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Facebook Live - Suicide Prevention

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>>Josh: Hello and welcome. My name is Dr. Joshua Gordon. I'm the director of the National Institute of Mental Health or NIMH. I'm joined by my colleague Dr. Jane Pearson, Chief of the Suicide Research Consortium and Program Chief for Suicide Prevention Efforts in NIMH's Division of Services and Intervention Research. We're hosting today's Facebook Live event in recognition of Suicide Prevention Week. During this chat, we're going to discuss some of our most recent research findings in suicide prevention as well as discussing treatment approaches, warning signs, and really how anyone can intervene to help save a life. Our Facebook viewers will also have the opportunity to ask questions. So please if you do have questions, type them into the comment section on our Facebook Live event page. We're going to try and get through as many as possible during the discussion. Before we get started though, I do want to say to anyone out there who might be having difficulties-- who might be thinking about harming themselves or trying to kill themselves, please call the Suicide Prevention Lifeline at 1-800-273-TALK. That's 1-800-273-8255 or visit their website suicidepreventionlifeline.org for help. Okay. Well before we get to questions, we're just going to talk a little bit to introduce you to the kinds of research findings we've been discovering here at NIMH. And to introduce us, I'll ask Jane to tell us about some of our chief goals in that area?

>>Jane: Great. Thanks, Josh. So NIMH has supported suicide prevention research for some time, but we've been accumulating evidence, so I think we're at some point in our science where we can really apply what we've learned. And it's coming at a good time. We have our partners at the National Action Alliance for Suicide Prevention who've set goals of reducing the suicide rate in the US by 20% by the year 2025, so you might hear of the 2025 goal advertised by them and having everybody work towards that same goal. And one way we've thought about this more recently is to understand where people have died-- when people have died by suicide, what setting had they been in recently? And we've looked at this from a number of ways in different age groups. And one of the things we're finding is that a lot of people go to healthcare before they die. Some talk about suicide, some don't. And it's not that going to healthcare necessarily is a risk factor, but because people go there yearly, typically that's an opportunity to find them.

>>Josh: So healthcare settings - whether it be permanent care doctors or emergency rooms - these are opportunities to identify who might be at risk. And although many people are identified by their healthcare providers as being at risk, what we've found  through the research is that if you ask everybody-- whether you're emergency room or you're a primary care doctor, if you ask everybody whether they've been thinking about harming themselves or killing themselves, you identify a lot more people who are at risk. And in fact, our research has shown further that once you can identify them, you can reduce that risk through some pretty straightforward interventions. So the idea of identifying opportunities, identifying individuals at risk, and intervening that's the mainstay of our research.

>>Jane: Absolutely. And what we're trying to develop now are tools for providers to think about, "Okay, if somebody is screening positive, how do we talk more about this to understand sort of their level of risk?" What kind of resources do they need and also helping them think through a clinical workflow because we know they're very busy already? So if we're asking them to add this to their list of questions. We want to make sure people get the appropriate care that they need.

>>Josh: So we've focused on healthcare providers, emergency rooms, and primary care doctors. We've also got research showing that using electronic medical records one can also identify people at risk so that we can remind doctors to ask the right questions as well as looking for effective means in intervening particularly in children and adolescents who we know the rates of suicide have been increasing dramatically in that younger age group. In fact, we've developed here in our own research centers at the NIMH a screening toolkit specifically designed for healthcare providers to be able to ask children and adolescents about suicide. It's called the ASQ. It's available through our website. That's NIMH.nih.gov. And it's an effective tool to identify children and adolescents at risk. So with that introduction, we're going to go ahead and take some questions from the Facebook Live viewing audience. So please, go ahead and type the questions into the comments and they'll pop up here. And we'll try to get to them, as many as possible. One of the questions that really comes up quite often is, and I see it's come up already here, is what are the indications that someone might be about to harm themselves? What are the things that a family member or a loved one can recognize? Can you tell us something about that, Jane?

>>Jane: Sure. So some of these you could call them warning signs. And they're not always specific to suicide., but they are things that you should start being concerned about and feel comfortable enough to ask if somebody's thinking about harming themselves or taking their own life. And we want to make sure everybody understands. That doesn't put an idea in somebody's head. It really can actually be reassuring to that person that you care enough to know what is really happening with them, what they're thinking about. And that gives you the opportunity to say, "Let's go get some help, and I'll go with you. Let's take care of this." So some of those risk factors could be somebody speaking about they feel like they're a burden to the family, you could have an increase in different mental health problems, anxiety, depression, too much sleep, too little sleep. If somebody's talking about wanting to die or death or giving things away, you should take that seriously even if they're not imminently suicidal like they don't have an immediate plan. It's really important to get help. And it's actually easier to get help if somebody's not [laughter] in an acute crisis. So it's actually a better thing if you're suspicious to get help sooner.

>>Josh: A related question from one of our viewers is, "Is self-harm an indication of potential suicide? And how does one differentiate between attention-seeking self-harm and serious self-harm?" And I think self-harmful behaviors are risk factors for suicide. And I would say even as a mental health professional it can be very difficult to differentiate between attention-seeking self-harm and serious self-harm. And I think any self-harmful event should be treated as if it's a suicide attempt because most of them-- many of them are. And certainly, it should be an indication to help if you notice it in yourself or in a friend to get help from a mental health professional.

>>Jane: Right. I think we've got research showing that at times people are saying, "This is more for relief or it's a habit." But sometimes it is potentially life-threatening. So people can go back and forth on that. And we do know it's a risk factor in the long run. So I would take it seriously. And it certainly isn't the best coping mechanism. It is a coping mechanism [laughter] people describe what we would prefer seeing how their coping mechanisms.

>>Josh: We have another question from a viewer. How do you feel about the collaborative care model to identify more patients in primary care at risk for suicide? So some of you may know, the collaborative care model is something that we've been funding research for for all sorts of purposes at the interface between primary care medicine and psychiatry. It involves what you might think, people working together to care for patients. We found that it can be helpful in all sorts of settings, and we have an ongoing study to examine the role of collaborative care for suicide prevention. So as a scientist, it's not so much how I feel about it as it is what's the evidence, and I think the evidence is very promising for the collaborative care model to assist in suicide prevention efforts.

>>Jane: I think one thing that's important about it is it's this collaboration, this team. And we know we don't have enough psychiatrists in this country, and it's a great way to extend their expertise. So they could be on the team. They can help people decide when treatments should change. It's a team that also does [inaudible] making sure people are still connected to care, so we also know that those are important factors. And it's also one of the things that we know-- just in depression screening, that works very well with this model. It means that you can identify people, get them to the right treatment. They do better. They get better faster through this model.

>>Josh: So you said in depression screening. We know that depression and other mental illnesses do raise the risk for suicide, and there's another question which is, "Is suicide genetic?" that came in from a viewer. And another way to phrase that is, "Are there genetic risk factors for suicidal behavior?"

>>Jane: Yes. Absolutely. But like anything else that has a genetic risk factor, if you know about it, you're aware of it, you can work to manage the risk. So that can be helpful in a healthcare setting for sure, and that could be added to medical record information. So we're actually in the middle of looking at how do we put all those pieces together to understand somebody's risk and then do something about it to mitigate the risk.

>>Josh: Here's a great question that popped up. What resources do we have for teens who are having peer challenges at school and having suicidal thoughts? Are there tip sheets or something for parents to use or, for that matter, for schools to use to try?

>>Jane: It's a great question, and I think youth are much, actually, more open to talking about suicide, and I think sometimes the adults are catching up with them. And what I would recommend for people joining us today is to check out the Suicide Prevention Resource Center. It's a great place to look at resources for schools, universities, and healthcare, as we were already mentioning. There are toolkits there for parents, for teachers, and this is something that I think will continue to evolve because I think we'll be improving health curricula at schools as kids understand more about this and as we can think about what's effective prevention so kids don't even get to the point of thinking about suicide.
So that's the Suicide Prevention Research Center--
Resource Center.
Resource Center. Thank you. And the website for that is--?
sprc.org.

>>Josh: sprc.org.

>>Jane: Yep. It's a great resource.

  I want to add, actually, while we have that moment-- I want to remind people what I said at the beginning of the Facebook Live event that if you are having trouble and want to reach out for help, a great source for help is the Suicide Prevention Lifeline at 1-800-273-TALK. That's 1-800-273-8255 or suicidepreventionlifeline.org. I also want to mention another web resource now that we're talking about web resources, which is hosted on our own website www.nimh.nih.gov. Within that, we have a suicide prevention page. The easiest way to get there is by going to our website nimh.nih.org/suicideprevention, or if you forget all that, Google nimh suicide prevention. That works too. So let's take another question. How can professionals engage families in suicide prevention?

>>Jane: So families end up being the therapists at home often if somebody's being treated in an outpatient setting. There's accreditation bodies for hospitals that have recommended that family members be informed, be a part of the treatment team. So if the professionals that you're seeing have not engaged with you yet around this, ask them. It's really a best practice because everybody needs to know what they're going to do. There's also this tool, or I'd say even call it an intervention, of safety planning. So you might want to develop ways of-- if something's feeling like a crisis is coming on, what can I do? Who do I talk to? What coping skills do I have that I should try to remember to try use? And you can have different levels of this. And this is a tool that's very useful for families and individuals to use.

>>Josh: Yeah. In my own practice seeing patients who had suicidal thoughts, safety planning was a tool that I used a lot. It can be modestly effective. But a key component of safety planning is involving family members and friends. And I would typically bring them into the office and have frank conversations with them and the person suffering and come up with plans together. And that's been shown to be effective ways. And we have additional research around that topic, for example, looking at caring communications that is approaches to increase communication around suicide as an effective therapeutic.
As a way of staying in touch and how are you doing, some of those communications can be reminding you to use those resources.
Now, we talked about identifying those at risk and an effective way of identifying is what we call universal screening, that is asking everyone who comes into a healthcare setting about their suicidal thoughts. And there's a great question pertaining to that: what is the best way to explain to parents that you are screening their young child for suicide and not having them get defensive or concerned? "Oh, you're asking my child about suicide?"

>>Jane: Sure. It's terrifying to a parent to that think their child is thinking about this. So I would suggest looking at that ASQ toolkit because there's a lot of information there to help both providers and help family members understand why this is the case. And what we've found in a lot of screening or even talking to-- if you're administering the screening orally, talking to somebody, if they're not suicidal, they'll say I'm not. If they are, they will tell you. And so it's really important to get that information out. It doesn't go away if you don't ask about it. It's there, so it's much better to understand what's there. And I think giving parents tools of here's what we're going to do about this. And how to make it a safer place is really important.

>>Josh: Yeah. No. I think it's really important to maintain open channels of communication, like in most areas of life, but in particular in healthcare provider, patient, and/or parent interactions. And the ASQ toolkit, which is again available through our site at nimh.nih.gov/suicideprevention, it provides not just the questionnaires but some context to the questionnaires to be able to explain to your patients and to their families. The next question: the latest CDC report found that about 54% of people people who died by suicide did not have a mental health diagnosis. Therefore it seems we need to expand beyond our current mental health-centric approach. What are my thoughts on that? So first, the CDC report did come out in the spring. And what many of us-- the surprising result that over half of those who die by suicide do not have a mental health diagnosis at the time of death. And there's two parts to that. One I think the question is completely correct. We do need to expand our approach to suicide prevention beyond mental health care settings. And that's why we've emphasized things like emergency rooms and primary care settings where you're seeing your general physician as places to identify those at risk. And that's the only way we're going to be able to reach that large chunk of people who are at risk of suicide, but who aren't seeing a mental health care provider. That said, we've long had research into the anti [seems?], that is the risk factors for suicide. We know that mental illnesses are strong risk factors. And we also know that if you look carefully into the lives of people who died by suicide, that many ore 54% of them will have evidence of a serious mental illness. Probably closer to 90% which means that most of those people who are succumbing to suicide, they are actually not getting the help they need for a mental illness that we can potentially treat. So that's all the more reason to reach out into these non-mental health settings to try to identify those at risk because we probably can help them in lots of different ways.
Another question. What are some healthy methods to discuss the topic of suicide with someone you fear is at risk, especially if you're afraid of triggering them, or of not validating their feelings?

>>Jane:  So it's a difficult topic to bring up. Absolutely. So you want to start asking them just generally how they are doing, if you can find out more about what's happening in their lives. And you can ask, ''I'm really concerned about you. Have you thought about taking your life because I'm-- here's what's worrying me about that.'' So it's all done in a caring and supportive way. The validating part comes-- that's sort of like a clinical question. But validating is really trying to understand that person's feelings and understand where they're at so you can meet them where they're at, and try to help them get some professional care.

>>Josh: Yeah. I think that's an excellent point. As we mentioned earlier, the research shows very clearly asking people about suicide does not increase their risk. Nonetheless, even though I know that data, I know it's hard to bring that up right off the bat, and so it is important to talk to someone generally about how they're feeling before asking them as what might seem as a rude or brisk question as, ''Are you thinking of hurting yourself?'' But the truth of the matter is that those who are not thinking about hurting themselves are not going to be too offended. And those who are thinking about killing themselves, they are the ones who will feel validated when you ask. They'll say, ''You know, I haven't wanted to talk about it. But yeah.'' And they will find that experience to be therapeutic in and of itself. And it's not just experience. We have data on that. We have research that shows that the act of asking is a helpful act.

>>Jane: That's right.

>>Josh: Another excellent question is are there resources for veterans? And    and the questioner points out that they account for about 14% of suicides in the US according to the Veterans Administration.

>>Jane: Absolutely. So, actually, the National Suicide Prevention Lifeline that we've been giving out 1-800-273-8255 has an option for veterans. And more counselors have been added in the past couple of years to provide that support. And anybody who's had military service could certainly call. And the part about switching to the veteran's crisis line section of that is they will know the resources available specifically for veterans to help you.

>>Josh: Okay. Another question that came in, what is the youngest age that researchers and/or doctors begin to identify those who die by apparent suicide as being victims of suicide versus being the victims of impulsive accidents?

>>Jane: That's a good question. I think we're starting to look at this as we saw the numbers for very young people go up. And I believe medical examiners and coroners are struggling to figure out how to do this because, in general, you'd have to understand developmental psychopathology to figure out, "Okay, at what point do kids see death as a final step?" And those are all really important research questions. We do know that people who die by accidents and suicide are sometimes these overlapping groups because it represents reckless behavior or there's common risk factors to both. Whether that's the case in very young children, we don't know. [inaudible] we certainly need to understand this better. Either way, there's an injury involved. And, maybe, we can find the risk factors that are common to both and try to reduce those.

>>Josh:   But I think your point is well-taken that, regardless of age, it can sometimes be challenging to determine--

>>Jane: Yes.

>>Josh: whether an accidental injury or suicide is at fault.

>>Jane: That's right.

>>Josh:   And it is possible that we're undercounting suicides because some of them are classified as accidental injuries or--
[crosstalk].
--for that matter, in this day and age especially, accidental overdoses.

>>Jane: Yes.

>>Josh: Do those who are grieving have higher rates of suicidal ideation, that is thinking about suicide? And how can one best determine risk when someone says something like they wish they were with their lost beloved?

>>Jane: Right. It's a really important question for people bereaved by suicide because it's nothing unusual to want to be with the person who's now passed on. However, we want to make sure that those people are getting the help they need. So there are interventions that, actually, NIMH has supported in complicated grief where we have some effective interventions.

>>Josh: Complicated grief, what do you mean by complicated grief?

>>Jane: So it's natural to go through grief. The symptoms of grief are distinguished often from depression because this is a reaction that you're going through. When you have a lot of thoughts about wanting to join that person, or you have your own thoughts of suicide because you feel like you can't go on and your life is not what you want it, that's an important time for intervention. So there are protocols. We have interventions that are helpful.

>>Josh: Right, so we talked about some risk factors, and I think they apply to complicated grief--

>>Jane: Yes.
--as well as other causes of potential suicidal ideation. Those warning signs that we talked about earlier, feeling like a burden, being isolated, but also things like increased anxiety, feeling trapped or in unbearable pain, increase in use of substances--

>>Jane: Yes.
--whether they be illegal drugs or alcohol, and then, when people talk about trying to find a way-- looking for a way to hurt themselves or kill themselves, increased anger or rage, mood swings, expressions of hopelessness, like you suggest, and then talking about or posting on social media sites about wanting to die. These are all risk factors that one can see. They don't necessarily mean someone's about to harm themselves or try to kill themselves. But they are indications of risk.  And then what do you do when you see those indications of risk? Well, the most important thing as we've mentioned before-- what's the most important thing?

>>Jane: So you want to-- after you've asked them-- we've talked about how to start that conversation, what to do, be with them, keep them safe. You want to keep them away from the means that they might use for suicide [crosstalk].

>>Josh:  So if they have guns, ask them to take their guns for them to keep them safe.

>>Jane: Medications that could be fatal. If you're in an area where somebody could jump, you want to get them out of that space.

>>Josh: Right. So we call that means restriction, making sure they don't have access to the ways that they can harm themselves. So asking, keeping them safe, what's next?

>>Jane:  Help them connect to some help. And, actually, the Lifeline that we've been giving helps you locate services in your area. And you can call them back if you're not able to find some help. And, hopefully, every state, every county has some way of doing this. The Suicide Prevention Resource Center, again, can actually map out for you in your state where there are state resources too.

>>Josh: Right. And just for everyone who may have missed it the first time, the Suicide Prevention Lifeline is 1-800-273-8255 - that's 1-800-273-TALK - or their website suicidepreventionlifeline.org and our NIMH website, nimh.nih.gov/suicideprevention.
So I want to thank everyone for joining us today. We've talked about some of the latest research from NIMH pertaining to suicide prevention. We've talked how what we're trying to do is focus on identifying those at risk. We've given you some hints about how you might be able to identify risk in those whom who care about around you and what to do when people do acknowledge thinking about suicide. And that most important thing to do which is ask. Well, we'll try to answer as many of your questions as possible that you've written in the comments on the Facebook Live site. And please, again, visit our website for more information and for the addresses of other websites we've mentioned along the way, the phone number for the Suicide Prevention Lifeline, and any other information that could be helpful.
So thank you again for joining us today.

>>Jane:  Yeah, thanks