Physicians Awareness Training

Saving Lives:Saving Lives:Understanding Depression And Understanding Depression And Preventing Suicide – Prevention Preventing Suicide – Prevention

Training For Physicians and Training For Physicians and Medical Personnel Medical Personnel

The Ohio Suicide Prevention The Ohio Suicide Prevention

FoundationFoundation Developed by Ellen J. Anderson, Ph.D., Developed by Ellen J. Anderson, Ph.D.,

SPCC, 2003-2008SPCC, 2003-2008

Physicians Awareness TrainingPhysicians Awareness Training 22

““Still the effort seems unhurried. Still the effort seems unhurried. Every 17 minutes in America, Every 17 minutes in America,

someone commits suicide. someone commits suicide. Where is the public concern and Where is the public concern and

outrage?”outrage?”

Kay Redfield JamisonKay Redfield Jamison

Author of Author of Night Falls Fast: Night Falls Fast: Understanding SuicideUnderstanding Suicide


Training GoalsTraining Goals Learn about local suicide prevention efforts, Learn about local suicide prevention efforts,

how these efforts connect with your how these efforts connect with your practice and patientspractice and patients

Understand the pivotal role of medical Understand the pivotal role of medical personnel in the treatment of depressed personnel in the treatment of depressed patients and in reducing suicide riskpatients and in reducing suicide risk

Increase awareness of suicide risk Increase awareness of suicide risk characteristics in patients who may not characteristics in patients who may not present as depressed/suicidalpresent as depressed/suicidal

Learn a brief suicide risk assessment modelLearn a brief suicide risk assessment model Learn to ask the “S” questionLearn to ask the “S” question


Why Do We Need To Improve Why Do We Need To Improve Suicide Prevention Efforts?Suicide Prevention Efforts?

Suicide is the last taboo Suicide is the last taboo We can talk about sex, alcoholism, cancer, but We can talk about sex, alcoholism, cancer, but

not suicide not suicide People need to understand the impact of People need to understand the impact of

depression and other mental illnesses, and depression and other mental illnesses, and how they lead to suicidehow they lead to suicide

Suicide is a preventable deathSuicide is a preventable death Integrating medical staff into the efforts of Integrating medical staff into the efforts of

suicide prevention coalitions to reduce deaths, suicide prevention coalitions to reduce deaths, increase awareness, and reduce stigma seems increase awareness, and reduce stigma seems critical to local, state, and national efforts to critical to local, state, and national efforts to change our approach to this age-old problemchange our approach to this age-old problem


Changing Our Approach: Changing Our Approach: Depression Is An Depression Is An IllnessIllness

Suicide has been viewed for countless Suicide has been viewed for countless generations as:generations as: A moral failing, a spiritual weaknessA moral failing, a spiritual weakness An inability to cope with lifeAn inability to cope with life ““The coward’s way out”The coward’s way out” A character flawA character flaw

This cultural view of suicide is not This cultural view of suicide is not validated by our current understanding validated by our current understanding of brain chemistry and it’s interaction of brain chemistry and it’s interaction with stress, trauma and genetics on with stress, trauma and genetics on mood and behaviormood and behavior

Physicians Awareness TrainingPhysicians Awareness Training 66Gatekeeper Training- Dr. Ellen Gatekeeper Training- Dr. Ellen AndersonAnderson 66

The Feel of DepressionThe Feel of Depression

““I am 6 feet tall. The way I have felt I am 6 feet tall. The way I have felt these past few months, it is as these past few months, it is as though I am in a very small room, though I am in a very small room, and the room is filled with water, up and the room is filled with water, up to about 5’ 10”, and my feet are to about 5’ 10”, and my feet are glued to the floor, and its all I can do glued to the floor, and its all I can do to breathe.”to breathe.”


The research evidence is overwhelming- what The research evidence is overwhelming- what we think of as depression is far more than a we think of as depression is far more than a sad mood. It includes:sad mood. It includes:

1. Weight gain/loss2. Sleep problems3. Sense of tiredness, exhaustion4. Sad mood 5. Loss of interest in pleasurable things, lack of

motivation6. Irritability7. Confusion, loss of concentration, poor memory8. Negative thinking9. Withdrawal from friends and family10. Often, suicidal thoughts

(DSMIVR, 2002)(DSMIVR, 2002)


20 years of brain research teaches that 20 years of brain research teaches that what we are seeing is the what we are seeing is the behavioralbehavioral result of:result of: Changes in the physical structure of the Changes in the physical structure of the

brainbrain Destruction or shutting down of brain Destruction or shutting down of brain

cells in the hippocampus and amygdala cells in the hippocampus and amygdala (5HTP axis)(5HTP axis)

Decrease in neurotransmittersDecrease in neurotransmitters increased agitation in the limbic system increased agitation in the limbic system

Depressed people suffer from a physical Depressed people suffer from a physical illness within the brain – what we might illness within the brain – what we might consider “faulty wiring”consider “faulty wiring”

(Braun, 2000; Surgeon General’s Call To Action, 1999,(Braun, 2000; Surgeon General’s Call To Action, 1999, Stoff & Mann, 1997, The Neurobiology of Suicide)Stoff & Mann, 1997, The Neurobiology of Suicide)


Faulty Wiring?Faulty Wiring? Literally, damage to certain nerve cells in our Literally, damage to certain nerve cells in our

brainsbrains The result of too many stress hormones – cortisol, The result of too many stress hormones – cortisol,

adrenaline and testosteroneadrenaline and testosterone Hormones activated by our Hormones activated by our AAutonomic utonomic NNervous ervous

SSystem to protect us in times of dangerystem to protect us in times of danger Chronic stress causes changes in the Chronic stress causes changes in the

functioning of the ANS, so that a high level of functioning of the ANS, so that a high level of activation occurs with little stimulusactivation occurs with little stimulus

Causes changes in muscle tension, imbalances Causes changes in muscle tension, imbalances in blood flow patterns leading to illnesses such in blood flow patterns leading to illnesses such as asthma, IBS, back pain and depressionas asthma, IBS, back pain and depression

(Goleman, 1997, Braun, 1999)(Goleman, 1997, Braun, 1999)


Faulty Wiring?Faulty Wiring? Without a way to return to rest, hormones Without a way to return to rest, hormones

accumulate, doing damage to brain cellsaccumulate, doing damage to brain cells Stress alone is not the problem, but how Stress alone is not the problem, but how

we interpret the event, thought or feelingwe interpret the event, thought or feeling People with People with genetic predispositionsgenetic predispositions, ,

placed in a highly placed in a highly stressful stressful environmentenvironment will experience damage to will experience damage to brain cells from stress hormonesbrain cells from stress hormones

This leads to the cluster of This leads to the cluster of thinking and thinking and emotional changesemotional changes we call depression we call depression (Goleman, 1997; Braun, 1999)(Goleman, 1997; Braun, 1999)


Where It Hits UsWhere It Hits Us


One of Many NeuronsOne of Many Neurons•Neurons make up the brain and cause us to think, feel, and act •Neurons must connect to one another (through dendrites and axons) •Stress hormones damage dendrites and axons, causing them to “shrink” away from other connectors•As fewer connections are made, more and more symptoms of depression appear


As damage occurs, thinking changes in the As damage occurs, thinking changes in the predictable ways identified in our 10 criteriapredictable ways identified in our 10 criteria

““Thought constriction” can lead to the idea Thought constriction” can lead to the idea that suicide is the only optionthat suicide is the only option

How do antidepressants affect this “brain How do antidepressants affect this “brain damage”?damage”?

May counter the effects of stress hormonesMay counter the effects of stress hormones We know now that antidepressants stimulate We know now that antidepressants stimulate

genes within the neurons (turn on growth genes within the neurons (turn on growth genes) which encourage the growth of new genes) which encourage the growth of new dendritesdendrites

(Braun, 1999)(Braun, 1999)


Renewed dendrites increase the Renewed dendrites increase the number of neuronal connectionsnumber of neuronal connections

The more connections, the more The more connections, the more information flow, the more flexibility information flow, the more flexibility and resilience the brain will haveand resilience the brain will have

Why does increasing the amount of Why does increasing the amount of serotonin, as many anti-depressants serotonin, as many anti-depressants do, take so long to reduce the do, take so long to reduce the symptoms of depression? symptoms of depression?

It takes 4-6 weeks to re-grow It takes 4-6 weeks to re-grow dendrites & axonsdendrites & axons

(Braun, 1999)(Braun, 1999)


Why Don’t We Seek Why Don’t We Seek Treatment?Treatment?

We don’t know we are experiencing a We don’t know we are experiencing a brain disorder – we don’t recognize the brain disorder – we don’t recognize the symptomssymptoms

When we talk to doctors, we are vague When we talk to doctors, we are vague about symptomsabout symptoms

We believe the things we are thinking We believe the things we are thinking and feeling are our fault, our failure, and feeling are our fault, our failure, our weakness, not an illnessour weakness, not an illness

We fear being stigmatized at work, at We fear being stigmatized at work, at church, at schoolchurch, at school


No Happy Pills For MeNo Happy Pills For Me

The stigma around depression leads to The stigma around depression leads to refusal of treatmentrefusal of treatment

Taking medication is viewed as a failure Taking medication is viewed as a failure by the same people who cheerfully take by the same people who cheerfully take their blood pressure or cholesterol medstheir blood pressure or cholesterol meds

Medication is seen as altering Medication is seen as altering personality, taking something away, personality, taking something away, rather than as repairing damage done to rather than as repairing damage done to the brain by stress hormonesthe brain by stress hormones


Therapy? Are You Kidding? I Therapy? Are You Kidding? I Don’t Need All That Woo-Woo Don’t Need All That Woo-Woo

Stuff!Stuff! How can patients seek treatment for How can patients seek treatment for

something they believe is a personal failure?something they believe is a personal failure? Acknowledging the need for help is not Acknowledging the need for help is not

popular in our culture (Strong Silent type, popular in our culture (Strong Silent type, Cowboy)Cowboy)

People who seek therapy may be viewed as People who seek therapy may be viewed as weakweak

Therapists are viewed as crazyTherapists are viewed as crazy They’ll just blame it on my mother or some They’ll just blame it on my mother or some

other stupid thingother stupid thing


How Does Psychotherapy How Does Psychotherapy Help?Help?

Medications may improve brain function, but do not Medications may improve brain function, but do not change how we change how we interpretinterpret stress stress

Psychotherapy, especially cognitive or interpersonal Psychotherapy, especially cognitive or interpersonal therapy, helps people change the (negative) patterns therapy, helps people change the (negative) patterns of thinking that lead to depressed and suicidal of thinking that lead to depressed and suicidal thoughtsthoughts

Research shows that cognitive psychotherapy is as Research shows that cognitive psychotherapy is as effective as medication in reducing depression and effective as medication in reducing depression and suicidal thinkingsuicidal thinking

Changing our beliefs and thought patterns alters our Changing our beliefs and thought patterns alters our response to stress – we are not as reactive or as response to stress – we are not as reactive or as affected by stress at the physical levelaffected by stress at the physical level (Lester, 2004)(Lester, 2004)


What Therapy?What Therapy?

The standard of care is medication and The standard of care is medication and psychotherapy combinedpsychotherapy combined

At this point, only cognitive behavioral At this point, only cognitive behavioral and interpersonal psychotherapies are and interpersonal psychotherapies are considered to be effective with clinical considered to be effective with clinical depression (evidence-based)depression (evidence-based)

Consider EMDR for patients with Consider EMDR for patients with trauma experiencestrauma experiences

Look for therapists with specific Look for therapists with specific training – Ask!training – Ask!


Yet most people do not understand the Yet most people do not understand the physical aspects of mental illness, as you physical aspects of mental illness, as you have no doubt found in talking with your have no doubt found in talking with your patientspatients

Suicide is strongly linked with certain Suicide is strongly linked with certain mental illnesses, and most people do not mental illnesses, and most people do not understand this connectionunderstand this connection

Your county Suicide Prevention Coalition is Your county Suicide Prevention Coalition is attempting to attempting to Reduce the stigmaReduce the stigma attached to mental illness, increase attached to mental illness, increase help-help-seeking behaviorseeking behavior, and , and increase increase awareness of the consequencesawareness of the consequences of of untreated depressionuntreated depression


Suicide Prevention EffortsSuicide Prevention Efforts First national effort established at NIMH in First national effort established at NIMH in

19691969

Surgeon General issued a call to action to Surgeon General issued a call to action to prevent suicide in 1999prevent suicide in 1999

In 2001, a National Strategy for Suicide In 2001, a National Strategy for Suicide Prevention Committee developed future goals Prevention Committee developed future goals and objectivesand objectives

An Ohio Suicide Prevention Plan was An Ohio Suicide Prevention Plan was developed in May, 2002, and grants for local developed in May, 2002, and grants for local coalitions were given out in November of 2002coalitions were given out in November of 2002


Development Of Development Of Prevention EffortsPrevention Efforts

Over the past 20 years, we have acquired Over the past 20 years, we have acquired valuable information on risk and protective valuable information on risk and protective factors, methods for preventing suicidal factors, methods for preventing suicidal behavior, and improved research methodsbehavior, and improved research methods

An increase in suicide prevention programs An increase in suicide prevention programs in schools in schools

The rapid development of suicidology as a The rapid development of suicidology as a multidisciplinary sub-specialtymultidisciplinary sub-specialty

Establishment of centers for the study and Establishment of centers for the study and prevention of suicideprevention of suicide


Framework For PreventionFramework For Prevention

Public health approach to prevention in Public health approach to prevention in contrast to clinical approaches used in the contrast to clinical approaches used in the pastpast

The prevailing model is the Universal, The prevailing model is the Universal, Selective, and Indicated model (WHO, 2002)Selective, and Indicated model (WHO, 2002)

Focuses attention on defined populations, Focuses attention on defined populations, from everyone, to specific at-risk groups, to from everyone, to specific at-risk groups, to specific high-risk individualsspecific high-risk individuals


8989 people complete suicide every day people complete suicide every day32,63732,637 people in 2005 in the US people in 2005 in the USOver Over 1,000,0001,000,000 suicides worldwide suicides worldwide

(reported)(reported)This data refers to completed suicides This data refers to completed suicides

that are documented by medical that are documented by medical examiners – it is estimated that 2-3 examiners – it is estimated that 2-3 times as many actually complete suicidetimes as many actually complete suicide

(Surgeon General’s Report on Suicide, 1999)(Surgeon General’s Report on Suicide, 1999)

Is Suicide Really a Is Suicide Really a Problem?Problem?


The Unnoticed DeathThe Unnoticed Death

For every 2 homicides, 3 people For every 2 homicides, 3 people complete suicide yearly– data complete suicide yearly– data that has been constant for 100 that has been constant for 100 yearsyears

During the Viet Nam War from During the Viet Nam War from 1964-1972, we lost 58,000 1964-1972, we lost 58,000 troops, and 220,000 people to troops, and 220,000 people to suicidesuicide


Who Is At Risk?Who Is At Risk? Most people assume young people Most people assume young people are more likely to complete suicide,are more likely to complete suicide, It is the 3It is the 3rdrd largest killer of youth ages 15-24 largest killer of youth ages 15-24 In 2005, 267 children aged 10-14 completedIn 2005, 267 children aged 10-14 completed Adult malesAdult males from from 35-5535-55 actually complete actually complete

suicide at a far greater rate than youth suicide at a far greater rate than youth The elderly are at significant risk; among The elderly are at significant risk; among

those over 75, 1 out of 4 attempts end in those over 75, 1 out of 4 attempts end in death because the elderly tend to use more death because the elderly tend to use more lethal meanslethal means

(Surgeon General’s call to Action, 1999)(Surgeon General’s call to Action, 1999)


Comparative Rates Of U.S. Comparative Rates Of U.S. Suicides-2004Suicides-2004

Rates per 100,000 populationRates per 100,000 population National averageNational average - 11.1 per 100,000* - 11.1 per 100,000* White malesWhite males - 18 - 18 Hispanic malesHispanic males - 10.3 - 10.3 African-American males African-American males - 9.1 ** - 9.1 ** Asians Asians - 5.2 - 5.2 Caucasian femalesCaucasian females - 4.8 - 4.8 African American females African American females - 1.5 - 1.5 Males over 85Males over 85 - 67.6 - 67.6

Annual Attempts – 811,000 (estimated)Annual Attempts – 811,000 (estimated) 150-1 completion for the young - 4-1 for the elderly150-1 completion for the young - 4-1 for the elderly

(*AAS website),**(Significant increases have occurred among (*AAS website),**(Significant increases have occurred among African Americans in the past 10 years - Toussaint, 2002)African Americans in the past 10 years - Toussaint, 2002)


Suicide Rate By Age Per Suicide Rate By Age Per 100,000100,000

0%

5%

10%

15%

20%

25%

15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+

Age

% S

uici

de p

er 1

00,0

00

Older people: 12.7% of 1999 population, but 18.8% of suicides. (Hovert, 1999)


Suicide Rates Among The Suicide Rates Among The ElderlyElderly

• The elderly have the highest suicide rate of any groupThe elderly have the highest suicide rate of any group

• Depression in late life affects six million people, one out Depression in late life affects six million people, one out of six patients in a general medical practiceof six patients in a general medical practice

• However, only one of those six patients is diagnosed and However, only one of those six patients is diagnosed and treated appropriatelytreated appropriately

• The majority of these people have seen their primary The majority of these people have seen their primary care physician within the last month of life care physician within the last month of life

• There is evidence that the majority of elderly suicide There is evidence that the majority of elderly suicide victims die in the midst of their victims die in the midst of their first episodefirst episode of major of major depression depression

• Depression is not a normal consequence of aging and can Depression is not a normal consequence of aging and can significantly alter the course of other medical conditionssignificantly alter the course of other medical conditions

(Empfield, 2003)(Empfield, 2003)


PCP’s And Diagnosis Of PCP’s And Diagnosis Of DepressionDepression

Seniors have often visited a health-care provider Seniors have often visited a health-care provider before completing suicidebefore completing suicide

20% of elderly (over 65 years) who complete suicide 20% of elderly (over 65 years) who complete suicide visited a physician within 24 hoursvisited a physician within 24 hours

41% within a week 41% within a week 75% within one month75% within one month

Patients may not use the words depression or sadnessPatients may not use the words depression or sadness Because of the stigma that is still attached to this Because of the stigma that is still attached to this

diagnosis, somatic symptoms may become the focus diagnosis, somatic symptoms may become the focus of complaintof complaint

There may be much denial and minimizing of There may be much denial and minimizing of affective symptomsaffective symptoms



Poor Quality Of Mental Poor Quality Of Mental Health Care For EldersHealth Care For Elders

Increased risk for inappropriate Increased risk for inappropriate medication treatment medication treatment (Bartels, et al., 1997, 2002)(Bartels, et al., 1997, 2002)

> 1 in 5 older persons given an > 1 in 5 older persons given an inappropriate prescription inappropriate prescription (Zhan, 2001)(Zhan, 2001)

The elderly are less likely to be treated The elderly are less likely to be treated with psychotherapy with psychotherapy (Bartels, et al., 1997)(Bartels, et al., 1997)

Lower quality of general health care is Lower quality of general health care is associated with increased mortalityassociated with increased mortality

(Druss, 2001)(Druss, 2001)


Depression Associated With Depression Associated With Worse Health OutcomesWorse Health Outcomes

Depression is common among older patients with Depression is common among older patients with certain medical disorders certain medical disorders

Associated with worse health outcomesAssociated with worse health outcomesGreater use and costs of medicationsGreater use and costs of medicationsGreater use of health services Greater use of health services

Medical illness greatly increasesMedical illness greatly increases the risk for the risk for depression particularly in:depression particularly in: Ischemic heart disease (e.g. MI, CABG) Ischemic heart disease (e.g. MI, CABG)

Stroke Cancer Chronic lung disease Stroke Cancer Chronic lung disease Alzheimer’s disease Parkinson’s disease Alzheimer’s disease Parkinson’s disease

Rheumatoid Arthritis Rheumatoid Arthritis (Empfield, 2003(Empfield, 2003))


In Cancer, depression leads toIn Cancer, depression leads toIncreased HospitalizationIncreased HospitalizationPoorer physical function Poorer physical function Poorer quality of lifePoorer quality of lifePoorer pain controlPoorer pain control

Increased mortality rates forIncreased mortality rates for Hip fracturesHip fractures Long Term Care ResidentsLong Term Care Residents Myocardial InfarctionMyocardial Infarction

In heart attack patients, depression is a In heart attack patients, depression is a significant predictor of death at 6 monthssignificant predictor of death at 6 months

( Frasure-Smith 1993, 1995; Mossey 1990; Penninx et al. 2001; Katz 1989, ( Frasure-Smith 1993, 1995; Mossey 1990; Penninx et al. 2001; Katz 1989, Rovner 1991, Parmelee 1992;Ashby1991; Shah 1993, Samuels 1997)Rovner 1991, Parmelee 1992;Ashby1991; Shah 1993, Samuels 1997)


Rates Of Depression Rates Of Depression Among Elders With IllnessAmong Elders With Illness

Cognitively intact nursing home patients Cognitively intact nursing home patients shown to have symptoms consistent with shown to have symptoms consistent with depressive disorders – depressive disorders – 60%60%

Chronically ill outpatients in a primary Chronically ill outpatients in a primary care practice - care practice - 25%25%

Hospitalized patients - Hospitalized patients - 20%20% In nursing homes, regardless of physical In nursing homes, regardless of physical

health, major depression increases the health, major depression increases the likelihood of mortality by likelihood of mortality by 59%59% in one year in one year



Benefits Of Treatment For Benefits Of Treatment For Depression In The ElderlyDepression In The Elderly

Depression is one of the few medical Depression is one of the few medical conditions in which treatment can make a conditions in which treatment can make a rapid and dramatic difference in an elderly rapid and dramatic difference in an elderly person’s level of function and quality of lifeperson’s level of function and quality of life

Treatment may help patients accept medical Treatment may help patients accept medical treatment that they otherwise might refuse treatment that they otherwise might refuse because of feelings of hopelessness or futility because of feelings of hopelessness or futility

Treatment also helps enhance or recover Treatment also helps enhance or recover coping skills needed to deal with the inevitable coping skills needed to deal with the inevitable losses associated with chronic medical illnesslosses associated with chronic medical illness



What Factors Put What Factors Put Someone At Risk?Someone At Risk?

Many things increase one’s risk for suicide- Many things increase one’s risk for suicide- biological, psychological, social factors all applybiological, psychological, social factors all apply

The single greatest risk factor for suicide The single greatest risk factor for suicide

completion - completion - HHaving a Depressive aving a Depressive DisorderDisorder

90% of reported US suicides are experiencing 90% of reported US suicides are experiencing depression depression

The 2nd biggest factor - having an The 2nd biggest factor - having an alcohol or alcohol or drug problem - drug problem - However, many people with However, many people with alcohol and drug problems are significantly alcohol and drug problems are significantly depressed, and are self-medicatingdepressed, and are self-medicating

(Lester, 1998)(Lester, 1998)


Other risk factors includeOther risk factors include:: Previous suicide attemptsPrevious suicide attempts A family history of suicide - increases our risk by A family history of suicide - increases our risk by

6 times6 times A significant loss by death, divorce, separation, A significant loss by death, divorce, separation,

moving, or breaking up with a loved one. Shock or moving, or breaking up with a loved one. Shock or pain, even long term lower level stress, can affect pain, even long term lower level stress, can affect the structure of the brain, especially the limbic the structure of the brain, especially the limbic systemsystem

30 years of research confirms the relationship 30 years of research confirms the relationship between between hopelessness hopelessness and suicide, across and suicide, across diagnosesdiagnoses

Impulsivity, particularly among youth, is Impulsivity, particularly among youth, is increasingly linked to suicidal behaviorincreasingly linked to suicidal behavior

Access to firearms – 60% of completed suicides Access to firearms – 60% of completed suicides used firearmsused firearms

(Surgeon General’s call to Action, 1999)(Surgeon General’s call to Action, 1999)


Biological factors:Biological factors: Biological changes are associated withBiological changes are associated with both completed and attempted suicide both completed and attempted suicide Changes include abnormal functioning ofChanges include abnormal functioning of the Hypothalamic-Pituitary-Adrenal axis,the Hypothalamic-Pituitary-Adrenal axis, a major component of the way we adapt to stressa major component of the way we adapt to stress

Psychological factors:Psychological factors: Changes in thinking (constricted thought) leading to Changes in thinking (constricted thought) leading to

the belief that suicide is the only answer; negative the belief that suicide is the only answer; negative automatic thoughts that lead to sadness, automatic thoughts that lead to sadness, hopelessness, loss of pleasure, inability to see a hopelessness, loss of pleasure, inability to see a future, low self-esteemfuture, low self-esteem

Suicidality, although clearly overlapping the Suicidality, although clearly overlapping the symptoms of associated MH disorders, does not symptoms of associated MH disorders, does not appear to respond to treatment in exactly the same appear to respond to treatment in exactly the same wayway

In some cases, depressive symptoms can be reduced In some cases, depressive symptoms can be reduced by medication without a reduction in suicidal thinkingby medication without a reduction in suicidal thinking


Protective FactorsProtective Factors Stigma reduction programs, especiallyStigma reduction programs, especially among youth, increase help-seeking behavioramong youth, increase help-seeking behavior Resiliency and coping skills to reduce risk can Resiliency and coping skills to reduce risk can

be taught (Dialectical Behavioral Training)be taught (Dialectical Behavioral Training) Spirituality improves defenses against Spirituality improves defenses against

suicidal thinkingsuicidal thinking Social support – those with close relationships Social support – those with close relationships

cope better with various stresses, including cope better with various stresses, including bereavement, job loss, and illnessbereavement, job loss, and illness

Social disapproval of suicide reduces ratesSocial disapproval of suicide reduces rates*(Berman & Jobes, 1996; Beck, 1985; Rush et al, 1992, Surgeon General’s Call To Action, 1999)*(Berman & Jobes, 1996; Beck, 1985; Rush et al, 1992, Surgeon General’s Call To Action, 1999)


TreatmentTreatment

Treatment of suicidality has improved Treatment of suicidality has improved dramatically in the last 20 yearsdramatically in the last 20 years

Evidence is clear that lithium treatment Evidence is clear that lithium treatment of bi-polar disorder significantly of bi-polar disorder significantly reduces suicide rates*reduces suicide rates*

A correlation has been noted between A correlation has been noted between an increase in prescription rates for an increase in prescription rates for SSRI’s and a decline in suicide rates**SSRI’s and a decline in suicide rates**

(*Baldessarini, et.al, 1999, **NIMH, 2002)(*Baldessarini, et.al, 1999, **NIMH, 2002)


However, medication alone is insufficient to reduce However, medication alone is insufficient to reduce suicidal ideationsuicidal ideation

Psychotherapy can reduce suicidality by helping people Psychotherapy can reduce suicidality by helping people learn to interpret the stresses in their lives more learn to interpret the stresses in their lives more effectively, reducing the level of stress hormones in the effectively, reducing the level of stress hormones in the bodybody

Psychotherapy provides a necessary therapeutic Psychotherapy provides a necessary therapeutic relationship that reduces risk through increased hope relationship that reduces risk through increased hope and supportand support

Cognitive-behavioral approaches that include problem-Cognitive-behavioral approaches that include problem-solving training reduce suicidal ideation and attempts solving training reduce suicidal ideation and attempts more effectively than other approachesmore effectively than other approaches

Medication combined with psychotherapy is the current Medication combined with psychotherapy is the current standard of care for clinical depressionstandard of care for clinical depression

(Beck, 1996(Beck, 1996,, Quinnett, 2000, Macintosh, 1996) Quinnett, 2000, Macintosh, 1996)


SSRI’s And SuicideSSRI’s And SuicideMore Mythology?More Mythology?

Media has sensationalized the idea that Media has sensationalized the idea that “Prozac” causes suicide in teens“Prozac” causes suicide in teens

There is a very low risk that SSRI’s can There is a very low risk that SSRI’s can induce suicidal agitation in a induce suicidal agitation in a very fewvery few individualsindividuals

Many teens on SSRI’s are, in fact already Many teens on SSRI’s are, in fact already suicidal, and meds may not work well enough, suicidal, and meds may not work well enough, or in timeor in time

The FDA has recently banned the use of Paxil The FDA has recently banned the use of Paxil for depression in adolescents, but Prozac has for depression in adolescents, but Prozac has been approved for use in teensbeen approved for use in teens


The American College of The American College of Neuropsychopharmacology's Task Force report Neuropsychopharmacology's Task Force report from January 21, 2004, which reviewed all clinical from January 21, 2004, which reviewed all clinical trials, epidemiological studies and toxicology trials, epidemiological studies and toxicology studies in autopsies did not find evidence for a link studies in autopsies did not find evidence for a link between SSRI's and increased risk of suicide in between SSRI's and increased risk of suicide in children and adolescentschildren and adolescents

In a recent preliminary study of 49 adolescent In a recent preliminary study of 49 adolescent suicides, researchers found that 24% had been suicides, researchers found that 24% had been prescribed antidepressants, but none had any trace prescribed antidepressants, but none had any trace of SSRI's in their system at the time of their deathof SSRI's in their system at the time of their death

There is an increased risk of suicide in depressed There is an increased risk of suicide in depressed individuals who do not take their medication; which individuals who do not take their medication; which is a factor common to adolescents is a factor common to adolescents

A 2003 World Health Organization study in over A 2003 World Health Organization study in over fifteen countries found a significant reduction, fifteen countries found a significant reduction, averaging about 33%, in the youth suicide rate that averaging about 33%, in the youth suicide rate that coincided with the introduction of SSRI'scoincided with the introduction of SSRI's

(Altesman, 2005)(Altesman, 2005)


A review of all the research on this topic was A review of all the research on this topic was conducted recentlyconducted recently

CONCLUSIONCONCLUSION: : “No increased susceptibility to “No increased susceptibility to aggression or suicidality can be connected with aggression or suicidality can be connected with fluoxetine or any other SSRI. In fact SSRI treatment fluoxetine or any other SSRI. In fact SSRI treatment may reduce aggression toward self or others”may reduce aggression toward self or others”

““In the absence of any convincing evidence to link In the absence of any convincing evidence to link SSRI’s causally to violence and suicide, the recent SSRI’s causally to violence and suicide, the recent media reports are potentially dangerous, media reports are potentially dangerous, unnecessarily increasing the concerns of depressed unnecessarily increasing the concerns of depressed patients who are prescribed antidepressants” patients who are prescribed antidepressants” (Goldberg, (Goldberg, 2003)2003)

In November, Newsweek reported that In November, Newsweek reported that prescriptions for SSRI’s for teens have prescriptions for SSRI’s for teens have dropped by 50% in 03 and 04 – suicide rates dropped by 50% in 03 and 04 – suicide rates have climbed 18% in 03have climbed 18% in 03


High Risk Behaviors and High Risk Behaviors and SuicideSuicide

Miller and Taylor (2000) analyzed high risk Miller and Taylor (2000) analyzed high risk behaviors in 9behaviors in 9thth-12-12thth graders and found a graders and found a correlation with suicide ideation and attemptscorrelation with suicide ideation and attempts

High risk health behaviors includedHigh risk health behaviors included High Risk Sex (multiple partners, before age 14)High Risk Sex (multiple partners, before age 14) Binge Drinking (5 or more in several hours)Binge Drinking (5 or more in several hours) Drug UseDrug Use Disturbed eating patterns (boys do not get asked Disturbed eating patterns (boys do not get asked

about this)about this) SmokingSmoking Violence (girls do not get asked about this)Violence (girls do not get asked about this)


The 17% of youth with more than three The 17% of youth with more than three problem behaviors were the youth who problem behaviors were the youth who actedacted

They accounted for 60% of medically They accounted for 60% of medically treated suicidal actstreated suicidal acts

Compared to adolescents with zero Compared to adolescents with zero problem behaviors, the odds of a medically problem behaviors, the odds of a medically treated suicide attempt were treated suicide attempt were 2.3 times greater among respondents with one2.3 times greater among respondents with one 8.8 with two8.8 with two 18.3 with three18.3 with three 30.8 with four30.8 with four 50.0 with five50.0 with five 227.3 with six227.3 with six

A count of problem behaviors may offer a A count of problem behaviors may offer a reliable way to identify suicide riskreliable way to identify suicide risk

(Miller & Taylor, 2000)(Miller & Taylor, 2000)


Barriers To TreatmentBarriers To Treatment Fragmentation of services and cost of care are Fragmentation of services and cost of care are

the most frequently cited barriers to treatmentthe most frequently cited barriers to treatment

About 67% of people with About 67% of people with significantsignificant mental mental disorders disorders do notdo not receive treatment receive treatment

Psychological autopsy studies reveal that less Psychological autopsy studies reveal that less than 14% of completers were receiving than 14% of completers were receiving adequate treatment, and fewer than 17% were adequate treatment, and fewer than 17% were being treated with psychiatric medicationsbeing treated with psychiatric medications

However, 50-70% had contact with health However, 50-70% had contact with health services in the weeks before their deathservices in the weeks before their death

Surgeon General’s Call To Action, 1999; Empfield, 2003Surgeon General’s Call To Action, 1999; Empfield, 2003


Currently, no psychological test, clinical technique Currently, no psychological test, clinical technique or biological marker is sensitive enough to or biological marker is sensitive enough to accurately and consistently predict suicideaccurately and consistently predict suicide

Primary care has become a critical setting for Primary care has become a critical setting for detection of the two most common factors: detection of the two most common factors: depression and alcoholism*depression and alcoholism*

Depression is the second most common chronic Depression is the second most common chronic disorder seen by PCP’sdisorder seen by PCP’s

According to the AMA, a diagnostic interview for According to the AMA, a diagnostic interview for depression is comparable in sensitivity to depression is comparable in sensitivity to laboratory tests commonly used in diagnosis, but laboratory tests commonly used in diagnosis, but currently, less than 50% of adults with diagnosable currently, less than 50% of adults with diagnosable depression are accurately diagnosed by PCP’s*depression are accurately diagnosed by PCP’s*

““Physicians are often reticent to talk with patients Physicians are often reticent to talk with patients about suicide intent or ideation, and patients about suicide intent or ideation, and patients seldom spontaneously report it”**seldom spontaneously report it”**

(*Surgeon General’s Call to Action, 1999; **Quinnett, 2000 ) (*Surgeon General’s Call to Action, 1999; **Quinnett, 2000 )


What Is Your County Doing?What Is Your County Doing? Suicide prevention coalitions have been Suicide prevention coalitions have been

developed over the past 3 years across the state developed over the past 3 years across the state with grants from Ohio Dept. of Mental Healthwith grants from Ohio Dept. of Mental Health

In many counties, the Mental Health Board is In many counties, the Mental Health Board is spearheading this process, with helpspearheading this process, with help

from all areas of the community, from all areas of the community, including health care providers, mentalincluding health care providers, mental health professionals, suicide survivors,health professionals, suicide survivors, clergy, school personnel, human resource clergy, school personnel, human resource personnel, police/sheriff dept, health personnel, police/sheriff dept, health department, and many othersdepartment, and many others


How Do We Know Suicide How Do We Know Suicide Prevention Coalitions Prevention Coalitions

Work?Work? In 1996 the U.S. Air Force decided to In 1996 the U.S. Air Force decided to

mount an assault on it’s high suicide ratemount an assault on it’s high suicide rate They targeted help-seeking behavior, They targeted help-seeking behavior,

stigma, and awarenessstigma, and awareness After 5 years of a major collaborative After 5 years of a major collaborative

effort within the service, suicide rates effort within the service, suicide rates dropped 78%dropped 78%

Comparable rates in the other 4 armed Comparable rates in the other 4 armed services remained the sameservices remained the same


How Can You Help?How Can You Help?

Medical personnel are the front line of Medical personnel are the front line of defense against this insidious killer - assess defense against this insidious killer - assess your patients for suicidal ideation when your patients for suicidal ideation when depressive symptoms arisedepressive symptoms arise

Specifically ask your patients if they are Specifically ask your patients if they are experiencing suicidal ideation – They may experiencing suicidal ideation – They may not volunteer the informationnot volunteer the information

Train staffTrain staff in depression awareness, and in in depression awareness, and in asking the “S” questionasking the “S” question

We must gain confidence in asking people if We must gain confidence in asking people if they are thinking about dyingthey are thinking about dying

(Surgeon General’s Call To Action, 1999)(Surgeon General’s Call To Action, 1999)


Comfort And Competence Comfort And Competence Lead To HopefulnessLead To Hopefulness

A study by Dr. Paul Quinett, a long-time A study by Dr. Paul Quinett, a long-time researcher and clinician in suicide, researcher and clinician in suicide, indicates that patients who felt their indicates that patients who felt their clinician was comfortable asking questions clinician was comfortable asking questions about their suicidal thoughts and feelings about their suicidal thoughts and feelings reported much higher levels of hope about reported much higher levels of hope about the futurethe future

The best outcome of asking the “S” The best outcome of asking the “S” question is immediate relief for the patientquestion is immediate relief for the patient

(Quinnett, 2001)(Quinnett, 2001)


Hopelessness is the most immediate risk Hopelessness is the most immediate risk factor for suicide, so instilling hope is factor for suicide, so instilling hope is essentialessential

If your patient is on anti-depressant or If your patient is on anti-depressant or anti-anxiety medication, refer them to a anti-anxiety medication, refer them to a psychologist or counselor who can work psychologist or counselor who can work with them on the with them on the maintaining causesmaintaining causes of of depressiondepression

Consider using a Consider using a risk assessment formatrisk assessment format to ensure you ask the right questionsto ensure you ask the right questions


What To Ask?What To Ask? Except for psychiatrists, routineExcept for psychiatrists, routine questioning about suicidal ideationquestioning about suicidal ideation is is notnot the current standard of care the current standard of care If you have a patient with depressive If you have a patient with depressive

symptoms or other mental health disorders symptoms or other mental health disorders (especially anxiety)(especially anxiety) Learn to Ask the “S” questionLearn to Ask the “S” question Not – you aren’t thinking of suicide are you? Not – you aren’t thinking of suicide are you? But - Some people who experience the amount of But - Some people who experience the amount of

pain you’re in think about killing themselves. Have pain you’re in think about killing themselves. Have you ever thought about it?you ever thought about it?

(Lester, 1998)(Lester, 1998)


Use Of A Structured Use Of A Structured InterviewInterview

Many patients will not overtly acknowledge Many patients will not overtly acknowledge common symptoms of depression, focusing common symptoms of depression, focusing more on vague painmore on vague pain

You may wish to develop or purchase a guided You may wish to develop or purchase a guided clinical interview for use with suicidal clientsclinical interview for use with suicidal clients

A structured form assesses current risk, sets A structured form assesses current risk, sets up a management plan, and ensures that all up a management plan, and ensures that all the right questions are askedthe right questions are asked

Most take just a few minutes to complete, and Most take just a few minutes to complete, and people are surprisingly honestpeople are surprisingly honest


Screening Screening RecommendationsRecommendations

The U.S. Preventive Services Task Force reviewed new The U.S. Preventive Services Task Force reviewed new evidence that patients fare best when medical professionals evidence that patients fare best when medical professionals recognize the symptoms of depression and make sure they recognize the symptoms of depression and make sure they receive appropriate treatmentreceive appropriate treatment

The USPSTF issued new depression screening The USPSTF issued new depression screening recommendations in May, 2002, asking PCP’s to routinely recommendations in May, 2002, asking PCP’s to routinely screen adult patients for depressionscreen adult patients for depression

Medical professionals should have systems in place to Medical professionals should have systems in place to assure accurate diagnosis, effective treatment, and follow-assure accurate diagnosis, effective treatment, and follow-up if patients are to benefit from screening up if patients are to benefit from screening

The journal of AAFP offers the article “Screening for The journal of AAFP offers the article “Screening for Depression across the Lifespan: A review of Measures of Depression across the Lifespan: A review of Measures of Use in Primary Care settings” to help medical professionals Use in Primary Care settings” to help medical professionals make appropriate choices of screening toolmake appropriate choices of screening tool (Sharp and Lipsky, 2002) (Sharp and Lipsky, 2002)


Possible Depression ScalesPossible Depression Scales Beck Depression InventoryBeck Depression Inventory Children’s Depression InventoryChildren’s Depression Inventory CES-DC (Center for Epidemiological CES-DC (Center for Epidemiological

Studies Depression Scale)Studies Depression Scale) Edinburgh Post-Natal Depression ScaleEdinburgh Post-Natal Depression Scale Geriatric Depression ScaleGeriatric Depression Scale QPRT - Question, Persuade, Refer or QPRT - Question, Persuade, Refer or

Treat -QPR Institute - Treat -QPR Institute - www.qprinstitute.comwww.qprinstitute.com

Zung Depression InventoryZung Depression Inventory


Learning “Learning “QPRQPR” – Or, How To ” – Or, How To Ask The “S” QuestionAsk The “S” Question

It is essential, if we are to reduce the number It is essential, if we are to reduce the number of suicide deaths in our country, that of suicide deaths in our country, that community members/gatekeepers learn “community members/gatekeepers learn “QPRQPR””

First identified by Dr. Paul Quinnett as an First identified by Dr. Paul Quinnett as an analogue to CPR, “analogue to CPR, “QPRQPR” consists of ” consists of QQuestion – asking the “S” questionuestion – asking the “S” question PPersuade– Getting the person to talk, and to seek ersuade– Getting the person to talk, and to seek

helphelp RRefer – Getting the person to professional helpefer – Getting the person to professional help

Medical staff can learn this method in a very Medical staff can learn this method in a very short timeshort time

(Quinnett, 2000)(Quinnett, 2000)


InterventionIntervention Once a patient has told someone they are Once a patient has told someone they are

thinking of suicide, you need a thorough thinking of suicide, you need a thorough suicide assessmentsuicide assessment

In your area, what mental health facilities In your area, what mental health facilities with emergency services are available?with emergency services are available?

Sending a suicidal patient Sending a suicidal patient alonealone to the to the emergency room could be a mistakeemergency room could be a mistake

Most mental health agencies have crisis Most mental health agencies have crisis workers who can come to your office to workers who can come to your office to interview your patient – suicidal people interview your patient – suicidal people should never be left alone!should never be left alone!


Psychiatric HospitalizationPsychiatric Hospitalization The actual prediction of suicide is, The actual prediction of suicide is,

essentially, impossibleessentially, impossible The base rates are too low, and risk level The base rates are too low, and risk level

changes from day to daychanges from day to day Statistically, you could almost always bet Statistically, you could almost always bet

that no given individual will complete that no given individual will complete suicidesuicide

Other risks are managed by understanding Other risks are managed by understanding what risk factors exist, and limiting as many what risk factors exist, and limiting as many of them as possible, like wearing sunscreenof them as possible, like wearing sunscreen

It is imperative that medical professionals It is imperative that medical professionals know risk factors for suicideknow risk factors for suicide

(MacIntosh, 1993)(MacIntosh, 1993)


The Top Ten Risk Factors The Top Ten Risk Factors When Thinking Of When Thinking Of

HospitalizationHospitalization Previous Suicide attempt(s)Previous Suicide attempt(s) Mental disorders (especially depression, Mental disorders (especially depression,

bipolar)bipolar) Co-occurring mental and AL/SA disordersCo-occurring mental and AL/SA disorders Family history of suicideFamily history of suicide Hopelessness (should this be first?)Hopelessness (should this be first?) Impulsive/aggressive tendenciesImpulsive/aggressive tendencies Barriers to accessing mental health Barriers to accessing mental health

treatmenttreatment Relational, social, work or financial lossRelational, social, work or financial loss physical illness (esp. with chronic pain)physical illness (esp. with chronic pain) Easy access to lethal methods, especially Easy access to lethal methods, especially

gunsguns(Surgeon General’s Call to Action to Prevent Suicide, 1999(Surgeon General’s Call to Action to Prevent Suicide, 1999 ))


Voluntary HospitalizationVoluntary Hospitalization

Best choice – less hard on the Best choice – less hard on the patient’s sense of self-worth – a way patient’s sense of self-worth – a way to buy time (to think it over, get to buy time (to think it over, get sleep, etc.)sleep, etc.)

Safety is the main message – a good Safety is the main message – a good night’s sleep, a start on medications, night’s sleep, a start on medications, talk with doctors, put things on hold talk with doctors, put things on hold for awhilefor awhile

Allows them to save face – I didn’t Allows them to save face – I didn’t want to, but they insisted…want to, but they insisted…


Sharing Knowledge Of Sharing Knowledge Of HospitalsHospitals

Ease the transition by addressing Ease the transition by addressing their fearstheir fears

Facts: hospital stays tend to be shortFacts: hospital stays tend to be shortStaff are well-trained and know about Staff are well-trained and know about

suicidal sufferingsuicidal sufferingECT cannot be given without patient ECT cannot be given without patient

permissionpermissionPatients rights are guaranteedPatients rights are guaranteedModern hospitals are not snake pitsModern hospitals are not snake pits


Know Your Local Resources Know Your Local Resources And AgenciesAnd Agencies

Where to hospitalizeWhere to hospitalizeWho do you callWho do you callHave your risk assessment Have your risk assessment

information readyinformation readyHelp to overcome barriers to Help to overcome barriers to

hospitalization such as child care, hospitalization such as child care, pets, transportation, calls to work, pets, transportation, calls to work, etc.etc.


Local Professional Local Professional ResourcesResources

Your Local Mental Your Local Mental Health AgenciesHealth Agencies

Your Local Mental Your Local Mental Health BoardHealth Board

School Guidance School Guidance CounselorsCounselors

Your Hospital Your Hospital Emergency RoomEmergency Room

Local Crisis HotlinesLocal Crisis Hotlines

National Crisis National Crisis HotlinesHotlines

School nursesSchool nurses

911911

Local Police/SheriffLocal Police/Sheriff

Local ClergyLocal Clergy


““Suicide is a Suicide is a

permanent solutionpermanent solution

to a to a

temporary problemtemporary problem””

Edwin Schneidman, MD.Edwin Schneidman, MD.

Founder of SuicidologyFounder of Suicidology


The Ohio Suicide Prevention The Ohio Suicide Prevention FoundationFoundation

The Ohio State University, Center on The Ohio State University, Center on Education and Training for Education and Training for

EmploymentEmployment

1900 Kenny Road, Room 20721900 Kenny Road, Room 2072

Columbus, OH 43210Columbus, OH 43210

614-292-8585614-292-8585


A Brief BibliographyA Brief Bibliography Anderson, E. “The Personal and Professional Impact of Anderson, E. “The Personal and Professional Impact of

Client Suicide on Mental Health Professionals. Client Suicide on Mental Health Professionals. Unpublished Doctoral dissertation, U. of Toledo, 1999Unpublished Doctoral dissertation, U. of Toledo, 1999

Berman, A. L. & Jobes, D. A. (1996) Berman, A. L. & Jobes, D. A. (1996) Adolescent Suicide: Adolescent Suicide: Assessment and InterventionAssessment and Intervention..

Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Suicide Over the Life Cycle: Risk Factors, Assessment, and Over the Life Cycle: Risk Factors, Assessment, and Treatment of Suicidal Patients.Treatment of Suicidal Patients. American Psychiatric American Psychiatric Press.Press.

Empfield, Maureen MD( 2002) PSYCHIATRY FOR THE Empfield, Maureen MD( 2002) PSYCHIATRY FOR THE PRIMARY CARE PHYSICIANPRIMARY CARE PHYSICIAN – Section 2. URL – Section 2. URL

Goldberg, I. SSRI’s and Suicide: Results of a MELINE Goldberg, I. SSRI’s and Suicide: Results of a MELINE Search. At: ttp://www.psycom.net/depression.central.ssri-Search. At: ttp://www.psycom.net/depression.central.ssri-suicide.htmlsuicide.html

Jacobs, D., Ed. (1999). Jacobs, D., Ed. (1999). The Harvard Medical School The Harvard Medical School Guide to Suicide Assessment and Interventions.Guide to Suicide Assessment and Interventions. Jossey- Jossey-Bass.Bass.


Jamison, K.R., (1999). Jamison, K.R., (1999). Night Falls Fast: Night Falls Fast: Understanding Suicide.Understanding Suicide. Alfred Knopf Alfred Knopf

Lester, D. (1998). Lester, D. (1998). Making Sense of Suicide: An In-Making Sense of Suicide: An In-Depth Look at Why People Kill Themselves.Depth Look at Why People Kill Themselves. American American Psychiatric PressPsychiatric Press

Oregon Health Department, Prevention. Notes on Oregon Health Department, Prevention. Notes on Depression and Suicide: Depression and Suicide: ttp://www.dhs.state.or.us/publickhealth/ipe/depressiottp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cfmn/notes.cfm

President’s New Freedom Council on Mental Health, President’s New Freedom Council on Mental Health, 20032003

Quinnett, P.G. (2000). Quinnett, P.G. (2000). Counseling Suicidal People.Counseling Suicidal People. QPR Institute, Spokane, WAQPR Institute, Spokane, WA

Shea, C., 2000. Shea, C., 2000. A Practical Interviewing Strategy for A Practical Interviewing Strategy for the Elicitation of Suicidal Ideation. Journal of Clinical the Elicitation of Suicidal Ideation. Journal of Clinical Psychiatry (supplement 20) 59: 58-72, 1998Psychiatry (supplement 20) 59: 58-72, 1998


Smith, Range & Ulner. “Belief in Afterlife as a buffer Smith, Range & Ulner. “Belief in Afterlife as a buffer in suicide and other bereavement.” Omega Journal of in suicide and other bereavement.” Omega Journal of Death and Dying, 1991-92, (24)3; 217-225.Death and Dying, 1991-92, (24)3; 217-225.

Stoff, D.M. & Mann, J.J. (Eds.), (1997). Stoff, D.M. & Mann, J.J. (Eds.), (1997). The The Neurobiology of SuicideNeurobiology of Suicide. American Academy of . American Academy of ScienceScience

Schneidman, E.S. (1996). Schneidman, E.S. (1996). The Suicidal MindThe Suicidal Mind. Oxford . Oxford University Press.University Press.

Styron, W. (1992). Darkness Visible. Vintage BooksStyron, W. (1992). Darkness Visible. Vintage Books Surgeon General’s Call to Action (1999). Department Surgeon General’s Call to Action (1999). Department

of Health and Human Services, U.S. Public Health of Health and Human Services, U.S. Public Health Service.Service.

Tang, T.Z. & De Rubeis, R.J. ((1999). “Sudden Gains Tang, T.Z. & De Rubeis, R.J. ((1999). “Sudden Gains and critical sessions in cognitive-behavioral therapy and critical sessions in cognitive-behavioral therapy for depression”. for depression”. Journal of Consulting and Clinical Journal of Consulting and Clinical Psychology 67: 894-904.Psychology 67: 894-904.

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