MEANS RESTRICTION THE HOW OF SUICIDE. Talking about the Tools of Suicide with Patients THE HOW OF SUICIDE. Methods of Self-Harm: 2004

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1 Talking about the Tools of Suicide with Patients Joseph H. Obegi PsyD THE HOW OF SUICIDE THE HOW OF SUICIDE Fatal Attempts 1.8% Cutting/ 3.7% Nonfatal Attempts 0.8% 0.7% 2.2% Piercing Other Firearm Suffocation Fall 21.1% 16.5% Other Poisoning 25.2% Suffocation 50.7% Firearm 21.9% Cutting/ Piercing 54.9% Poisoning 0.6% Fall Methods of Self-Harm: 2004 Self-injury by firearm was the most lethal method with an 85% fatality rate. Suffocation was the next most lethal method (69% fatality rate). Cutting and poisoning, which includes drug overdoses, infrequently lead to death. Harvard Injury Control Research Center (2012) JOSEPH H. OBEGI 3

2 JOSEPH H. OBEGI 4 THE HOW OF SUICIDE 8 7 Firearm Suicide 6 Rate per 0K Firearm Homicide Year Firearm-Related Death Rates The rate of firearm homicide has declined steadily while firearm suicide rate has begun rising, increasing roughly 14 percent between 2006 and Together these trends keep the overall gun death rate the same (Brady Campaign, 2016) Brady Campaign (2016); Wintemute (2015) FIREARMS AND SUICIDE 25 All suicide mortality Firearm suicide mortality Rate per 0K % Adults living with a firearm in the home Firearm Suicides: Ownership, Urbanization, and Age The rate of suicide by firearm rises as the percentage of adults owning a firearm in a state is larger. Having a firearm in the home raises the risk of suicide by about 3 times (Anglemyer et al., 2014). Risk is higher if the the firearm is kept loaded or unlocked (Kellerman et al., 1992). The rate of suicide also increases as the area becomes more rural and people age. JOSEPH H. OBEGI 5 Miller et al. (2012) FIREARMS AND SUICIDE 9 8 Cut Drowning Fall Firearm Poisoning Suffocation Rate per 0K Large central metro Large fringe metro Medium metro Small metro Micropolitan NonCore Extent of Urbanization Firearm Suicides: Ownership, Urbanization, and Age The rate of suicide by firearm rises as the percentage of adults owning a firearm in a state is larger. Having a firearm in the home raises the risk of suicide by about 3 times (Anglemyer et al., 2014). Risk is higher if the the firearm is kept loaded or unlocked (Kellerman et al., 1992). The rate of suicide also increases as the area becomes more rural and people age. JOSEPH H. OBEGI 6 Miller et al. (2012)

3 JOSEPH H. OBEGI 7 FIREARMS AND SUICIDE Firearm homicides Firearm suicides Rate per 0K Age group (yrs) Firearm Suicides: Ownership, Urbanization, and Age The rate of suicide by firearm rises as the percentage of adults owning a firearm in a state is larger. Having a firearm in the home raises the risk of suicide by about 3 times (Anglemyer et al., 2014). Risk is higher if the the firearm is kept loaded or unlocked (Kellerman et al., 1992). The rate of suicide also increases as the area becomes more rural and people age. Wintemute (2015) WORKS Myth: Inevitability of Suicide 74% of people believe that all or most jumpers would have found another way to die However, means substitution does generally not occur JOSEPH H. OBEGI 9 Betz et al. (2013); Miller et al. (2006)

4 JOSEPH H. OBEGI Rates per 0K Male Total Co Year Female Total Co Year Carbon Monoxide Suicides in England As natural gas replaced coal gas and cleaner oil-based gases became more common in England and Wales, the percentage of carbon monooxide (Co) dropped from % in 1964 to a small fraction of 1% in During this period the overall suicide rate decreased by more than 30%. Adapted from Kreitman (1976) Most lethal pesticides banned Rate per 0K Poisoning Hanging Other Year Poisoning Suicides in Sri Lanka The proportion of suicides due to pesticide poisoning increased from 37% in 1959 to 72% Suicides by poison fell dramatically after the most lethal pesticides were banned in 1995 and1998. There was not corresponding shift in suicide methods. JOSEPH H. OBEGI 11 Gunnell et al. (2007) Why Restrict Access to Means? Many suicides are impulsive Suicidal crises are time limited Most attempt survivors do not go on to die by suicide Means restriction works JOSEPH H. OBEGI 12 Simon et al. (2001); Drum et al. (2009); Carroll et al. 2014

5 JOSEPH H. OBEGI 13 No Yes Rate per 0K National rate: Waiting period Background check Open carry restricted Gun lock required Firearm Suicides and State Handgun Legislation States that makes handguns more difficult to obtain have substantially lower rates of firearm suicide (Anestis & Anestis (2005). Moreover, states that repeal laws regulating firearms, see an immediate and lasting increase in firearm suicides (Anestis & Anestis, 2015; Crifasi et al., 2015). Anestis & Anestis (2015) 0 Trained parents Untrained parents Percentage of parents restricting access or disposing Prescribed Over-the-counter Alcohol Firearms medication medication Parent Education and Restricting Access When hospital staff provided injury education prevention to parents making an emergency mental health visit for their children, parents were 3.6 times more likely to limit access to lethal means than were parents who did not receive education. JOSEPH H. OBEGI 14 Kruesi et al. (1999) Attempt with less Fewer deaths by Suicidal persons Lethal means not available lethal means Delay in attempt suicide Suicidal urges pass Effective help Fewer suicide attempts JOSEPH H. OBEGI 15 Adapted from CDC (1992)

6 COUNSELING! Ongoing Monitoring Regularly assessing progress and suicide risk level so that treatment can be adapted as necessary Suicide Risk Assessment Systematically collecting clinical data to estimate the degree of suicide risk and devise an plan that reduces risk # " Treatment Intervening to instill hope, address the drivers of suicidal behavior, and teach more adaptive coping skills Safety Management Apply interventions that address the patient s immediate or near-term safety. $ JOSEPH H. OBEGI 17 Steps 1. Ask about firearms 2. Inform about risks 3. Explore options 4. Enlist supportive others 5. Confirm JOSEPH H. OBEGI 18 Adapted from Bryan et al. (2011)

7 JOSEPH H. OBEGI 19 Ask about Firearms Is there a gun in the home or any other place? How many? Where and how are the guns and ammunition stored? What is the purpose of the firearm? Do you intend to purchase a gun? Bryan et al., (2011); Simon (2007) Inform about Risks A suicidal person with access to a gun is 7x more likely to plan to die with a gun A gun in the home raises the risk of suicide by 3x Most adolescent suicides are by firearm Risk is higher when guns are loaded or unlocked 85% of suicides with a gun are fatal JOSEPH H. OBEGI 20 Betz et al. (2011); Brent (2001); Vyrostek et al. (2004) Talking to Gun Owners Not anti-gun but anti-suicide Not gun control but gun safety Respect gun rights Emphasize that removal is temporary Present a menu of options JOSEPH H. OBEGI 21 Bryan et al. (2011)

8 JOSEPH H. OBEGI 22 Options: Storage* Use gun safes and trigger locks Store unloaded Store and lock ammunition separately Key or combination kept with supportive other or in a bank s safe deposit box Dismantle firearm and give a critical piece to a supportive other Bryan et al. (2011); Kruesi et al (1995) Options: Removal Temporarily held by supportive other outside the home (not hidden in the home) Temporarily held by local law enforcement Dealers and shooting ranges may rent storage JOSEPH H. OBEGI 23 Bryan et al. (2011); Kruesi et al (1995) Options: Disposal Sell the firearm (but interim safety steps are still need) Disposal by local law enforcement* JOSEPH H. OBEGI 24 Bryan et al. (2011); Kruesi et al (1995)

9 JOSEPH H. OBEGI 25 Confirm the Restriction From the supportive other not the gun owner Verbal or written (means receipt); no texting Bryan et al. (2011) Returning the Firearm Reassessment of suicide risk completed Crisis has passed Meaningful reduction in emotional distress Absence of warning signs JOSEPH H. OBEGI 26 CONTACT ME Joseph H. Obegi PsyD Address 2055 Anderson Road Davis, CA Phone & Web JOSEPH H. OBEGI 27

10 CONTACT ME Photos by Dese'Rae L. Stage livethroughthis.org Joseph H. Obegi PsyD Address 2055 Anderson Road Davis, CA Phone & Web JOSEPH H. OBEGI 28 Anestis, M. D., & Anestis, J. C. (2015). Suicide rates and state laws regulating access and exposure to handguns. American Journal of Public Health, e1-e. Betz, M. E., Miller, M., Barber, C., Miller, I., Sullivan, A. F., Camargo, C. A. J., & Boudreaux, E. D. (2013). Lethal means restriction for suicide prevention: Beliefs and behaviors of emergency department providers. Depression and Anxiety, 30(), Brent, D. A. (2001). Firearms and suicide. Annals of the New York Academy of Sciences, 932, ; discussion; Bryan, C. J., Stone, S. L., & Rudd, M. D. (2011). A practical, evidence-based approach for means-restriction counseling with suicidal patients. Professional Psychology: Research and Practice, 42(5), Carroll, R., Metcalfe, C., & Gunnell, D. (2014). Hospital presenting self-harm and risk of fatal and non-fatal repetition: Systematic review and meta-analysis. PloS One, 9(2), e CDC. (1992). Youth suicide prevention programs: A resource guide. Retrieved from p /p asp. Drum, D. J., Brownson, C., Burton Denmark, A., & Smith, S. E. (2009). New data on the nature of suicidal crises in college students: Shifting the paradigm. Professional Psychology: Research and Practice, 40(3), Gunnell, D., Fernando, R., Hewagama, M., Priyangika, W. D., Konradsen, F., & Eddleston, M. (2007). The impact of pesticide regulations on suicide in sri lanka. International Journal of Epidemiology, 36(6), doi:.93/ije/dym164 Harvard Injury Control Research Center. (2012)Retrieved from MeansMatter_Brochure.pdf. Johnson, R. M., Frank, E. M., Ciocca, & Barber, C. W. (2011). Training mental healthcare providers to reduce at-risk patients' access to lethal means of suicide: Evaluation of the CALM project. Archives of Suicide Research, 15(3), Kreitman, N. (1976). The coal gas story. United kingdom suicide rates, British Journal of Preventive & Social Medicine, 30(2), Kruesi, M. J. U. I., Grossman, J., Pennington, J. M., Woodward, P. J., Duda, D., & Hirsch, J. G. (1999). Suicide and violence prevention: Parent education in the emergency department. Journal of the American Academy of Child & Adolescent Psychiatry, 38(3), Kruesi, M. J. U. I., Grossman, J., Pennington, J. M., Woodward, P. J., Duda, D., & Hirsch, J. G. (1999). Suicide and violence prevention: Parent education in the emergency department. Journal of the American Academy of Child & Adolescent Psychiatry, 38(3), Lester, D. (2012). Suicide prevention by lethal means restriction. In R. I. Simon & R. E. Hales (Eds.), The american psychiatric publishing textbook of suicide assessment and management (pp ). Washington, D.C.: American Psychiatric Publishing. Lubin, G., Werbeloff, N., Halperin, D., Shmushkevitch, M., Weiser, M., & Knobler, H. Y. (20). Decrease in suicide rates after a change of policy reducing access to firearms in adolescents: A naturalistic epidemiological study. Suicide & Life-threatening Behavior, 40(5), Miller, M., & Hemenway, D. (2008). Guns and suicide in the united states. New England Journal of Medicine, 359(), Miller, M., Azrael, D., & Barber, C. (2012). Suicide mortality in the united states: The importance of attending to method in understanding population-level disparities in the burden of suicide. Annual Review of Public Health, 33, Miller, M., Azrael, D., & Hemenway, D. (2006). Belief in the inevitability of suicide: Results from a national survey. Suicide and Life- Threatening Behavior, 36(1), Rogers, S. C., DiVietro, S., Borrup, K., Brinkley, A., Kaminer, Y., & Lapidus, G. (2014). Restricting youth suicide: Behavioral health patients in an urban pediatric emergency department. J Trauma Acute Care Surg, 77(3 Suppl 1), S23-8. Simon, R. I. (2007). Gun safety management with patients at risk for suicide. Suicide & Life-threatening Behavior, 37(5), Suicide Prevention Resource Center. (n.d.). Counseling on access to lethal means. Retrieved from description.php#course3. Vyrostek, S. B., Annest, J. L., & Ryan, G. W. (2004). Surveillance for fatal and nonfatal injuries: United states, Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C. : 2002), 53(7), Wintemute, G. J. (2014). The epidemiology of firearm violence in the twenty-first century united states. Annual Review Public Health. Yip, P. S., Caine, E., Yousuf, S., Chang, S. -S., Wu, K. C. -C., & Chen, Y. -Y. (2012). Means restriction for suicide prevention. The Lancet, 379(9834),