Webinar 1: Why Do People Become Suicidal?

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1 Webinar 1: Why Do People Become Suicidal? January 29, 2015 National Council for Behavioral Health in Collaboration with the Action Alliance and the National Institute of Mental Health Webinar Series

2 Moderator Cheryl S. Sharp, MSW, MWT, is the Senior Advisor for Trauma-Informed Care for the National Council for Behavioral Health. She serves as project coordinator and faculty lead for the National Council s 2011, 2012, 2013, and 2014 Adoption of Trauma- Informed Approaches Learning Community. She holds the unique perspective of a person with lived experience both as a family member and as an exconsumer of services as well as a provider of services. She is an ordained minister, Master WRAP Trainer and serves as an international trainer/consultant for the Copeland Center for Wellness & Recovery, a Mental Health First Aid Trainer, and a trainer of Intentional Peer Support (Shery Mead). Cheryl has worked with over 600 organizations to support their work in trauma-informed practices. She most recently became project director for the National Council s Crisis and Suicide Response initiatives.

3 The death rates for eight of the 10 leading causes of death have decreased significantly, but not for the tenth leading cause suicide. The national suicide rate has increased to 12.6 suicide deaths per 100,000 and for ages 18 to 35 the prime of one s life only unintentional injuries account for more death. Suicide is not Chosen

4 National Council for Behavioral Health in Collaboration with the Action Alliance and the National Institute of Mental Health Webinar Series January 29: Why do people become suicidal? February 24: How can we better detect/predict suicide risk? April 2: What interventions prevent suicidal behavior? April 29: What are the most effective services to treat and prevent suicidal behavior? May 27: What suicide interventions outside of health care settings reduce risk? June 24: What research infrastructure do we need to reduce suicidal behavior?

5 Dimensions of Zero Suicide

6 Conference Track Register at

7 Presenters Jane Pearson, Ph.D. chairs the National Institute of Mental Health's (NIMH) Suicide Research Consortium. She is the Associate Director for Preventive Interventions in the Division of Services and Intervention Research, and she is currently leading the staffing for the National Action Alliance for Suicide Prevention Research Prioritization Task Force. Dr. Pearson serves as the National Institutes of Health representative to the DHHS Federal Steering Group on Suicide Prevention. She assisted in the development of the Surgeon General's Call to Action to Prevent Suicide and the first National Strategy for Suicide Prevention. She served as a member of the Veterans Administration Blue Ribbon Workgroup on Suicide Prevention. Dr. Pearson is an adjunct associate professor at Johns Hopkins University, a Fellow of the American Psychological Association, a recipient of a U.S. Health and Human Services Secretary's Award, the American Association of Suicidology Marsha Linehan Award for Treatment Research, and a Public Service award from the American Foundation for Suicide Prevention. She has had a private practice in clinical psychology, and has authored papers on the ethical and methodological challenges of suicide research.

Presenters Elizabeth Ballard, Ph.D. Dr. Elizabeth Ballard is a clinical psychologist and research fellow in the Intramural Program at the National Institute of Mental Health.

8 Presenters Elizabeth Ballard, Ph.D. Dr. Elizabeth Ballard is a clinical psychologist and research fellow in the Intramural Program at the National Institute of Mental Health. She has extensive clinical experience working with suicidal patients and completed her clinical internship in the VA Eastern Colorado Healthcare System and a postdoctoral fellowship at Johns Hopkins School of Medicine. Dr. Ballard is currently spearheading research on the neurobiology of suicide at NIMH, including short term risk factors and rapid acting treatments for suicidal thoughts. She has recently published several articles on clinical and neural correlates of suicidal thoughts in response to ketamine, which is being studied as a potential antisuicidal treatment.

9 A PRIORITIZED RESEARCH AGENDA FOR SUICIDE PREVENTION: KEY QUESTIONS FOR BEHAVIORAL HEALTH PROVIDERS JANUARY 29, 2015 National Council for Behavioral Health Webinar Series Released February

10 National Action Alliance for Suicide Prevention The Action Alliance is the Public/Private Partnership Advancing the National Strategy for Suicide Prevention (NSSP) in the U.S. More than 200 organizations are involved in Action Alliance activities (via the Executive Committee, 14 Task Forces, Priority Initiatives, and Advisory Groups). Mission: To advance the NSSP by: Championing suicide prevention as a national priority. Catalyzing efforts to implement high-priority objectives from the NSSP. Cultivating the resources needed to sustain progress.

11 Action Alliance Leadership Co-Chairs: Public Sector: Ms. Jessica L. Garfola Wright, Under Secretary of Defense for Personnel and Readiness, U.S. DoD Private Sector: Mr. Robert W. Turner, Senior Vice President- Corporate Relations, Union Pacific Corporation 40-member Executive Committee: Behavioral health and substance abuse (e.g., National Council for Behavioral Health, Odyssey House) Business (e.g., Facebook, Union Pacific) Federal Agencies (e.g., DoD, DOI, DOJ, ED, HHS, VA) Health care (e.g., Universal Health Services), Law enforcement (e.g., International Association of Chiefs of Police) Other faith/interfaith, media, older adult services, veteran services. 11

12 What will be included in this webinar Overview of the Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives, as a product of the National Action Alliance for Suicide Prevention Jane Pearson Consider the research needed to address Key Question 1. Why do People Become Suicidal? Jane Pearson, Elizabeth Ballard

13 Suicide is among the 10 Leading Causes of Death in the U.S.

Suicide among all persons by sex: United States, 1933-2012 Rate per 100,000 population 30 25 20 15 10 5 Male Female

14 Suicide among all persons by sex: United States, Rate per 100,000 population Male Female Total Year CDC vital statistics; Crosby 2014

15 Self-inflicted injury among all persons by age and sex: United States, Rate per 100,000 population Males Females Age Group in years CDC WISQARS NEISS; Crosby 2014

16 Geographic Variation in U.S. Suicide Rates by County

17 Two US National Strategies for Suicide Prevention have called for a National Research Agenda 2001 Objective 10.1: By 2002, develop a national suicide research agenda with input from survivors, practitioners, researchers, and advocates 2012 National Strategy for Suicide Prevention Goal 12.1 Develop a national suicide prevention research agenda with comprehensive input from multiple stakeholders 17

National Action Alliance for Suicide Prevention s Research Prioritization Task Force PHIL SATOW CO-LEAD PRIVATE SECTOR; EXCOM REPRESENTATIVE FROM NAT L

DURHAM SAUL FELDMAN THOMAS FRIEDEN ROBERT GEBBIA MICHAEL HOGAN DAVID GROSSMAN DANIEL REIDENBERG EXECUTIVE DIRECTOR, AMERICAN ASSOCIATION OF SUICIDOLOGY

18 National Action Alliance for Suicide Prevention s Research Prioritization Task Force PHIL SATOW CO-LEAD PRIVATE SECTOR; EXCOM REPRESENTATIVE FROM NAT L COUNCIL; CO-FOUNDER & BOARD PRESIDENT, JED FOUNDATION THOMAS INSEL CO-LEAD PUBLIC SECTOR; DIRECTOR, NATIONAL INSTITUTE OF MENTAL HEALTH ALAN BERMAN MARY DURHAM SAUL FELDMAN THOMAS FRIEDEN ROBERT GEBBIA MICHAEL HOGAN DAVID GROSSMAN DANIEL REIDENBERG EXECUTIVE DIRECTOR, AMERICAN ASSOCIATION OF SUICIDOLOGY VICE-PRESIDENT, THE CENTER FOR HEALTH RESEARCH, KAISER PERMANENTE CHAIRMAN EMERITUS, UNITED BEHAVIORAL HEALTH DIRECTOR, U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION EXECUTIVE DIRECTOR, AMERICAN FOUNDATION FOR SUICIDE PREVENTION COMMISSIONER, NEW YORK STATE OFFICE OF MENTAL HEALTH MEDICAL DIRECTOR, PREVENTIVE CARE, GROUP HEALTH RESEARCH INSTITUTE EXECUTIVE DIRECTOR, SUICIDE AWARENESS VOICES OF EDUCATION & MANAGING DIRECTOR OF THE NAT L COUNCIL FOR SUICIDE PREVENTION

19 Research Prioritization Task Force Overarching Goal Overall U.S. rates of suicide deaths have not decreased appreciably in 50 years. Each year, over 678,000 individuals report that they received medical attention for a suicide attempt; each year, more than 30,000 individuals die by suicide. RPFT Goal: To develop an agenda for research that has the potential to reduce morbidity (attempts) and mortality (deaths) each, by at least 20% in 5 years, and 40% or greater in 10 years, if implemented successfully.

20 Research Prioritization Task Force Agenda Development Process Process Designed Burden of Suicide Deaths and Attempts Identified Literature Review and Portfolio Analysis NIH Request for Information (methodological roadblocks and proposed new paradigms) Stakeholder Survey and Delphi Process Selection of Aspirational Goals Research Agenda Development (short- and long-term objectives) Models of Potential Attempts Averted and Lives Saved Expert Consultants Dissemination of Agenda Claassen et al, 2013, Crisis Maintenance, Updating 20

Stakeholders Suicide research funders Scientists/Researchers Leaders of organizations and sectors that can reach individuals at risk Clinicians

21 Stakeholders Suicide research funders Scientists/Researchers Leaders of organizations and sectors that can reach individuals at risk Clinicians and care providers Survivors of suicide loss Overlapping Groups! Suicide attempt survivors Those at risk for suicide Concerned family members 21

22 Example Aspirational Research Ideas Proposed by Providers That Imply Theories of Why Individuals Consider Suicide Find treatment targets for acute risk, so fast acting interventions can be identified (can t wait weeks for a treatment to work) The lack of personal connection contributes to perceptions that nobody cares for them. They have no reason to live. Provide prevention and self-care skills, not simply screening and mental health treatment. Booth, 2014 AJPM 22

23 6 Key Questions & 12 Aspirational Goals (AGs) Question 1: Why Do People Become Suicidal? Aspirational Goal 1: Know what leads to, or protects against, suicidal behavior, and learn how to change those things to prevent suicide. Question 2: How Can We More Optimally Detect/Predict Risk? Aspirational Goal 2: Determine the degree of suicide risk (e.g., imminent, near-term, longterm) among individuals in diverse populations and in diverse settings through feasible and effective screening and assessment approaches. Aspirational Goal 3: Assess who is at risk for attempting suicide in the immediate future. Question 3: What Interventions Prevent Individuals From Engaging in Suicidal Behavior? Aspirational Goal 4: Ensure that people who are thinking about suicide but have not yet attempted, receive interventions to prevent suicidal behavior. Aspirational Goal 5: Find new biology treatments and better ways to use existing treatments to prevent suicidal behavior. Aspirational Goal 6: Ensure that people who have attempted suicide can get effective interventions to prevent further attempts. 23

24 6 Key Qs and 12 AGs (continued) Question 4: What Services Are Most Effective for Treating the Suicidal Person and Preventing Suicidal Behavior? Aspirational Goal 7: Ensure that health care providers and others in the community are well trained in how to find and treat those at risk. Aspirational Goal 8: Ensure that people at risk for suicidal behavior can access affordable care that works, no matter where they are. Aspirational Goal 9: Ensure that people getting care for suicidal thoughts and behaviors are followed throughout their treatment so they don t fall through the cracks. Aspirational Goal 10: Increase help-seeking and referrals for at-risk individuals by decreasing stigma. Question 5: What Other Types of Preventive Interventions (Outside Health Care Settings) Reduce Suicide Risk? Aspirational Goal 11: Prevent the emergence of suicidal behavior by developing and delivering the most effective prevention programs to build resilience and reduce risk in broad-based populations. Aspirational Goal 12: Reduce access to lethal means that people use to attempt suicide. Question 6: What Existing Infrastructure Can Be Better Utilized, and What New Infrastructure Needs Must Be Met In Order to Further Reduce Suicidal Behavior in the United States? 24

25 Develop a Burden Map of Suicide Decedent Subgroups in the United States Note overlap in subgroups and multiple opportunities to reach individuals American Indians/AN ~430 Jail and Prison Inmates ~500 3 Data Sources: 1. CDC WISQARS CDC WONDER Bureau of Justice Statistics DoDSER CY 2011 Report 5. Trofimovich et al Department of Veterans Affairs CDC WISQARS 2010 & Owens et al, 2002 Firearm Deaths (51% of all suicides) 19,392 1 Active Duty Military ~300 4 Motor Vehicle CO Poisoning U.S. Army (CONUS) Deaths ~ ~200 (est.) Accessed healthcare within 30 days of death ~ 17,100 5 Male Veterans Military Veterans Seen in Emergency ~7,000 (est.) ~ Department for suicide Criminal Justice attempt in past year System ~ 7,800 7 ~465

26 Past Year Suicide Attempts in Boundaried Settings

27 20% of Suicide Deaths Prevented by Example Interventions 20% US Suicide Deaths (in 2010)= 7,471 Total = 6,710 using 1 year, optimal reduction estimates

28 Who are the Funders of Suicide Research? How will They Track Research Progress? U.S. Federal Government (Public) Agency for Healthcare Research and Quality (AHRQ) Centers for Disease Control and Prevention (CDC) Department of Defense (DoD) Department of Veterans Affairs (VA) Department of Transportation (DOT)/Federal Railroad Administration (FRA) National Institutes of Health (NIH) National Institute of Justice (NIJ) National Science Foundation (NSF) Substance Abuse and Mental Health Services Administration (SAMHSA) U.S. Private Foundations American Foundation for Suicide Prevention (AFSP) Brain & Behavior Research Foundation (BBRF)

29 Who are the Funders of Suicide Research? How will They Track Research Progress? Goal 12 of the 2012 National Strategy for Suicide Prevention: Develop a prioritized approach for allocating funds and monitoring future suicide research to ensure that available resources target research with the greatest likelihood of reducing suicide morbidity and mortality. determine where investments have already been made consider how future studies can leverage current efforts identify and make public basic information on funded studies to promote knowledge sharing early in the research process promote research collaborations (e.g., multi-disciplinary needs; comparable study approaches; measure harmonization, etc.) facilitate efforts devoted to assessing the value of information for policy makers.

30 Key Question 1. Why do People Become Suicidal? Jane Pearson Elizabeth Ballard National Institute of Mental Health

31 Clinicians are not surprised that the following clients would be suicidal. Why? Male age 20 with schizophrenia Male veteran age 67 with insomnia and chronic pain Male American Indian age 14 with binge alcohol disorder Female age 34 with borderline personality disorder Female age 43 with opioid addiction Male age 51 recently criminally charged

32 Social Determinants Complex Contributing Factors Considered Clinical Factors Neurocognitive Factors Biomarkers that Reflect Biological Processes What enhances risk or protection?

33 Complex Contributing Factors Considered Examples of Social Determinants Protection: Healthy connectedness can be between individuals, families, neighborhoods, cultural groups and society as a whole. An intervention that increased healthy connections in community was found to reduce suicide risk in elders in a Japanese study (Oyama et al 2004) Caring contacts: Caring postcards sent after a patient left a psychiatric unit was associated with reduced rates of death by suicide (Motto and Bostrum, 2001)

34 Complex Contributing Factors Considered Examples of Social Determinants, cont. Risk: Social networks, in person and through social media, can contribute to contagion, potentially through imitation or by normalizing suicidal behavior (Cheng et al 2014). Social networks can be leveraged to promote protective influences (Wyman et al 2010). Child abuse and neglect: 10 40% of individuals who experience suicidal thoughts and behavior have a child abuse history (Brezo et al 2008).

35 Clinical Factors: Note Complex Contributing Factors Considered Suicide risk assessment is based on self report, such as thoughts, past behaviors or current symptoms. To date, there is no reliable blood test (or genetic test; imaging; or neurological test) indicating heightened risk for suicide and clinical actions. To date, there have been few opportunities to examine health care conditions with mortality outcomes (EHRs linked with vital statistics) and we need very large samples.

36 Complex Contributing Factors Considered Examples of Clinical Factors: Risk: Psychiatric Depression, anxiety, post-traumatic stress, substance abuse Physical symptoms Physical pain, insomnia Thoughts Suicidal thoughts, making a plan, hopelessness, feeling like a burden

37 Complex Contributing Factors Considered Examples of Clinical Factors, cont. Protective: The vast majority of individuals with behavioral health and physical illness diagnoses, do not kill themselves Therefore, protective factors should be maintained and supported! Much of intervention depends on patient report: Studies of attempt survivors are needed regarding their experience of symptoms and interactions with services and interaction with providers Family member observations may also be critical

38 Complex Contributing Factors Considered Neurocognitive Factors Delay discounting measures impulsive decision-making. Individuals are given a choice between a small monetary reward now or a larger reward later. Inability to delay rewards in this task has been linked to active suicidal thoughts or recent attempt (Caceda et al 2014). Other tests of impaired decision-making such as the Iowa Gambling Test, have detected impaired thinking in adolescent suicide attempters (Bridge et al 2012). None of these factors are entirely specific to suicide, nor are they currently actionable as clinical predictors.

39 Complex Contributing Factors Considered Neurocognitive Factors, cont. Individuals who have attempted suicide may have altered response to facial expressions, particularly angry faces, on fmri (Jollant et al 2008). Suicide Implicit Association Task (IAT) has been shown to predict who will attempt suicide in the future. (Nock et al 2010) o Can be administered on the computer in 5-10 minutes o Currently studied in emergency department environments

40 Complex Contributing Factors Considered Biomarkers that Reflect Biological Processes Some evidence that suicidal behavior is heritable. Twin studies report 36 43% heritability; and non-fatal suicide attempts have heritability estimates of 17 45%, even after controlling for psychiatric disorder (Mann et al., 2009). Parental history of suicide attempt is associated with five times the odds of a suicide attempt in offspring and may be related to impulsive aggression (Brent et al 2015). Specific genetic markers for suicidal behavior have been identified, but require replication (Guintivano et al 2014).

41 Complex Contributing Factors Considered Biomarkers that Reflect Biological Processes, cont. Other potential biological processes: - Serotonergic functioning (Mann et al 2006) - Most commonly studied system - Glutamatergic functioning (Erhardt et al 2013) - May explain possible response to ketamine infusion - Responsiveness to stress in the HPA (hypothalamic pituitary adrenal) axis (Turecki et al 2012) - Has been linked childhood traumatic experiences - Immune functioning (Serafini et al 2013) - Primary association through major depression

42 Complex Contributing Factors Turecki et al., AJPM 2014

43 Key Question 1. Why Do People Become Suicidal? Aspirational Goal 1. Know what leads to, or protects against, suicidal behavior, and learn how to change those things to prevent suicide Short-term Objectives A. Discover models that explain contagion as well as resilient, healthy social connections among at risk groups. B. Identify biomarkers (e.g., genetic, epigenetic, immune function, neuropsychiatric profiles) and their interactions that are associated with current and future risk status. C. Identify cognitive dysfunction/neural circuitry profiles (e.g., anhedonia, impaired executive functioning) associated with suicide risk that may be amenable to current interventions.

44 Key Question 1. Why Do People Become Suicidal? Aspirational Goal 1. Know what leads to, or protects against, suicidal behavior, and learn how to change those things to prevent suicide Long-term Objectives A. Determine how to improve and sustain beneficial social connection processes that reduce suicide risk. B. Identify multiple risk models based on integrated data sources (genetic, epigenetic, life event exposures, health conditions, traits, brain circuitry, neuropsychological profiles, etc.) for future intervention development. C. Determine if processes that reduce risk conditions (e.g., insomnia, addiction, agitation, pain) also mitigate suicide risk.

45 Social Media Connect with the Action Alliance via social media... Download the Research Agenda and the National Strategy for Suicide Prevention...

46 Thank You.

Webinar 4: What are the most effective services to treat and prevent suicidal behavior?

Webinar 4: What are the most effective services to treat and prevent suicidal behavior? April 29, 2015 National Council for Behavioral Health in Collaboration with the National Action Alliance for Suicide