,965 annual suicide decedents Age ,532I Vehicle emissions Poisoning ~ 791B Firearm Deaths 22,938A Youth Under 18 2,023H Seen in ED for any reason in past year 21,583G Data Sources: A. CDC WISQARS 2016 B. CDC WONDER 2014 C. Bureau of Justice Statistics million annual suicide attempts SU Treatment* 110,000A Inmates 621C Military 466D Age ,000A Veterans ~7,300E Accessed healthcare within 30 days of death ~ 20,000F E. Department of Veterans Affairs 2016 F. Luoma et al, 2002; Ahmedani et al 2014 G. Ahmedani, Personal communication H. CDC WISQARS 2016 College: Full Time 90,000A Part time 52,000A Parole* 28,000A Age ,000A Outpatient MH Treatment* 410,000A Probation* 79,000A Veterans?B Data Sources: A. National Survey on Drug Use and Health B. In progress C. In progress Military?C

13 Preventing suicide A global imperative

14 National Strategy for Suicide Prevention Developed by the U.S. Surgeon General and the National Action Alliance for Suicide Prevention The National Strategy for Suicide Prevention (NSSP) is a comprehensive, multi-sectoral strategy to reduce suicide in America. Details 13 goals and 60 objectives for reducing suicide over 10 years, including: o o o Integrating suicide prevention into health care policies Encouraging transformation of health care systems to prevent suicide Changing the way the public talks about suicide and suicide prevention 14

15 You can t fix what you can t measure. Perhaps a third of all suicide decedents accessed care prior to death, but few U.S. health care systems track suicide outcomes. Of those with contact with health care, 45% had a psychiatric diagnoses 15 Ahmedani BK et al (2014). Health care contacts in the year before suicide death. Journal of General Internal Medicine, online Feb 25. DOI: /s Karch, DL, Logan, J, McDaniel, D, Parks, S, Patel, N, & Centers for Disease Control and Prevention (CDC). (2012). Surveillance for violent deaths national violent death reporting system, 16 states, Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, DC: 2002), 61(6), 1-43.

16 A System-Wide Approach Saved Lives: Henry Ford Health System EDC, Inc. All Rights Reserved.

17 Suicides per 10,000 seen per year Zero Suicide at Centerstone: Results 3.5 Annual Suicides per 10,000 Clients Seen (Rolling 12 months) EDC, Inc. All Rights Reserved.

18 The Garrett Lee Smith (GLS) Suicide Prevention National Outcomes Evaluation is supported through contract no. HHSS I/HHSS T (reference no ) awarded to ICF International by the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), US Department of Health and Human Services (HHS). THE IMPACT OF GLS SUICIDE PREVENTION PROGRAM ON YOUTH SUICIDAL BEHAVIOR Lucas Godoy Garraza (ICF International); Christine Walrath (ICF International); David Goldston (Duke CSSPI); Hailey Reid (ICF International), Richard McKeon (SAMHSA)

19 count per 100, count per 100, Results: Difference in Suicide Mortality Suicide Suicide 25+ Training year (T) T + 1 year T + 2 years Training year (T) T + 1 year T + 2 years GLS implementation GLS + 1 year GLS + 2 years GLS implementation GLS + 1 year GLS + 2 years Solid lines represent the estimated outcome trajectory following GLS training implementation. Dashed lines represent the estimated outcome trajectory during the same period had GLS not been implemented. 90% and 50% confidence intervals around the trajectory are represented by dark gray and light gray, respectively. 19

20 count per 100, count per 100, Results: Difference in Nonfatal Attempts Attempts Attempts 24+ Training year (T) T + 1 year T + 2 years Training year (T) T + 1 year T + 2 years GLS implementation GLS + 1 year GLS + 2 years GLS implementation GLS + 1 year GLS + 2 years Solid lines represent the estimated outcome trajectory following GLS training implementation. Dashed lines represent the estimated outcome trajectory during the same period had GLS not been implemented. 90% and 50% confidence intervals around the trajectory are represented by dark gray and light gray, respectively. 20

21 21 Joint Commission Sentinel Event Alert 56: Detecting and Treating Suicide Ideation in All Settings The suggested actions in this alert cover suicide ideation detection, as well as the screening, risk assessment, safety, treatment, discharge, and follow-up care of atrisk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care. Education Development Center Inc All Rights Reserved.

22 Innovations Zero Suicide Screening and assessment-phq-9 CSSRS ASQ Surveillance-NVDRS, Biosense, Child Fatality Review, survival rates/ismicc Collaborative Safety Planning Treatment-DBT, CBT, CAMS, ASSIP, Ketamine Care Transitions/Caring letters and texts/telephonic follow up Air Traffic Control Model for Crisis Care National Suicide Prevention Hotline Improvement Act 22

23 23 WITHOUT IMPROVED SUICIDE CARE, PEOPLE SLIP THROUGH GAPS Education Development Center Inc All Rights Reserved.

24 24 THE TOOLS OF ZERO SUICIDE FILL THE GAPS Education Development Center Inc All Rights Reserved.

25 Risk following completion of PHQ9 (sample size = 1.2 million) 25

26 ALL Behaviors Are Prevalent and Predictive n = 28,699 administrations Each behavior is EQUALLY PREDICTIVE to an attempt No Behavior: 28,303 Actual Attempt: 70 Interrupted Attempt: 178 Aborted Attempt: 223 Preparatory Behavior: 71 Multiple behaviors = greater risk *Only 1.7% had any worrisome answer *Only.9% with ~50,000 administrations.2%.6%.8%.2%.2% % 472 Interrupted, Aborted and Preparatory (87%) vs. 70 Actual Attempts (13%) Mundt et al., 2011

27 ASQ-Ask Suicide Screening Questions In the past few weeks, have you wished you were dead? Yes/No In the past few weeks have you felt that you or your family would be better off if you were dead? Yes/No In the past week, have you been having thoughts about killing yourself? Yes/No If yes, how? When? If yes to any of the above, ask acuity question: Are you having thoughts about killing yourself right now? 27

28 Resource: Safety Planning Intervention 28 Access at: Education Development Center Inc All Rights Reserved.

29 Treat Suicidality Directly Both treating suicidality directly as well as treating underlying conditions is crucial. There are now multiple RCT s showing reductions in suicidal behavior. All focus directly on suicidality. DBT, CBT (civilian and military), CAMS,ASSIP CBT for insomnia can reduce suicidal ideation 29

30 Attempted Suicide Short Intervention Program 30

31 Suicide Assessment Five-step Evaluation Triage 31

32 Suicide Assessment Five-step Evaluation Triage 32

33 Suicide Prevention App for Health Care Providers Free for Apple and Android mobile devices Suicide Safe Helps Providers: Integrate suicide prevention strategies into practice and address suicide risk Learn how to use the SAFE-T approach Explore interactive sample case studies Quickly access and share information and resources Learn Browse more conversation bit.ly/suicide_safe. starters Locate treatment options 33

34 Assessing and Managing Suicide Risk

35 Examples of Opportunities Expand payment for & use of Collaborative Care (CPT 99492/3/4) and other Behavioral Health Integration (CPT 99484) services Incentivize within-encounter interventions, and telephone follow-up & caring communications, via appropriate payment (& CPT codes), and consensus about who is responsible for furnishing these services Expand access to behavioral health expertise in emergency care settings, including via telehealth, to help address in-person shortages Track & analyze patient survival, and cause/manner of death, in patients with suicide-related index events, such as emergency department presentation with intentional self-harm or suicidal ideation (~ parity with other areas medicine, such as cancer & heart surgery) Expand use of professional guidelines on talking with the media about suicide (including celebrity suicides)

36 Resources / Questions e%20recommended%20standard%20care%20final.pdf

37 Improving Post Discharge Safety The Emergency Department Safety Assessment and Follow-up Evaluation (ED- SAFE) demonstrated reduction in suicidal behavior for suicidal people discharged from EDs doing telephonic follow up. White Mountain Apache/Johns Hopkins University Center for American Indian Health o Almost 40% reduction in suicides from o Centerpiece is tribally mandated reporting 40

38 Improving Post Discharge Safety Safe-Vet- Safety planning in the Emergency Room for suicidal veterans combined with telephonic follow up led to 50% reduction in suicidal behavior compared to tau Twice as many veterans connecting to outpatient behavioral health care SAMHSA evaluation studies show that 90% of suicidal callers report that follow up phone calls helped them stay safe and not 41

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40 Lifeline s Imminent Risk Policy (2011) 43 Education Development Center Inc All Rights Reserved.

41 What is the Crisis Now model? Call Center Hub Mobile Crisis Crisis Facilities Air Traffic Control Crisis Call Center Hub Connects and Ensures Timely Access and Data

42 Ubiquitous and inexpensive technology is changing nearly every other industry.

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44 Thank you. 47 SAMHSA s mission is to reduce the impact of substance abuse and mental illness on America s communities. Richard McKeon, Ph.D., M.P.H. Branch Chief, Suicide Prevention, SAMHSA Richard.mckeon@samhsa.hhs.gov SAMHSA-7 ( ) (TDD) 47 Education Development Center Inc All Rights Reserved.