making’the’case’for’a’comprehensive’ approach’to’suicide...

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Making the Case for a Comprehensive Approach to Suicide Preven9on and

Injury Preven9on A New Focus on Commonali1es Instead of

Differences Jerry Reed, PhD, MSW

August 4, 2016


The River


Injury Defined

Injury

Inten1onal (Violence) Uninten1onal

An act that damages or hurts


A Typology of Violence

Source: World Health Organiza1on


Commonali9es among Different Types of Injury

◦ Mechanisms ▪  Falls ▪  Fire and heat ▪  Firearm ▪  Motor vehicle ▪  Struck by / against ▪  Water

◦  SeUngs ◦ Medical Outcome

Interpersonal Violence

Self-‐Directed Violence Uninten1onal


Suicide by Means, U.S., 2014

Cut Pierce 2%

Drowning 1% Fall

2%

Firearm 50%

Poisoning 16%

Suffoca9on 27%

Other 2%

Source: CDC WISQARS Fatal Reports, 2014


Scope of the Problem


5 Leading Causes of Death, U.S., 2014

Source: CDC WISQARS Fatal Report, 2014


Deaths Are Not the Whole Picture

Deaths 199,756

Hospitaliza9ons

2,521,244

Emergency Department Visits 26,997,976

Source: CDC WISQARS Fatal and Non-‐Fatal Reports, 2014, All Ages, All Injuries


Burden by Intent

Deaths 42,773

ED Visits 121,362

Hospitaliza9ons 214,805

Source: CDC WISQARS Fatal and Non-‐Fatal Reports, 2014, All Ages, All Injuries

Deaths 136,053

Hospitaliza9ons 2,170,947

ED Visits 25,474,794

Suicide Uninten9onal

Deaths 15,809

Hospitaliza9ons 130,785

ED Visits 1,328,758

Homicide


5 Leading Causes of Injury Deaths, U.S., 2014

Source: CDC WISQARS Fatal Reports, 2014


5 Leading Causes of Injury Hospitaliza9ons, U.S., 2014

Source: CDC WISQARS Non-‐Fatal Reports, 2014


5 Leading Causes of Injury ED Visits, U.S., 2014

Source: CDC WISQARS Non-‐Fatal Reports, 2014


Leading Causes of Injury, U.S., 2014

Falls Interpersonal Violence Motor Vehicle Crashes

Poisoning Suicide and Self-‐Harm


Data Sources Uninten9onal Motor Vehicle Crashes

Uninten9onal Falls

Suicide and Self-‐Harm


Uninten9onal Poisoning

Vital Sta1s1cs X X X X X

Hospital Discharge Data X X X X X

Emergency Department Data X X X X X

Child Welfare Reports X X

Violent Death Repor1ng Systems

X X X

Poison Control Centers X X


Iden9fying Risk and Protec9ve Factors


Socio-‐Ecological Model

Society

Community

Rela1onship

Individual

• Policies • Culture • Social Norms

• SeUngs or ins1tu1ons in which social rela1onships take place

•  Interac1on between two or more people

•  Personal Characteris1cs •  Behavior •  Biological Factors •  Experience


Risk Factors Uninten9onal Motor Vehicle Crashes

Uninten9onal Falls




Neighborhood Poverty X X X X

High Alcohol Outlet Density X X X X

Poor Behavioral Control / Impulsiveness

X X X X

Substance Use X X X X X

Social Isola1on X X

Poor Parent-‐Child Rela1onships X X

Sources: World Health Organiza1on; CDC, Connec1ng the Dots: An Overview of the Links Among Mul1ple Forms of Violence


Protec1ve Factors Uninten9onal Motor Vehicle Crashes

Uninten9onal Falls




Associa1on with Prosocial Peers X X X

Access to Mental Health and Substance Abuse Services

X X X X

Community Support / Connected-‐ness

X X X X

Connectedness with a Caring Adult

X X X X X

Source: CDC, Connec1ng the Dots: An Overview of the Links Among Mul1ple Forms of Violence


Injuries as Risk Factors

Suicide Risk

In9mate Partner Violence

Trauma9c Brain Injury


Trauma9c Brain Injury & Suicide


A blow or jolt to the head or a penetrating head injury that disrupts the function of the brain

Trauma9c Brain Injury Defined


Physical Trauma: Also known as "injury", is a physiological wound caused by an external source. It can also be described as "a physical wound or injury, such as a fracture or blow".

Psychological Trauma: a deeply distressing or disturbing experience. An experience that produces psychological injury or pain.

Trauma Defined


“Trauma1c brain injury is associated with substan1ally elevated risks of premature mortality, par1cularly for suicide, injuries, and assaults, even ader adjustment for sociodemographic and familial factors.”

Fazel 2014

“The risk for commiUng suicide is two to four 1mes greater for individuals with TBI than for the general popula1on. Even mild brain injury increases risk.” Center for Substance Abuse Treatment 2010

TBI as a Risk Factor for Suicide


Substance Abuse •  Can lead to TBI •  Oden co-‐occurs with suicidality

•  Can be a symptom of sustaining a TBI

“When a psychiatric disorder or SUD co-occurs with TBI, the risk for attempted or completed suicide is further increased.” Center for Substance Abuse Treatment 2010

TBI and Suicide: Co-‐Occurring Risk Factors


Experiences with Violence •  In1mate Partner Violence •  Child Maltreatment •  Veterans

TBI and Suicide: Co-‐Occurring Risk Factors


In9mate Partner Violence & Suicide


Not a One Way Street

Suicide Risk In9mate Partner Violence

In9mate Partner Violence & Suicide


•  Percep1ons of Perpetrators •  Screening •  Crisis Lines:

•  Training & Role of Responder •  Times of High Risk •  Follow Up

Naviga9ng Cultures


Preven9on Strategies


Injury Trends

Source: CDC WISQARS Fatal Reports, 2014, Ages <1-‐19

0

1

2

3

4

5

6

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Fatal Injuries by Cause, 2001-‐2014 Ages 0-‐19

Falls Suicide Homicide Motor Vehicle Poisoning


Injury Trends

Source: CDC WISQARS Fatal Reports. 2014, Ages 20-‐64

0

5

10

15

20

25

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Fatal Injuries by Cause, 2001-‐2014 Ages 20-‐64



Injury Trends

Source: CDC WISQARS Fatal Reports. 2014, Age 65+

0

10

20

30

40

50

60

70

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Fatal Injuries by Cause, 2001-‐2014 Ages 65+



Preven9on Strategies

Parent Educa9on

School-‐Wide Interven9ons and Supports

Distribu9on & Use of Safety Devices

Home Visi9ng

Homicide X X X

Suicide X X X X

Motor Vehicle Crashes X X X X

Falls X X X X

Uninten1onal Poisoning X X


Parent Educa9on

• Triple P Posi1ve Paren1ng Program hnp://www.triplep.net/glo-‐en/home/ • Parent-‐Child Interac1on Therapy • Training in non-‐violent problem solving skills • Coping skills


• Triple P Posi1ve Paren1ng Program hnp://www.triplep.net/glo-‐en/home/ • Incredible Years hnp://incredibleyears.com/ • Strengthening Families Program hnp://www.strengtheningfamiliesprogram.org/ • Counseling on Access to Lethal Means (CALM) Project hnp://legacy.nreppadmin.net/ViewInterven1on.aspx?id=15

Suicide • Safety seat educa1on that is provided by physicians and other health care professionals in clinical seUngs • Proper installa1on and use of safety seats and booster seats through hands-‐on educa1on •  Parent involvement in teen driving through knowledge of Graduated Driver Licensing regula1ons (Parents Are the Key to Safe Teen Drivers -‐-‐ A campaign from the CDC) • Parent/teen driving agreements that address Graduated Driver Licensing requirements

Motor Vehicle

• An1cipatory guidance from physicians about falls and trauma1c brain injuries • Social norms campaigns, such as the Children Can’t Fly Program hnp://www.ncbi.nlm.nih.gov/pmc/ar1cles/PMC1653830/

Falls Poisoning

An1cipatory guidance from physicians about safe storage of medica1ons out of reach of children and prompt and appropriate disposal of unused or expired medica1ons to prevent misuse by children and adolescents

Children’s Safety Network


School-‐Wide Interven9ons & Supports

• Preschool programs, such as state pre-‐K and Head Start • Social and emo1onal learning programs, such as the Good Behavior Game (hnp://legacy.nreppadmin.net/ViewInterven1on.aspx?id=201) and Coaching Boys into Men (hnp://www.coachescorner.org) •  School-‐Wide Posi1ve Behavioral Interven1ons and Supports (PBIS) (hnps://pbis.org)


•  Good Behavior Game (hnp://legacy.nreppadmin.net/ViewInterven1on.aspx?id=201) •  Sources of Strength (hnp://legacy.nreppadmin.net/ViewInterven1on.aspx?id=248) •  Linking Educa1on and Awareness of Depression and Suicide (LEADS) for Youth Curriculum •  Coping and Support Training (CAST) (

hnp://www.sprc.org/resources-‐programs/cast-‐coping-‐and-‐support-‐training) Suicide

•  Peer-‐to-‐peer educator programs, such as: Teens in the Driver’s Seat (hnp://www.hhs.gov/ash/oah/news/e-‐updates/eupdate-‐9.html#)

Impact Teen Drivers (hnp://impacneendrivers.org/ Champion Schools Program (hnp://www.ugotbrains.com/chamion-‐schools)

Motor Vehicle

•  Return to Play Guidelines & Coach Training (hnp://www.cdc.gov/headsup/highschoolsports/training/index.html)

Falls



Distribu9on & Use of Safety Devices

Cabinet locks and gun locks (Reducing a Suicidal Person’s Access to Lethal Means of Suicide: A Research Agenda (hnp://www.sciencedirect.com/science/ar1cle/pii/S0749379714002475)

Suicide

Free or reduced cost child safety seats and booster seats combined with proper installa1on and use of these seats (Na1onal Child Safety Seat Distribu1on Program Evalua1on Assesses Training, NHTSA, hnp://www.nhtsa.gov/About+NHTSA/Traffic+Techs/current/Na1onal+Child+Safety+Seat+Distribu1on+Program+Evalua1on+Assesses+Training)

Motor Vehicle

•  Installa1on of stair guards •  Installa1on of window guards •  Use of bicycle helmets •  Safe playground design, especially installa1on of protec1ve surfaces and removal of especially dangerous equipment

Falls



Home Visi9ng

•  Nurse-‐Family Partnership (hnp://www.nursefamilypartnership.org/) •  CDC’s Essen1als for Childhood: Steps to Create Safe, Stable, and Nurturing Rela1onships and

Environments for All Children (hnp://www.cdc.gov/violencepreven1on/childmaltreatment/essen1als.html


•  Conduct psychosocial screening •  Provide guidance on reducing access to lethal means Suicide

•  Educa1on, distribu1on, and installa1on of child safety seats and booster seats •  Educa1on about the importance of consistent use of seat belts by older children and teens

Motor Vehicle

•  Use of home safety checklist to iden1fy and remove fall hazards (American College of Preventa1ve Medicine Childhood Injury Risk Assessment Tool hnp://www.acpm.org/?page=ChildInjuryRisk)

Falls Poisoning •  Safe storage of household chemical products to keep them out of the reach of children

•  Safe storage of medica1ons out of reach of children and prompt and appropriate disposal of unused or expired medica1ons to prevent misuse by children and adolescents



Future Direc9ons


•  Collect and analyze data to iden1fy geographic areas, seUngs, and popula1ons at increased risk of injuries and suicide

•  Work across programs, departments, agencies, and disciplines to reduce and eliminate silos

•  Build coali1ons and networks that understand the commonali1es among different types of injuries

Moving to a Comprehensive Approach


•  Iden1fy cross-‐cuUng risk and protec1ve factors •  Screen for and address mul1ple risk factors •  Strengthen mul1ple protec1ve factors •  Implement and scale up cross-‐cuUng preven1on strategies

Moving to a Comprehensive Approach


References

•  Alaska Mental Health Trust Authority (2007) Alaska Suicide Follow-back Study Final Report: http://alaskainjurypreventioncenter.org/wp-content/uploads/2013/03/AIPC_FINAL_report-2-07.pdf

•  Alcaraz. Charlie (2014) Traumatic Brain Injury (TBI): The Substance Abuse Connection Pima Prevention Partnership: Presentation to the TBI CoP June 4th, 2014 http://edc.adobeconnect.com/p5arg39fmge/

•  Belanger HG, Curtiss G, Demery JA, Lebowitz BK, Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic brain injury: a meta-analysis. J Int Neuropsychol Soc. 2005;3:215-27.

•  Brenner, Lisa A. PhD, ABPP; Ignacio, Rosalinda V. MS; Blow, Frederic C. PhD Suicide and Traumatic Brain Injury Among Individuals Seeking Veterans Health Administration Services Journal of Head Trauma Rehabilitation: July/August 2011 - Volume 26 - Issue 4 - p 257–264 doi: 10.1097/HTR.0b013e31821fdb6e

•  Center for Substance Abuse Treatment. (2010). Treating Clients With Traumatic Brain Injury. Substance Abuse Treatment Advisory, Volume 9, Issue 2. http://store.samhsa.gov/shin/content//SMA10-4591/SMA10-4591.pdf

•  Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2005) [2016, June 28]. Available from URL: www.cdc.gov/injury/wisqars

•  Children’s Safety Network. (2016). Evidence-Based Strategies and Readings for Child Safety CoIIN. Waltham, MA: Education Development Center, Inc.

•  Fazel S, Wolf A, Pillas D, Lichtenstein P, Långström N. Suicide, Fatal Injuries, and Other Causes of Premature Mortality in Patients With Traumatic Brain Injury: A 41-Year Swedish Population Study. JAMA Psychiatry. 2014;71(3):326-333. doi:10.1001/jamapsychiatry.2013.3935.

•  Iverson, Grant L, (2013) Chronic traumatic encephalopathy and risk of suicide in former athletes Br J Sports Med bjsports-2013-092935Published Online First: 31 October 2013doi:10.1136/bjsports-2013-092935


References

•  Klonoff PS, Lage GA (1995) Suicide in patients with traumatic brain injury: risk and prevention. J Head Trauma Rehabil 10:16–24.

•  Kuipers, P. & Lancaster, A. (2000). Developing a suicide prevention strategy based on the perspectives of people with brain injuries. The Journal of Head Trauma Rehabilitation, 15, (6): 1275-1284

•  Leon-Carrion J (1997) An approach to the treatment of affective disorders and suicide tendencies after TBI. in Neuropsychological rehabilitation: fundamentals, innovation and directions. ed León-Carrión J (GR/St Lucie Press, Delray Beach, FL), pp 415–429

•  M. V. Morton, P. Wehman (1995) Psychosocial and emotional sequelae of individuals with traumatic brain injury: a literature review and recommendations Brain Injury 9:1, 81-92

•  Mazaux, Jean-Michel; Masson, Francoise; Levin, Harvey S.; Alaoui, Patrice; Maurette, Pierre et al. (1997) Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury Archives of Physical Medicine and Rehabilitation vol. 78 (12) p. 1316-1320

•  Ownsworth TL, Oei TP (1998) Depression after traumatic brain injury: conceptualization and treatment considerations. Brain Inj 12:735–751.

•  Persinger MA (1994) Sense of a presence and suicidal ideation following traumatic brain injury: indications of right-hemispheric intrusions from neuropsychological profiles. Psychol Rep 75:1059–1070

•  Silver, J.M., Kramer, R., Greenwald, S., Weissman, M. (2001). The association between head injuries and psychiatric disorders: findings from the New Haven NIMH Epidemiological Catchment Area Study. Brain Injury, 15 (11):935-945.

•  Simpson G. and Tate, R. (2005). Clinical Features of Suicide Attempts After Traumatic Brain Injury. The Journal of Nervous and Mental Disease, 13, 10, 680-685.

•  Simpson, G. & Tate, R. (2002). Suicidality after traumatic brain injury: demographic, injury and clinical correlates. Psychological Medicine, 32, 687-697.


References

•  Tate R, Simpson G, Flanagan S, et al. (2000) Completed suicide after traumatic brain injury. J Head Trauma Rehabil 12:16–28

•  Teasdale TW, Engberg AW (2000) Disability pensions in relation to traumatic brain injury: a population study. Brain Inj 14:363–372.

•  Teasdale, T. W. & Engberg, A. W. (2001). Suicide after traumatic brain injury: A population study. The Journal of Neurology, Neurosurgery and Psychiatry, 71, (4): 436-440.

•  Wilkins, N., Tsao, B., Hertz, M. Davis, R., Klevens, J. (2014). Connecting the Dots: An Overview of the Links Among Multiple Forms of Violence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Oakland, CA: Prevention Institute.

•  World Health Organization. (2002). World Report on Violence and Health: Summary. Geneva. A Typology of Violence, Pg. 5. http://www.who.int/violence_injury_prevention/violence/world_report/en/summary_en.pdf


Jerry Reed, PhD, MSW Educa1on Development Center

[email protected] (202) 572-‐3771

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