SUICIDE PREVENTION LANDSCAPE OVERVIEW NATIONAL ACADEMY SEPT 2018 CHRISTINE MOUTIER, M.D AFSP CHIEF MEDICAL OFFICER

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1 SUICIDE PREVENTION LANDSCAPE OVERVIEW NATIONAL ACADEMY SEPT 2018 CHRISTINE MOUTIER, M.D AFSP CHIEF MEDICAL OFFICER

2 Disclosures Disclosures/conflicts None (AFSP funds 25% of all suicide studies) Acknowledgments Yeates Conwell, Dave Jobes, Elizabeth Ballard

3 Agenda Game Plan National trends Suicide preventive treatment National Rate Goal: Project 2025 Gaps

4 NATIONAL TRENDS

5 SOCIETAL TRENDS Science Permeating Societal Views Scientific field growing Public awareness, stigma diminishing Movement gaining strength, ppl personally affected speaking out More collaboration, consensus on effective strategies at community and clinical levels

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7 CULTURE TRENDS 2016 AP Stylebook Change Avoid Commit suicide Successful/failed attempt Say Died by suicide Attempted suicide

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9 ADVOCACY TRENDS Advocacy in Action 32 states passed laws mandating K12 teacher training (since 2006) 18 states- laws prevention & postvention K12 schools (since 2012) 9 states- laws healthcare training (since 2012) 11 states- laws higher ed prevention (since 2016) 4+2 State laws enforcing parity (since 2016) 13 major federal laws/policies enacted- suicide prevention

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14 Limiting Access to Means PUBLIC EDUCATION

15 Prevention Resources EDUCATIONAL RESOURCES

16 TREATMENT

17 RISK REDUCING CARE Innovation in Treatment Suicide-specific targeted treatments Brief interventions The role of technology Least restrictive, evidence-based, cost-effective treatments Systematic healthcare with suicide outcomes in mind

18 Critical Windows of Suicide Risk Week after psychiatric admission, week after psychiatric discharge, ED discharge for SA First weeks after starting an antidepressant Time of Acute Risk Time of Acute Risk Emergency Services Psychiatric Hospitalization Discharge to Community TIME Qin et al., 2005; Olfson et al., 2014

19 RISK REDUCING TX Suicide Risk-Reducing Therapy Dialectic Behavioral Therapy DBT (Linehan 2006) Cognitive Behavioral Therapy CBT (Beck, Brown 2005, Bryant, Rudd 2007, Holloway) CBT for Adolescent Attempters TASA (Brent 2009) Collab Assmt & Mngemt Suic CAMS (Jobes, Comtois) Attachment Based Family Tx ABFT (Diamond) Attempted Suicide Short Int ASSIP (Michel, Gysin-Maillart)

20 DBT v Expert Therapy Suicide Re-Attempts Linehan M et al. Two-year RCT and f/u of DBT v therapy by experts for suicidal behaviors and BPD. JAMA 2006

21 Cumulative Survival CBT Reduces Repeat Suicide Attempt Cognitive Therapy Intervention Control Brown GK et al. (2005) JAMA, 294, Days *p <.05

22 Brief Cognitive Behavior Therapy (B-CBT) M. David Rudd & Craig Bryan Ft. Carson Randomized Clinical 60% between-group reduction in suicide attempts (Am J Psych 2015)

23 Meta-Analysis of CBT for Suicidal Behaviors Mewton L, Andrews G. Cognitive behavioral therapy for suicidal behaviors: improving patient outcomes. Psychology Research and Behavior Management 2016

24 Medications Maximize management of primary condition(s) Suicide specific considerations Lithium for mood disorders (Baldessarini 2003, 2006) Clozapine for schizophrenia, only FDA w suicide indication (Meltzer 2003) Antidepressants Pharmaco-epidemiologic study (Gibbons, Mann 2006) Counties w/ higher AD Rx~lower suicide rate Monitor closely in youth <24 On the horizon- NMDA antagonists/partial FDA Breakthrough Therapy designation

25 Ketamine and Other NMDA Data suggests positive outcomes for refractory MDD Partially independent of mood, rapid reduction in SI Controversy relates to small scale studies, abuse potential, side effects, and length of therapeutic effect Pipeline: Eskatamine i.v. & nasal, rapastinel, others

26 Clinical & System Pearls RISK REDUCING CARE Clinicians can learn to filter and dial in information that informs suicide risk Consider patient s logic and language Suicide Risk Assessment goes further than SI/plan Other important factors past hx, prior attempt, support, hope/pain, FH, ambivalence Communicate after discharge and between visits Suicide-specific therapy Consider medications to reduce suicide risk Health system changes and training

27 PROJECT 2025

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29 Project 2025 PROJECT 2025 AFSP has set a bold goal to reduce the annual rate of suicide in the U.S. 20% by 2025.

30 Four Critical Areas PROJECT 2025 Settings not subgroups Potential to save the most lives in shortest time Accelerate and scale-up progress through strategic partnerships Monitor, evaluate, and adjust approach in real-time FIREARMS Nearly half of all suicides are by firearms EMERGENCY DEPARTMENTS 39% make an ED visit in the year prior a suicide; 70% don't attend 1st outpatient appointment after an attempt HEALTHCARE SYSTEMS Up to 45% of individuals who die by suicide visit their primary care physician in the month prior CORRECTIONS SYSTEM Suicide is the leading cause accounting for 35% of all jail deaths. Suicide in state prisons up 30% in just one year ( )

31 GAPS & SOLUTIONS

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34 ACTION SOLUTIONS Where are the gaps? Universal Mental Health Literacy Implementation science to measure impact Inclusion in clinical trials Surveillance, health systems can capture suicide events Clinician training prediction/prevention Integrated MH care/screening in primary care Bill for services, e.g., Safety Planning, Lethal Means Counseling, Telemedicine, Peer Enforcement of MH Parity

35 Together we can save lives and improve the quality of many more.

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37 @afspnational Contact: Christine Moutier, M.D.