Best Practices in Comprehensive Suicide Prevention Richard McKeon, Ph.D. Chief, Suicide Prevention Branch

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1 Best Practices in Comprehensive Suicide Prevention Richard McKeon, Ph.D. Chief, Suicide Prevention Branch

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. Slide 2

3 Preventing suicide A global imperative

4 National Strategy for Suicide Prevention

5 Why comprehensive suicide prevention? Suicide in the United States continues to increase. We need to better understand why, and why we have not yet stopped it. This is the central challenge for suicide prevention in the United States. This presentation will attempt to address what we still need to do.

6 Saving Lives: Impact of the 2012 National Strategy for Suicide Prevention American Association of Suicidology 2015 Annual Meeting Copyright Education Development Center, Inc. All Rights Reserved

7 Notable Findings Most states are currently using the NSSP in revising and updating their state plan. Some activity is occurring for every objective. Magnitude of effort and potential for having measurable impact is variable. Absence of state, tribal, and community infrastructure hampers successful suicide prevention efforts. Efforts to integrate and coordinate suicide prevention efforts across sectors are not standard practice. Copyright Education Development Center, Inc. All Rights Reserved

8 Recommendations Strengthen State, tribal, and community -level suicide prevention infrastructure Translation of NSSP to community-friendly tool. Specification of components and roles for community suicide prevention, and need for coordinated effort. Regular monitoring of NSSP implementation and coordination Copyright Education Development Center, Inc. All Rights Reserved

9 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)

10 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. 10

11 Results: Difference in Nonfatal Attempts *Solid lines represent the estimated trajectory of the outcome following GLS implementation. Dashed lines represent the estimated trajectory of the outcome during the same period had GLS not been implemented. 90% and 50% confidence intervals around the difference in the trajectories are represented by dark gray and light gray, respectively. 1

12 Implications Results suggest there is an important reduction on youth suicide and attempts following the implementation of GLS. More than 400 deaths were avoided between (There were 776 county-years where GLS trainings were implemented during and 41K youth on average per county, i.e. 776*41K*-1.33/100,000). More than 100,000 attempts among youth were avoided during approximately the same period. (There were 776 county-years where GLS trainings were implemented during and 29K youth on average per county, i.e. 776*29K*-4.9/1,000). 1

13 Comprehensive Suicide Prevention Requires two strong elements Strong, multi-pronged community effort Strong multi-pronged healthcare effort Attention to transitions across a range of settings Should be data driven, coordinated by a public-private partnership, and sustained by a strong state infrastructure.

14 Community Suicide Prevention Schools/colleges Settings Justice settings (adult and youth-utah Youth Suicide Study) Workplace Faith Communities Foster care Veterans/military/National Guard Social Media

15 Community Suicide Prevention CDC Suicide Prevention Technical Package Action Alliance Comprehensive Community Suicide Prevention White Paper Upstream AND Comprehensive Safety Net

16 Common Risk Factors for Premature Death HOMICIDE MVAs & Accidental Poisoning Suicide Legal System Involvements Emergency Room Visits Mental Health & Chemical Dependency Treatment Contacts Prevention & Intervention Opportunities Indicated & Clinical Emerging Behavioral Problems & Mental Health Disturbances School Difficulties Alcohol and Substance Misuse Disruptive Family Factors Disadvantaged Economic & Social Factors Selective & Indicated Universal & Selective

17 Implications for Veterans How do we reach the majority of veterans who die by suicide who are not in VA? (average of 14 out of 20) What are the systems outside VHA that veterans are touching before their death? Other non-vha health systems Faith communities, workplaces, justice settings

18 Healthcare Settings Zero Suicide-generated tremendous interest Powerful challenge to pessimism 9 million $ appropriation-current FOA Currently most efforts in mental health Substance Abuse Treatment Emergency Depts/Crisis Services Primary Care

19 Continuous Quality Improvement The Elements of Zero Suicide in a Health Care Organization Create a leadership-driven, safety-oriented culture Pathway to Care Identify and assess risk Screen Assess Evidence-based care Safety Plan Restrict Lethal Means Treat Suicidality and MI Continuous support as needed Electronic Health Record Develop a competent, confident, and caring workforce

20 Substance Abuse and Suicide Alcohol and suicide NVDRS and NSDUH Opioid crisis Screening SBIRT model Training and Capacity Building Development of specific treatments Emergency Department needs

21 Critical Data Sources NVDRS Child Fatality Review Utah Juvenile Justice Foster Care-Michigan Public Behavioral Health-Kentucky, Vermont, New York, Ohio Medicaid-Ohio, Utah

22 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 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),

23 Deconstructing Suicide Deaths in the U.S. = Already Modeled 23

24 Adult ED visits related to Suicidal Ideation Rate increased 12% annually, 15% in West and Midwest By 2013, 903,400 ED visits related to suicidal ideation, 1% of all adult ED visits 72% were admitted to the same hospital or transferred to another facility

25 Components of Comprehensive Crisis Systems Mobile crisis response teams Crisis stabilization beds Hotlines (data, technology, dispatch, monitor) Crisis chat and text, warmlines Crisis respite Psych emergency/walk in Post crisis follow up engagement and support Peers

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27 Lifeline s Imminent Risk Policy (2011) 27 Education Development Center Inc All Rights Reserved.

28 Improving Care Transitions There are lethal gaps in many systems. Period after IPU and ED discharge is one of high risk, particularly the first 30 days. Rates of follow up care are poor. Intervention during this time has been shown to save lives and reduce suicidal behavior.

29 Mortality After Recent Suicide Attempts SAMHSA NSDUH data Significant post non-fatal attempt suicide mortality-3.2 % Higher among men then women 45 and older with less then a high school education -16% 40.6% had any outpatient mental health treatment, 15.8% had 1-4 visits,

30 Improving Post Discharge Safety ED SAFE demonstrated reduction in suicidal behavior for suicidal people discharged from ED s doing telephonic follow up. White Mountain Apache/JHU Center for American Indian Health almost 40% reduction in suicides from centerpiece is tribally mandated reporting and follow up

31 Clients Perceptions of Care: Cohort II (preliminary) 7 To what extent did the follow-up call(s) stop you from killing yourself? Callers (n= 283) Hosp. Clients (n= 70) Total (n= 353) A lot 60.8% 51.4% 58.9 % A little 22.6% 14.3% 21.0 % Not at all 16.6% 32.9% 19.8 % It made things (17 callers, 2 hosp. clients had missing data) 0.0% 1.4% 0.3

32 EMERGENCY DEPARTMENT Percent of Patients F/U Fleischmann et al (2008) Randomized controlled trial; 1867 Suicide attempt survivors from five countries (all outside US) Brief (1 hour) intervention as close to attempt as possible 9 F/u contacts (phone calls or visits) over 18 months 3 Results at 18 Month F/U Died of Any Cause Usual Care Brief Intervention Died by Suicide

33 Major International Efforts Have Reduced Suicides Taiwan-nationwide effort to intervene with those who have attempted suicide 63.5% reduction in suicide attempts among those who accepted the program.. English National Strategy- 24 hours crisis care strongly associated with reduction in suicides. Proactive outreach and discharge f/u 7 days

34 European Alliance against Depression (EAAD): The 4-level intervention concept

35 Suicidal Acts Model project Nuremberg Alliance against Depression ,4% ,0% ,2% 420 Chi² (one-tailed): 2000 versus 2001; p< 0, versus 2002; p< 0, versus 2003; p< 0, ,01% ,7% 196-5,5% Nuremberg Wuerzburg (control region) Hegerl et al. 2006, 2010

36 Number of suicidal acts Number of suicidal acts Number of suicidal acts Number of suicidal acts OSPI-Europe: Main outcomes on suicidal behaviour Germany Hungary Baseline Baseline Intervention Region Control Region Average for the two years after onset of the intervention χ 2 = 1.12; p = 0.14 (one-tailed) Intervention Region Control Region Average for the two years after onset of the intervention χ 2 = 0.33; p = 0.28 (one-tailed) Portugal Ireland Intervention Region Control Region Baseline Average for the two years after onset of the intervention χ 2 = 4.82; p = 0.01 (one-tailed) Intervention Region Control Region Baseline Average for the two years after onset of the intervention χ 2 = 2.55; p = 0.06 (one-tailed)

37 Lifespan-New South Wales Black Dog Institute 9 components Aftercare and crisis care,pychosocial and pharmacotherapy treatments,gp Capacity Building and Supports, frontline staff and gatekeeper training, school programs, commmunity campaigns, media guidelines and means restriction

38 Preventing Suicide Is Everyone s Business To those who have lost their lives by suicide, To those who struggle with thoughts of suicide, To those who have made an attempt on their lives, To those caring for someone who struggles, To those left behind after a death by suicide, To those in recovery, and To all those who work tirelessly to prevent suicide and suicide attempts in our nation. We believe that we can and we will make a difference. Dedication from the 2012 National Strategy for Suicide Prevention

39 Richard McKeon, Ph.D., M.P.H. Branch Chief, Suicide Prevention, SAMHSA