What Is in Your Treatment Toolbox? Clinical Interventions to Prevent Suicidal Behavior

By Dr. Jane Pearson, National Institute of Mental Health & Action Alliance; Dr. Joel Sherrill, National Institute of Mental Health; and Colleen Carr, National Action Alliance for Suicide Prevention Secretariat

Community behavioral health providers are expected to know how to treat suicidal patients. As so often is the case, though, the practice demands are ahead of the research. New studies are testing the best ways to treat and prevent suicidal behavior, but how do you treat these behaviors without a full toolbox?

Medication Interventions

Many individuals with suicidal ideation will receive medications to address symptoms and “underlying” psychiatric conditions. However, most medication takes weeks to provide relief from psychiatric symptoms.

Currently, the only medication with a specific FDA indication relevant to suicide is clozapine. Clozapine is indicated for reducing the risk of recurrent suicidal behavior in patients with schizophrenia or schizoaffective disorder. However, agranulocytosis, a rare side effect of clozapine, results in the need for frequent monitoring of white blood cells, which limits its use in practice.

Although not FDA-indicated, lithium medication has been associated with lowering suicide risk in individuals with bipolar disorder. Research has found that individuals who remained adherent to lithium treatment were at lower risk for suicide, but placebo-controlled studies of lithium are still needed to isolate the medication versus compliance benefits in reducing suicide risk.

Ketamine, originally used as an anesthetic, is a repurposed medication that is showing promise as a fast-acting treatment for severe depression and suicidal ideation. Additional research is needed to determine the safety, feasibility, dose and duration for the use of Ketamine, but it does open up the potential for future fast-acting medication treatments for suicidal ideation that could be used in acute care settings.

In addition to tracking possible untoward side effects, there is also a need to test suicidal events as outcomes in medication research studies focused on treating mental disorders. In the past, many industry-sponsored trials excluded suicidal individuals from efficacy trials.

Psychotherapy Interventions

Several research reviews have found that outpatient psychotherapies (e.g., cognitive behavior therapy; dialectical behavior therapy; problem solving therapy) reduce suicidal thinking and re-attempts among high-risk adult patients. One review notes that psychotherapy recipients had, on average, a 32 percent reduction in the likelihood of a suicide attempt compared with usual care within a year.

Another study from the Danish health care registry followed recipients of psychotherapy and those not receiving psychotherapy for up to 20 years. Those who received psychotherapy were 16 percent less likely to attempt suicide and 25 percent less likely to die by suicide.

Modeling the future

In 2014, the Action Alliance’s Research Prioritization Task Force modeled optimal implementation of evidence-based psychotherapy delivered to the U.S. population of adults seen in emergency care for suicide attempts. The model estimated that more than 109,000 suicide attempts and more than 13,000 suicide deaths could be averted over 5 years by delivering effective psychotherapy to adults seen in emergency care settings for self-harm. This demonstrates enormous potential for successful intervention. In the meantime, we must continue to invest in suicide research.

Unanswered Questions

Research challenges include the need to better understand developmental and contextual factors:

• Youth, adult, older adult;
• Transitional, work and health contexts such as discharge from military and COPD onset;
• Co-occurring psychopathology (e.g., substance use);
• Social context (LGTBQ; domestic violence; recent loss);
• Prior suicidal behavior;
• Treatment history and
• Current setting–including immediate (referred from inpatient or emergency care)–in intervention research.

We need to know how to better match potential interventions to the patient’s needs. New treatment targets (e.g., isolation; anhedonia; insomnia; agitation; psychosis) might also be more efficiently addressed.

While suicide research around effective interventions is rapidly increasing, there remain many questions left to answer. For lives to be saved, effective research must be translated into practice.

As community behavioral health providers on the front line, you are the lifeline for patients at risk for suicide and those recovering from an attempt.

(See Section IX in the Research Agenda for citations for all research mentioned above. )

This post has been cross-posted on the National Council for Behavioral Health site.

What We Know (and What We Don’t) About Predicting Suicide Risk

By Dr. Jane Pearson, National Institute of Mental Health & Action Alliance; Dr. Lisa Colpe, National Institute of Mental Health; and Colleen Carr, National Action Alliance for Suicide Prevention Secretariat

Screening for suicide risk is common to most suicide prevention efforts and clinical practices that aim to identify at-risk individuals. To reduce suicide’s burden, there are a number of research-supported screening and risk detection tools to employ, but there is no doubt that further research is necessary to better understand the various factors that put people at risk of suicide.

The Continuum of Suicide Risk
Ideas about screening reflect our assumptions about a continuum of suicide risk—it is assumed there is a progression of suicide ideation, plans and eventual behavior (i.e., suicide attempts, suicide death). For example, multinational surveys have found that about a third of individuals who think about suicide make a plan and about a third go on to attempt suicide. Meanwhile, another subgroup reports having made an attempt with little or no ideation or planning.

Active versus Passive Ideation
Current approaches to assessing risk are heavily weighted toward identifying active ideation with a plan versus passive ideation (e.g., desire for death). However, some studies have found that passive ideation is just as strongly associated with morbidity as active ideation.

Screening Approaches
Many stakeholders consider screening for suicide risk an essential step in reducing suicides—and there are many opportunities to screen. Holding an annual depression screening day in the workplace or a school screening event following a suicide are two community examples. Screenings can be standalone, web-based for use in public settings or clinical tools (e.g., PHQ-9) integrated into primary care or other intake procedures to detect and monitor depression with suicide ideation. In fact, research looking at a large set of electronic health record data found a six-fold increased risk for suicide attempt (includes 709 attempts and 46 deaths) if someone responded ‘every day’ to the question, “Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or hurting yourself in some way?” on PHQ-9.

Screening within Health Systems
Screening practices are ahead of research. The Joint Commission recommends screening in all medical care settings to prevent suicide attempts and deaths. However, health care settings vary with regard to the proportion of patients at risk and the steps necessary to get identified patients to adequate care. In any setting, risk detection alone will not reduce suicide. Assessment, adequate intervention and ongoing monitoring must support screening and detection efforts to have the desired impact of reduced suicidal behavior.

Promising Research
Research links neurocognitive science with risk detection and screening. For example, the Suicide Implicit Association Task (IAT) has shown to improve prediction of who will attempt suicide in the future. It examines reaction times to ‘life’ and ‘death’ words and can be administered on the computer in 5-10 minutes. It is currently being studied in emergency department environments with both youth and adults.

Recent research has also identified specific genetic markers for suicidal behavior, but the studies require replication before having a role in clinical practice.

How Can Risk Detection Contribute to Achieving a 20% Reduction in Suicide?
There are a number of ways to model how our nation could achieve a 20% reduction in suicides. One strategy is to stratify risk and identify those in the high-risk group due to risk factors and those in the low-risk group due to risk and protective factors. If we can identify those in the high-risk group and intervene so we move more individuals into the lower part of the triangle (see graphic), we can begin to reduce suicide’s burden on our nation.

On January 29, the National Council launched a six-part webinar series highlighting the National Action Alliance for Suicide Prevention’s Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives. This series is a collaborative effort between the National Council for Behavioral Health,National Action Alliance for Suicide Prevention and the National Institute of Mental Health. Subsequent webinars will describe how this current understanding influences detecting those at risk, clinical care and services, as well as highlighting a number of the pressing research needs to reduce the burden of suicide. For more information about this webinar series, see Linda Rosenberg’s recent blog post announcing this collaboration.

This post has been cross-posted on the National Council for Behavioral Health site.

The Four Factors that Lead to (and Protect Against) Suicide

By Dr. Jane Pearson, National Institute of Mental Health & Action Alliance; Dr. Elizabeth Ballard, National Institute of Mental Health; and Colleen Carr, National Action Alliance for Suicide Prevention Secretariat

The ultimate answer to “Why do people become suicidal?” is complex, and as depicted in the figure below, research has focused on several long- and short-term risk factors that interact to place an individual at increased suicide risk.

1. Social Determinants

Healthy connectedness with family members, neighborhoods, cultural groups and society can serve as a protective factor against suicide. Conversely, social isolation is associated with increased risk. Social networks can be leveraged to promote protective influences across all ages. Young people’s attachment to their family and schools can serve as a protective factor with “school-connected” teens exhibiting a decreased risk for suicidal behavior over time. Interventions that increase healthy connections have been related to reduced suicide risk in older Japanese adults.

At the same time, certain types of social networks can relate to increased suicide risk, both in person and via media influences. Social networks can contribute to a “contagion” of suicidal behavior, potentially through imitation, idealizing and/or by ‘normalizing’ suicidal behavior. Media reporting of high-profile suicides also carries a concern for increased suicidal behavior.

2. Clinical Factors

Research has identified a host of clinical suicide risk factors. Psychiatric risk factors for suicide include depression, anxiety, post-traumatic stress and addiction; physical symptoms include pain and insomnia. Suicide has been associated with specific cognitive symptoms such as suicidal thoughts, making a plan, hopelessness, feeling like a burden and impulsiveness. However, it is important to note that the vast majority of people with behavioral health and physical illness diagnoses do not kill themselves.

3. Neurocognitive Factors

There is a connection between suicide attempts and deficits in basic cognitive functions (e.g., attention, memory), executive performance (e.g., conceptual processes, reversal learning), impulse control, decision-making and implicit thought processes (e.g., implicit associations, like preference and self-esteem). The neurocognitive findings associated with suicide risk include motor impulsivity, decision-making, response inhibition, flexibility of response generation, self-monitoring/error-processing, sensitivity to others’ anger, impaired response to positive emotional stimuli, harm avoidance and an inability to delay rewards. Recent research demonstrates that teens who attempt suicide may have impaired decision making on tasks such as the Iowa Gambling Test.

None of these factors has been determined to be entirely specific to suicide—whether or not these factors can be used reliably as clinical predictors remains to be seen.

4. Biomarkers that Reflect Biological Processes

Early research provided some evidence that suicidal behavior is heritable. Twin studies report 36-43 percent heritability; non-fatal suicide attempts have heritability estimates of 17-45 percent, even after controlling for any psychiatric disorders. In addition, children are five times more likely to attempt suicide if a parent has a history of suicide attempts, and it may relate to impulsive aggression. Another example of tragic and toxic parent-child outcomes, between 10-40 percent of individuals who experience suicidal thoughts and behavior have a child abuse history.

Immune factors, patterns of brain activity observed with imaging and genetic variants, have all been studied to identify biomarkers that can help predict risk or resilience. Current research trends include serotonergic functioning, glutamatergic functioning and responsiveness to stress in the HPA (hypothalamic–pituitary–adrenal) axis, which may be linked to childhood traumatic experiences.

At this point in time, there is no biomarker with diagnostic clinical utility.

There is a great deal to be hopeful about with regard to improving our understanding of why people consider and try to kill themselves. For more information and detailed citations on the information presented above, see the full Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives.

On January 29, the National Council launched a six-part webinar series highlighting the National Action Alliance for Suicide Prevention’s Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives. This series is a collaborative effort between the National Council for Behavioral Health, National Action Alliance for Suicide Prevention and the National Institute of Mental Health. Subsequent webinars will describe how this current understanding influences detecting those at risk, clinical care and services, as well as highlighting a number of the pressing research needs to reduce the burden of suicide. For more information about this webinar series, see Linda Rosenberg’s recent blog post announcing this collaboration.

This post has been cross-posted on the National Council for Behavioral Health site.

Breaking the Silence – Learning from the experience of Suicide Attempt Survivors

By Doryn Chervin, Action Alliance Executive Secretary

We live during a time, for better or worse, in which suicide is prominently covered in the media. Whether the story is a high-profile suicide, the ongoing fight to prevent military and veteran suicide, or other tragic stories of grief and loss, there is one voice that has been missing – the voice of the suicide attempt survivor. There is a movement underway to change this.  Suicide attempt survivors are emerging with a collective voice and a plan for re-shaping the delivery of suicide care in health care, strengthening community services, and improving suicide prevention efforts.

This Suicide Prevention Week, September 8 – 14, we embrace and support the suicide attempt survivor movement. For far too long, the perspectives of those with lived experience of suicide have not been integrated into treatment services and suicide prevention efforts. Whether this was due to fear, stigma, shame, or other reasons – the important fact is that this is changing.

For the many thousands of Americans who are now living as attempt survivors, their experience of resiliency and lived experience is an untapped resource that could potentially advance suicide prevention and save the lives of others in suicidal despair.  They understand better than providers or researchers how to find meaning in the midst of great darkness.

The National Action Alliance for Suicide Prevention (Action Alliance) is the nation’s public-private partnership advancing the National Strategy for Suicide Prevention and championing suicide prevention as a national priority. The Action Alliance’s Suicide Attempt Survivors Task Force, recently released a groundbreaking report, The Way Forward, which makes recommendations to improve our nation’s health systems, emergency services, and suicide prevention efforts based on the experience of attempt survivors. This report, which incorporates the lived experience of recovery and resilience, provides the missing bridge between suicide attempt survivors and treatment services, suicide prevention leaders, and policy makers.

The Way Forward marks the beginning of a new era, in which families, communities, clinicians, and health systems do not fear persons with a known history of suicidal thoughts and behaviors. Similar fears and concerns were once directed at persons with histories of mental illness, and alcohol or drug abuse; yet we have increasingly benefited and learned from the inclusion of persons with these lived experiences.

Let’s mark this week, 2014 Suicide Prevention Week, as the moment when families, communities, and organizations commit to fully supporting suicide attempt survivors in their recovery and in our efforts.

As the Executive Secretary of the Action Alliance, I welcome this movement. I welcome the stories of survival, hope, and recovery that suicide attempt survivors contribute to the cause of suicide prevention. The era of silence is over. Just as people once whispered about cancer, we will one day look back in wonder that we ever whispered about this.

If you, or someone you know is in crisis (no matter how small or big), help is available. By calling the 24/7 National Lifeline, 1-800-273-TALK (8255), you’ll be connected to a skilled, trained counselor who will help you find a reason to keep living.

Doryn Chervin, Dr.P.H., M.Ed.

Executive Secretary, National Action Alliance for Suicide Prevention
Vice President and Senior Scientist, Health and Human Development Division, Education Development Center, Inc.

The Framework for Successful Messaging

By Dr. Jerry Reed, member of our National Strategy for Suicide Prevention Revision/Update Task Force and Director of the Suicide Prevention Resource Center

Each September, World Suicide Prevention Day and National Suicide Prevention Week provide special opportunities to bring our message of prevention to millions of people around the world. This year, we have an exciting new resource to help us engage the public in suicide prevention and enlist them in supporting the cause that means so much to so many of us. The new resource is the National Action Alliance for Suicide Prevention’s Framework for Successful Messaging.

The Framework is a web-based resource developed to support the Action Alliance’s priority to “change the national narratives around suicide and suicide prevention to ones that promote hope, connectedness, social support, treatment, and recovery.” It will help everyone who communicates with the public about suicide – educators, researchers, policy makers, practitioners, and advocates – to create messages based on the best available evidence about safe, effective, and helpful communications. The Framework should be used when developing any message for the public, including educational materials, newsletters, event publicity, and fund-raising appeals.

The Framework outlines four critical issues to consider when messaging to the public about suicide. These issues are:

Strategy. Successful messages are focused and intentional. Understanding the audience and tailoring messages to their context is key to successful messaging. It is important to ask ourselves questions such as:
Why we are messaging?
How does the message fit into our overall mission and connect to other suicide prevention efforts?
Who is the audience for this message?
What channels will best reach this audience?
What do we want the audience to do in response to the message?
How can we frame the message to achieve this result?

Safety. Safety focuses on avoiding potentially harmful message content. We have made great strides in ensuring that we do not unintentionally raise the risk of suicide by, for example, discussing the data on suicide risk in ways that normalize suicide or imply that there is nothing that can be done to prevent suicidal behavior. We have worked hard to spread this message to our colleagues in mental health services and journalism, and must continue to consciously ensure that our own messaging is both safe and helpful.

Positive Narrative. We need to ensure that our messages “accentuate the positive” about suicide prevention and offer solutions rather than focus on the problem of suicide. There are many ways to promote a positive narrative; the best approach will be guided by your strategy. Our messages can help the public envision prevention by including concrete actions that the audience can take to help prevent suicide; sharing stories of coping, resilience, and recovery; describing the successes of prevention programs; helping people access valuable resources; and sharing what we know about effective prevention.

Guidelines. It is important to consult recommendations and best practices that apply to your particular messages. The Guidelines section of the Framework website links to a variety of resources, for example, guidelines for telling personal stories, discussing LGBT suicide, reaching young people, and creating culturally specific messages. Additional guidelines will be added over time.

As we prepare for World Suicide Prevention Day on September 10 and National Suicide Prevention Week September 8-14, let us be intentional about our messaging. By considering Strategy, Safety, Positive Narrative, and Guidelines as we craft our important messages, we can engage the public to take action and join us in our quest to prevent suicide and save lives. I urge everyone who creates suicide prevention messages to visit the Action Alliance Framework for Successful Messaging and take advantage of this unique resource.

This post was cross-posted on the Suicide Prevention Resource Center's Director's Corner.

New Directions for Suicide Prevention among Juvenile Justice-Involved Youth

By Joseph J. Cocozza, Ph.D., Director of the National Center for Mental Health and Juvenile Justice at Policy Research Associates, Inc. and co-lead of the National Action Alliance for Suicide Prevention’s Youth in Contact with the Juvenile Justice System Task Force

The suicide rate among American youth is alarmingly high, and the rate for justice-involved youth is even more concerning. Specifically, data show that:

• youth in juvenile justice residential facilities have nearly three times the rate of suicide compared to their peers in the general population; 
• suicide continues to be the leading cause of death for youth in custody; and
• up to one-third of justice-involved youth report having experienced suicidal ideation in the past year. 

Despite the gravity of these findings, there exists a significant gap between the seriousness of the problem and the adequacy of response to it. Given this disparity, the National Action Alliance for Suicide Prevention formed the Youth in Contact with the Juvenile Justice System Task Force (Task Force), which I was pleased to have co-led along with Melodee Hanes, the former Acting Administrator for the Office of Juvenile Justice and Delinquency Prevention.

As members of our Task Force came together, it became abundantly clear that much needed to be done to address this issue. Many juvenile justice practitioners and providers require a greater awareness of how significant and frequent the problem of suicide is for youth in their care. In an effort to bridge the gap from awareness to action, specific training and prevention protocols need to be implemented. Additionally, we need to learn more through research and evaluation about what works best to prevent suicide among justice-involved youth.

The goal of the Task Force was to focus attention on the unique needs of youth in contact with the juvenile justice system by developing new suicide prevention resources for the field. Objectives were organized around four areas:

• raising public awareness and education regarding suicide and prevention
• reviewing and integrating the best available research into the resources
• providing guidance around suicide prevention programming and training
• encouraging greater collaboration among the mental health and juvenile justice systems

Task Force members’ review of the available information, identification of the gaps in knowledge and practice, and recommendations for action, represent the best researched and documented body of work on their topics. The Task Force produced the following:

• Need to Know: A Fact Sheet Series on Juvenile Suicides provides concise, practical information about youth suicide prevention to three critical groups: 1) judges and juvenile courts, 2) juvenile detention and secure care staff, and 3) juvenile probation staff. Each fact sheet includes data on the prevalence of juvenile suicide, risk and protective factors associated with suicide, and steps that both staff and systems can take to prevent suicide.
•  Suicidal Ideation and Behavior among Youth in the Juvenile Justice System: A Review of the Literature summarizes the relevant, peer-reviewed literature on suicide in the juvenile justice system. It explores the prevalence of recent and past suicidal ideation and suicide attempts among justice-involved youth, gender and ethnic differences, and variables associated with suicidal ideation and attempt.
•  Screening and Assessment for Suicide Prevention: Tools and Procedures for Risk Identification among Juvenile Justice Youth examines the juvenile justice system’s responsibilities in preventing suicide, the contexts in which screening and assessment instruments are used, and specific instruments that are available. It also provides recommendations for implementing tools for both detecting and intervening with youth at risk for suicide.
• Guide to Developing and Revising Suicide Prevention Protocols for Youth in Contact with the Juvenile Justice System offers a standardized approach for youth suicide prevention among juvenile justice programs and providers. It describes critical components of a sound justice system, as well as strategies for implementing these components across the points of contact with the juvenile justice system.
•  Preventing Juvenile Suicide through Improved Collaboration: Strategies for Mental Health and Juvenile Justice Agencies recommends priorities and strategies that mental health and juvenile justice agencies at the state and local levels can pursue to inform joint policy and budgeting decisions associated with suicide prevention for youth involved in juvenile justice in an effort to enhance the provision of appropriate services to this vulnerable population.

A complete list of the membership, products, and findings of the Task Force can be found in the Executive Summary.

To help disseminate this important information, a variety of activities are occurring. The Action Alliance released the work of the Task Force on its website, and many Task Force members have disseminated the information via their own organizations’ Listserv, website, and/or newsletter. On April 17, I was joined by Dr. Linda Teplin, a Task Force member and an expert on youth suicide from Northwestern University, in presenting Preventing Suicide among Justice-Involved Youth: Newly Developed Tools, Recommendations, and Research, which was the first of a series of free webinars hosted by the Action Alliance and the Substance Abuse and Mental Health Services Administration (SAMHSA). Additionally, the National Center for Mental Health and Juvenile Justice developed a new web resource, Preventing Suicide Among Justice-Involved Youth, for the Mental Health and Juvenile Justice Collaborative for Change website, which also includes other information and resources about mental health and juvenile justice.

It is my hope that through this work, in addition to our ongoing collective efforts, youth suicide can be prevented. Our duty to protect children, in particular those who are most vulnerable, is an obligation that must be taken seriously. This mission requires an urgency that cannot be overstated and I am privileged to have a role in seeing it succeed.

New Social Media Guidelines Offer Tips for Talking Effectively About Mental Health and Suicide Online

By Brian Dyak, President & CEO of Entertainment Industries Council, Inc. and co-lead of the Action Alliance Public Awareness and Education Task Force

Social media has become ubiquitous. People communicate online about their lives and get their information about the world from sites like Facebook, Twitter and blogs. When one in four people experience mental health challenges each year, social media is a place where some will turn to talk about their experiences, to seek support from their friends and to find helpful information. Social media offers a venue in which people are more comfortable discussing their own mental health issues, which in turn increases the likelihood that others will seek help when they need it.

With that in mind, the Entertainment Industries Council’s TEAM Up project has just released the first-of-its-kind Social Media Guidelines for Mental Health Promotion and Suicide Prevention. These new guidelines are designed to assist individuals and organizations in safely and effectively talking about mental health and suicide-related issues via social media. With tips for posting and responding on Facebook pages, groups, Twitter feeds, Tumblr pages, websites and blogs and more, the guidelines take into account the unique safety, privacy and stigma-related aspects of these issues.

The recommendations in this document were reviewed by experts in social media and the related health fields. Organizational supporters of the Guidelines include the National Action Alliance for Suicide Prevention, California Mental Health Services Authority, Facebook Inc. and leading journalism organizations the National Association of Broadcasters and Radio Television Digital News Association.

“Whether you want to share your own story, discuss events in the news or help others understand mental illness and encourage them to seek help when they need it, these recommendations will be a helpful resource for everyone, especially in teaching children and teens how to communicate about these issues. Safe, constructive communication via social media, that avoids stigmatizing or derogatory language and does no harm, changes the conversation and decreases discrimination,” said Brian Dyak, Entertainment Industries Council, President and CEO and Co-Chair National Action Alliance for Suicide Prevention Public Awareness & Education Task Force, when the Guidelines were released.

“Social media makes it easier than ever to connect and share with the people you care about,” said Joe Sullivan, Chief Security Officer, Facebook and Co-Chair of the National Action Alliance for Suicide Prevention Public Awareness & Education Task Force. “Knowing effective ways to seek input and offer support to your friends and families about difficult topics is an important part of building a safe online community."

“The guidelines have been reviewed by experts in social media and the related health fields. When communicating online avoiding descriptions and images of suicide acts or methods can help reduce the risk of suicide contagion. Anyone can use this new tool to help someone who may be in crisis and potentially help save a life,” Executive Director, Suicide Awareness Voices of Education Dr. Dan Reidenberg commented.

Social media can be instrumental in bringing about social change – by spreading ideas from person to person, by bringing people together for a common purpose, by sharing and reinforcing social norms and by making it easy for people to take action. Social media is not about the technology, but rather it’s about people talking to people, often on a massive scale. By using these powerful tools in a strategic way, and encouraging others to do so as well, we can harness their power to change how people think about mental health and suicide prevention.

Visit TEAM Up for more information.