Myths vs. Facts: True or False? Talking openly about suicide will cause it. Anyone can learn to help someone who is struggling with thoughts of suicid

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1 Adolescent Suicide & Management By Dr Lam Chun Associate Consultant Quality & Safety Director Kowloon Hospital Date: 3 December 2018

2 Myths vs. Facts: True or False? Talking openly about suicide will cause it. Anyone can learn to help someone who is struggling with thoughts of suicide. If someone decides that they want to take their own life, there s nothing we can do to stop them. If someone talks about suicide they don t need to be taken seriously. There are signs that we can look for that may indicate someone is considering suicide.

3 Common Terms Suicide Intentionally taking one s own life Suicide Behavior Thoughts, plans, or actions which if implemented could result in death Suicidal ideation - having suicidal thoughts, thoughts of ending one s life. Suicide act or gesture Actions to deliberately injure oneself or attempt to injure oneself without resulting in death. Self-harm - an attempt to alter one s mood by inflicting physical harm on oneself

4 Self-harm Intentional self-poisoning or self-injury irrespective of motive or extent of suicidal intent. (NICE 2011) Up to 10% of adolescents have self-harmed in the past 12 months. (Madge et al 2008; Hawton et al 2002). Rates of self-harm increase from early adolescence - age 12 (Hawton, Saunders & O Connor 2012) Self-harm is associated with depression and anxiety (Moran et al 2012) Self-harm more common in females (5:1) (Hawton,Saunders & O Connor 2012)

5 Acts of self-harm Cutting and overdose are the most common methods (Morey et al 2008) Most occurs in private (Madge et al 2008) 1 in 8 episodes present to hospital for treatment (Hawton et al 2002) Approximately half who self-harm will do so only once (Madge et al 2008)

6 Why self-harm? Tension relief a way of getting relief from a terrible state of mind Self-punishment feel worthless and a bad person who should be punished Attention Seeking Express distress - let others know how bad they were feeling Desire to die very rare and often a temporary wish to escape from a difficult situation/feeling

7 Statistics on Suicide A worldwide review found 9.7% of adolescents reported a suicide attempt (Evans et al 2005). Suicide is the second leading causes of death in young people worldwide (Hawton et al 2012) Suicide is uncommon before the age of 15. In the UK in 2013 there were 13 recorded suicides for children aged (ONS 2014). Males are more likely to die by suicide than females.

8 Statistics on Suicide (US) 8 44,965 Americans died by suicide in 2016; about 1 person every 12 minutes 1 Suicide deaths are 2.3 times the number of homicides (homicides=19,362) 1 10th leading cause of death across the lifespan 1 2nd leading cause of death for year olds Males account for 77% of suicide deaths 1 Veterans account for approximately 17% of all suicides 3 Since 2009, suicides have exceeded motor vehicle crash related deaths 1 1. U.S. CDC WISQARS Fatal Injury Data, 2016 update. Accessed January 2018; 2. Maine Hospital Inpatient Database, Maine Health Data Organization, Hospital discharge data for intentional self-inflicted injury related hospital discharges defined as hospital discharges in which any listed external cause of injury was coded as ICD-9CM E950-E Suicide Among Veterans and Other Americans report, updated 3 August 2016, U.S. Department of Veteran Affairs.

9 Statistics on Suicide (US) In 2010, there were 4,600 reported youth suicides in the United States. There are between teen attempts before completing suicide Girls attempt more often (3:1) Boys complete suicide more often (4:1) Most common method is firearms followed by suffocations

10 Attempted Suicide

11 Suicide rates in young people aged per 100,000 (Hawton, Saunders & O Connor 2012)

12 Study on Suicidal Ideation (Hoberman and Garfinkel 1988) In a study of 229 completed youth suicides: 62% had made a suicidal statement 45% had consumed alcohol within 12 hours of killing themselves 76% had shown a decline in academic performance in the past year

13 The Teenage Brain Adolescence is a time of profound brain growth. Greatest changes to the brain that are responsible for impulse control, decision making, planning, organization, and emotion occur in adolescence (prefrontal cortex). Do not reach full maturity until age 25.

14 Eustress Vs Distress

15 Perceived Stress

16 What do teens deal with? Increased school pressures as they progress through higher grades Possibly first romantic relationships Exploring increased independence and identity Experimenting with substance use Puberty and Hormone fluctuation Relationship problem Digital World Bullying

17 Relationship Problem Several studies have found relationships between suicidal behavior and social isolation, sexual orientation, and peer rejection. 70% of suicide completions and attempts occur following the loss or conflict with family and peers.

18 Digital World Young people are frequent users of IT

19 CYBERSPACE is the new environment where youth are forming communities.

20 The Influence of Social Media Positive Support for marginalized populations Elimination of geographic barriers Suicide support groups/resources Online PSAs Partnering with suicide prevention programs Negative Virtual friendships vs. real life friendships Impact and risk of cyberbullying Media contagion Online videos-self injury and suicide Live-streaming

21 Cyber bullying 93% of teens ages are on the Internet. 75% of teens own a cell phone. A typical teen sends about >100 text messages a day. Most teen cell phone users make just 1-5 calls per day. 82% of online teens ages are on social network sites

22 Bullying effects Withdraws socially; has few or no friends. Feels isolated, alone, and sad. Feels picked on or persecuted. Feels rejected and not liked. Complains frequently of illness. Doesn t want to go to school; avoids some classes or skips school. Brings home damaged possessions or reports them lost. Cries easily; displays mood swings and talks about hopelessness. Has poor social skills. Talks about running away/suicide.

23 Bullying risks for suicide Both victims and perpetrators of bullying are at a higher risk for suicide than their peers. Children who are both victims and perpetrators of bullying are at the highest risk One study found that victims of cyberbullying had higher levels of depression than victims of face-to-face bullying

24 Why People Hesitate to Ask for Help Unwilling to admit needing help Afraid to upset/anger others Unable describe their feelings/needs Unsure of available help or resources Struggling with symptoms of depression Don t know what to expect Shame, fear of stigma May prefer to confide in peers

25 Why People Hesitate to Ask for Help Not sure about how severe the risk is; what if they re wrong? Worry about doing/saying the right thing Feelings of inadequacy Afraid to put the idea in someone s head Feel it s not their issue Bystander Effect

26 From a Suicidal Person s Point of View Crisis point has been reached Pain is unbearable Solutions to problems seem unavailable Thinking is affected HOWEVER: Ambivalence exists Communicating distress is common Invitations to help are often extended

27 Definitions Risk Factors- Stressful events or situations that may increase the likelihood of a suicide attempt or death. (Not predictive!) Warning Signs- the early observable signs that indicate increased risk of suicide for someone in the near-term. (Within hours or days.) Protective Factors- Personal and social resources that promote resiliency and reduce the potential of suicide and other high-risk behaviors.

28 Risk Factors

29 Risk Factors Long Term (Unchanging) Long Term (Modifiable) Triggers Family Family history of: Suicide Mental illness Substance abuse Race Gender Unrealistic parental expectations Abuse (emotional, physical, sexual) Major family conflict Exposure to suicide of family member Anniversary of death Moving often Previous suicide attempt Extreme perfectionism Rejection Personal Behavioral Loss through death, abandonment, divorce Mental illness Substance abuse Poor coping/social skills Impulsivity Relationship break-up Current acute mental illness Severe stress/anxiety Isolation Increased use of substances Social/ Environmental Inconsistent, neglectful or abusive parenting Sexual orientation Gender identity Experience of repeated loss Chronic severe stress Ongoing harassment Bullying, Harassment Arrest/Incarceration Active suicide cluster in community Access to lethal means

30 Suicide Risk Factors Yellow Light Proceed with Caution Mental disorders-particularly mood or eating disorders Substance abuse disorders Family history of suicide Hopelessness Impulsive and /or aggressive tendencies Barriers to accessing mental health treatment Divorced parents or poor family communication

31 Suicide Risk Factors Yellow Light Proceed with Caution Relational, social, work, or financial loss Physical illness Previous suicide act Easy access to lethal methods, especially guns Age, Culture, Lack of connectedness Exposure to sensational media reports of suicide

32 Warning Signs indicate someone is in crisis!

33 Suicide Warning Signs Red Light Stop Get Help Talking, reading, or writing about suicide/death. Talking about feeling worthless or helpless. Saying I m going to kill myself, I wish I was dead, or I shouldn t have been born. Visiting or calling people to say goodbye. Giving things away or returning borrowed items. Self destructive or reckless behavior. Significant change in behavior Running away

34 Suicide Warning Signs Red Light Stop Get Help Hopelessness typical hopeless statements: There s no point in going on I can t take it anymore I have nothing left to live for I can t stop the pain I can t live without My life keeps getting worse and worse I might as well kill myself

35 Clear Signs Of A Suicidal Crisis 1. Someone threatening to hurt or kill themselves 2. Someone looking for the means (gun, pills, rope etc.) to kill themselves; has a clear plan. 3. Someone showing signs of distress/ agitation/ anxiety Get the facts and take action!

36 Warning Signs: IS PATH WARM I S Ideation / threatened or communicated Substance abuse / excessive or increased? P Purposelessness / no reasons for living A Anxiety /agitation / insomnia T Trapped / feeling no way out H Hopelessness / nothing will ever change W Withdrawal from friends, family, society A Anger (uncontrolled)/ rage / seeking revenge R Recklessness/ risky acts / unthinking M Mood changes (dramatic)

37 Protective Factors

38 Protection Against Suicide Green Light Good to Go! Getting help for mental, physical and substance abuse disorders - Especially depression Restricted access to highly lethal methods of suicide especially firearms An established relationship with a doctor, clergy, teacher, counselor or other professional who can help Connectedness to community, family, friends Learned skills in problem solving and non-violent conflict resolution Cultural/religious beliefs that discourage suicide

39 Protective Factors Skills to think, communicate, solve problems, manage anger and other negative emotions, Purpose & value in life; hope for the future, pets, work/ life focus Personal characteristics- health, positive outlook, healthy choices, spirituality or religious belief Supports- parents, friends, mentors, and other caring adults Safe Environment restricted access to lethal means; positive school climate

40 Underlying Mental Illness

41 Although suicide is the 11 th leading cause of death for the overall population, it is the 3 rd leading cause of death for year olds.

42 Adolescent Depression Extreme sensitivity to rejection or failure Low self-esteem and feelings of guilt Frequent complaints of physical illnesses such as headaches and stomachaches Frequent absences from school or poor performance in school Threats or attempts to run away from home Major changes in eating or sleeping patterns (American Academy of Child and Adolescent Psychiatry, 8/98)

43 Adolescent Depression Sad, blue, irritable and/or complains that nothing is fun anymore Trouble sleeping, low energy, poor appetite and trouble concentrating Socially withdrawn or performs more poorly in school Can be suicidal National Institute of Mental Health, Treatment of Adolescent Depression Study (TADS)

44 Alcohol and Suicide Alcoholics have a suicide rate 50 times higher than the general population Alcohol dependent persons make up 25% of all suicides 18% of alcoholics eventually complete suicide States with the most restrictive policies toward alcohol have the lowest suicide rates (Lester, 1993)

45 Management

46 Assessment Tools Patient Health Questionnaire Modified for Teens (PHQ-9 Modified) years of age Less than five minutes to complete and score Adolescent Suicide Assessment Protocol (ASAP-20) Semi- structured clinical interview Addresses 20 items associated with suicide risk

47 What to Do (1) Take it seriously Almost 80% of all suicides had given some warning of their intentions Ask Directly If you think that someone is suicidal, ask them about it

48 What to do (2) Be Genuine Listen and don t show shock or disapproval Show that you care, it is more important than saying the right thing. Avoid trying to explain away the feelings (saying things like you have a lot to live for or you are just confused right now ) Stay There Don t leave them alone. Seek Help Be actively involved in seeking professional help

49 Plan for Safety KEEP SAFE Agreement Safety Contact (s) Safe/no use of alcohol and drugs Link to resources Disable the suicide plan Link to services Plan for Life

50 Biological Intervention (Medications) Medications can help with such symptoms as depression, anxiety and suicidal thoughts. Antidepressants and anxiolytics are the medications most often used to treat adjustment disorders. As with therapy, one may need medications only for a few months.

51 Problem Solving Techniques Target at the Distress

52 Problem-Solving Techniques

53 Problem-Solving Technique First goal is to remove or reduce the stressor By means of Problem Solving techniques

54

55 Cognitive Behavioral Therapy Second Wave Psychotherapy

56 Beck s Cognitive Triad The way you think, affects the way you feel, affects the way you behave.

57 Cognitive Behavior Therapy

58 Mindfulness-based Therapy Third Wave Psychotherapy

59

60 Prevention

61 Types of prevention

62 Core elements of Suicide Prevention Program Raise awareness of mental health and suicide Identify at risk students Increase acceptability of help-seeking Improve access to specialist help Develop social connections and support Develop coping skills

63 Screening Program

64 Curriculum based Approach

65 Gate Keeper Training

66 Skills Training

67 Treatment

68 Q&A Session

69 Effect of Suicide The Loss is: Sudden Unexpected Premature Self-inflicted The Reaction is: Shock, hurt, anger Loss and grief Questions & torment Guilt and regret Community Friends Co-workers Family/loved ones Suicide

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