The Role of Fatality Review in Suicide Prevention Richard McKeon Ph.D.
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 3
Preventing suicide A global imperative
National Strategy for Suicide Prevention
Saving Lives: Impact of the 2012 National Strategy for Suicide Prevention American Association of Suicidology 2015 Annual Meeting Copyright 2010 2015 Education Development Center, Inc. All Rights Reserved
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 2010 2015 Education Development Center, Inc. All Rights Reserved
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 2010 2015 Education Development Center, Inc. All Rights Reserved
SAMHSA Suicide Prevention programs GLS State/Tribal Youth Suicide Prevention grants GLS Campus grants NativeConnections NSSP/Zero Suicide Suicide Prevention Resource Center National Suicide Prevention Lifeline Mayor s Challenge (with VA)
The Garrett Lee Smith (GLS) Suicide Prevention National Outcomes Evaluation is supported through contract no. HHSS283201200007I/HHSS28342002T (reference no. 283-12-0702) 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)
Results: Difference in Suicide Mortality suicide 10-24 suicide 25+ count per 100,000 6 7 8 9 10 11 12 count per 100,000 14 16 18 20 22 24 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
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 2
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 2007-10. (There were 776 county-years where GLS trainings were implemented during 2006-2009 and 41K youth 10-24 on average per county, i.e. 776*41K*-1.33/100,000). More than 100,000 attempts among youth 16-23 were avoided during approximately the same period. (There were 776 county-years where GLS trainings were implemented during 2006-2009 and 29K youth 16-23 on average per county, i.e. 776*29K*-4.9/1,000). 1 3
Critical Data Sources NVDRS Child Fatality Review Utah Juvenile Justice Foster Care-Michigan Public Behavioral Health-Kentucky, Vermont, New York, Ohio Medicaid-Ohio, Utah
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: 10.1007/s11606-014-2767-3. 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, 2009. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, DC: 2002), 61(6), 1-43. 15
Deconstructing Suicide Deaths in the U.S. = Already Modeled 16
CDR and Garrett Lee Smith grants Grants are required to have a public/private coordinating group. Grantees are strongly encouraged to include CDR in this coordinating group. CDR can help identify what systems a youth at risk might have touched (justice, foster care, mental health) or whether a more universal approach is needed (schools, pediatrics)
Critical Questions What can review of an individual child s death contribute to community or state suicide prevention efforts? How can death reviews complement surveillance systems such as the NVDRS? What were the prevention possibilites identified by a Child Death Review?
GLS and CDR coordination Rhode Island 46% had documented MH diagnosis 46% receiving active mental health services (CDR/RCA) 40% known history of substance abuse 7% recent immigrant youth CRT published report with youth suicide prevention recommendations
Suicide Clusters On average around 2 percent of suicides amongst 15 to 19 year olds in the U.S. were found to cluster spatially and temporally beyond that expected by chance, although this figure was as high as 13 percent in some states. 1 In this study, the two states with the highest proportion of youth suicide clusters were among the three states that had the largest American Indian and Alaska Native (AI/AN) populations. These estimates stemmed from Gould, Wallenstein, and Kleinman s analysis (1990) of vital statistic mortality data from 1978 to 1985 for 12 states. However, the estimates are still considered reasonable. 1 Mesoudi, 2009, p. e7252
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 2006-2012- centerpiece is tribally mandated reporting and follow up
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 reduce suicidal behavior Suicide attempts in youth may be marker for later significant problems
Link between interpersonal trauma & suicide 10-fold increase for suicide among youth exposed to interpersonal violence 1 ACES study: for every additional ACE, suicide risk increases by 60% 2 Chronicity of victimization is associated with risk over and above other factors 3 23 1. Castellví et al., 2017 2. Dube, Anda, Felliti, Chapman, Williamson, & Gilles, 2001 3. Geoffroy et al., 2016
Foster Care Screening Project 24
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
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
Richard McKeon, Ph.D., M.P.H. Branch Chief, Suicide Prevention, SAMHSA 240 276 1873 Richard.mckeon@samhsa.hhs.gov