saving lives: understanding depression and suicide in our communities sponsored by the ohio suicide...

SAVING LIVES:SAVING LIVES:Understanding Depression And Understanding Depression And

Suicide In Our CommunitiesSuicide In Our Communities

Sponsored By The Ohio Suicide Sponsored By The Ohio Suicide Prevention Foundation and the Athens Prevention Foundation and the Athens County Suicide Prevention CoalitionCounty Suicide Prevention Coalition

Developed By Ellen Anderson, Developed By Ellen Anderson, Ph.D., PCC, 2003-2008Ph.D., PCC, 2003-2008

Gatekeeper Training- Dr. Ellen AnGatekeeper Training- Dr. Ellen Andersonderson

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Training ObjectivesTraining Objectives

• Learn the connection between Learn the connection between depression and suicidedepression and suicide

• Dispel myths and misconceptions Dispel myths and misconceptions about suicideabout suicide

• Learn risk factors and signs of suicidal Learn risk factors and signs of suicidal behavior among community members behavior among community members

• Learn to assess risk and find help for Learn to assess risk and find help for those at risk – Asking the “S” questionthose at risk – Asking the “S” question


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Suicide Is The Last Taboo – Suicide Is The Last Taboo – We Don’t Want To Talk We Don’t Want To Talk About ItAbout It• Suicide has become the Last Taboo – we can talk Suicide has become the Last Taboo – we can talk

about AIDS, sex, incest, and other topics that used about AIDS, sex, incest, and other topics that used to be unapproachable. We are still afraid of the “S” to be unapproachable. We are still afraid of the “S” word word

• Understanding suicide helps communities become Understanding suicide helps communities become proactive rather than reactive to a suicide once it proactive rather than reactive to a suicide once it occursoccurs

• Reducing stigma about suicide and its causes Reducing stigma about suicide and its causes provides us with our best chance for saving livesprovides us with our best chance for saving lives

• Ignoring suicide means we are helpless to stop itIgnoring suicide means we are helpless to stop it


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Why Should I Learn Why Should I Learn About Suicide?About Suicide?

• It is the 11th largest killer of Americans, It is the 11th largest killer of Americans, and the 3and the 3rdrd largest killer of youth ages 10-24 largest killer of youth ages 10-24

• As many as 25% of adolescents and 15% As many as 25% of adolescents and 15% of adults consider suicide seriously at some of adults consider suicide seriously at some

point in their livespoint in their lives• No one is safe from the risk of suicide – No one is safe from the risk of suicide –

wealth, education, intact family, popularity wealth, education, intact family, popularity cannot protect us from this riskcannot protect us from this risk

• A suicide attempt is a desperate cry for help A suicide attempt is a desperate cry for help to end excruciating, unending, to end excruciating, unending, overwhelming painoverwhelming pain, 1996), 1996)


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• 8989 people complete suicide every day people complete suicide every day• 32,63732,637 people in 2005 in the US people in 2005 in the US• Over 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?


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The Gender IssueThe Gender Issue

• Women perceived as being at higher risk than Women perceived as being at higher risk than menmen

• Women do make attempts 4 x as often as menWomen do make attempts 4 x as often as men

• But - Men complete suicide 4 x as often as But - Men complete suicide 4 x as often as womenwomen

• Women’s risk rises until midlife, then Women’s risk rises until midlife, then decreasesdecreases

• Men’s risk, always higher than women’s, Men’s risk, always higher than women’s, continues to rise until end of lifecontinues to rise until end of life


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What Factors Put What Factors Put Someone At Risk For Someone At Risk For Suicide?Suicide?• Biological, physical, social, psychological or Biological, physical, social, psychological or

spiritual factors may increase risk-for example:spiritual factors may increase risk-for example:

• A family history of suicide increases risk by 6 A family history of suicide increases risk by 6 timestimes

• Access to firearms – people who use firearms in Access to firearms – people who use firearms in their suicide attempt are more likely to dietheir suicide attempt are more likely to die

• Social Isolation: people may be rejected or Social Isolation: people may be rejected or bullied because they are “weird”, because of bullied because they are “weird”, because of sexual orientation, or because they are getting sexual orientation, or because they are getting older and have lost their social network older and have lost their social network (Goleman, 1997)(Goleman, 1997)


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• A significant loss by death, separation, A significant loss by death, separation, divorce, moving, or breaking up with a divorce, moving, or breaking up with a boyfriend or girlfriend can be a triggerboyfriend or girlfriend can be a trigger

• The 2nd biggest risk factor – The 2nd biggest risk factor –

having an alcohol or drug problemhaving an alcohol or drug problem– Many with alcohol and drug problems are Many with alcohol and drug problems are

clinically depressed, and are self-clinically depressed, and are self-medicating for their painmedicating for their pain

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


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• The biggest risk factor for suicide completion? The biggest risk factor for suicide completion?

Having a Depressive IllnessHaving a Depressive Illness

• People with clinical depression often feels helpless People with clinical depression often feels helpless to solve his or her problems, leading to hopelessness to solve his or her problems, leading to hopelessness – a strong predictor of suicide risk– a strong predictor of suicide risk

• At some point in this chronic illness, suicide seems At some point in this chronic illness, suicide seems like the only way out of the pain and sufferinglike the only way out of the pain and suffering

• Many Mental health diagnoses have a component of Many Mental health diagnoses have a component of depression: anxiety, PTSD, Bi-Polar, etcdepression: anxiety, PTSD, Bi-Polar, etc

• 90%90% of suicide completers have a depressive illness of suicide completers have a depressive illness (Lester, 1998, Surgeon General, 1999)(Lester, 1998, Surgeon General, 1999)


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Depression Is An Depression Is An IllnessIllness• Suicide has been viewed for countless generations Suicide has been viewed for countless generations

as: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

•Our cultural view of suicide is wrong - Our cultural view of suicide is wrong - invalidated by our current understanding invalidated by our current understanding of brain chemistry and it’s interaction of brain chemistry and it’s interaction with with stress, trauma and geneticsstress, trauma and genetics on on mood and behaviormood and behavior


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• The research evidence is overwhelming - The research evidence is overwhelming - depression is far more than a sad mood. It depression is far more than a sad mood. It includes:includes: 1.1. Weight gain/lossWeight gain/loss

2.2. Sleep problemsSleep problems

3.3. Sense of tiredness, exhaustionSense of tiredness, exhaustion

4.4. Sad or angry moodSad or angry mood

5.5. Loss of interest in pleasurable things, lack of Loss of interest in pleasurable things, lack of motivationmotivation

6.6. IrritabilityIrritability

7.7. Confusion, loss of concentration, poor memoryConfusion, loss of concentration, poor memory

8.8. Negative thinking (Self, World, Future)Negative thinking (Self, World, Future)

9.9. Withdrawal from friends and familyWithdrawal from friends and family

10.10.Usually, suicidal thoughtsUsually, suicidal thoughts(DSMIVR, 2002)(DSMIVR, 2002)


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20 years of brain research teaches that 20 years of brain research teaches that these symptoms are the these symptoms are the behavioralbehavioral result ofresult of InternalInternal changes in the physical changes in the physical

structure of the brainstructure of the brain Damage to brain cells in the Damage to brain cells in the

hippocampus, amygdala and hippocampus, amygdala and limbic systemlimbic system

As Diabetes is the result of low insulin As Diabetes is the result of low insulin production by the pancreas, depressed production by the pancreas, depressed people suffer from a physical illness – people suffer from a physical illness – what we might consider “faulty wiring”what we might 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)


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

brains - the result of too many stress hormones brains - the result of too many stress hormones – cortisol, adrenaline and testosterone – the – cortisol, adrenaline and testosterone – the 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 high levels of functioning of the ANS, so that high levels of activation occur with low stimulusactivation occur with low 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

(Braun, 1999)(Braun, 1999)


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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)


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One of Many NeuronsOne of Many Neurons•Neurons make up the brain and their action is what causes 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 and fewer connections are made, more and more symptoms of depression appear


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• As damage occurs, thinking changes in the As damage occurs, thinking changes in the predictable ways identified in our list of 10 predictable ways identified in our list of 10 criteriacriteria

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

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

• They mayThey may counter the effects of stress hormonescounter 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) genes within the neurons (turn on growth genes) which encourage the growth of new dendriteswhich encourage the growth of new dendrites

(Braun, 1999)(Braun, 1999)


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• Renewed dendrites:Renewed dendrites:– increase the number of neuronal connectionsincrease the number of neuronal connections– allow our nerve cells to begin connecting againallow our nerve cells to begin connecting again

• The more connections, the more The more connections, the more information flow and resilience the brain information flow and resilience the brain will havewill have

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

• It takes 4-6 weeks to re-grow dendrites & It takes 4-6 weeks to re-grow dendrites & axonsaxons

(Braun, 1999)(Braun, 1999)


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Why Don’t We Seek Why Don’t We Seek Treatment?Treatment?• We don’t know we are experiencing a brain We don’t know we are experiencing a brain

disorder – we don’t recognize the symptomsdisorder – we don’t recognize the symptoms

• When we talk to doctors, we are vague about When we talk to doctors, we are vague about symptomssymptoms

• Until recently, Doctors were as unlikely as the rest Until recently, Doctors were as unlikely as the rest of the population to attend to depression symptomsof the population to attend to depression symptoms

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

• We fear being stigmatized at work, at church, at We fear being stigmatized at work, at church, at schoolschool


1919

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


2020

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 we seek treatment for something we How can we seek treatment for something we

believe is a personal failure?believe is a personal failure?

• Acknowledging the need for help is not popular Acknowledging the need for help is not popular in our culture (Strong Silent type, Cowboy)in our culture (Strong Silent type, Cowboy)

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

• Therapists are all crazy anywayTherapists are all crazy anyway

• 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


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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 of therapy, helps people change the (negative) patterns of thinking that lead to depressed and suicidal thoughtsthinking that lead to depressed and suicidal thoughts

• 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 Changing our beliefs and thought patterns alters 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 level affected by stress at the physical level (Lester, 2004)(Lester, 2004)


2222

What Happens If We Don’tWhat Happens If We Don’tTreat Depression?Treat Depression?

• Significant risk of increased alcohol Significant risk of increased alcohol and drug useand drug use

• Significant relationship problemsSignificant relationship problems

• Lost work days, lost productivity (up to Lost work days, lost productivity (up to $40 billion a year)$40 billion a year)

• High risk for suicidal thoughts, High risk for suicidal thoughts, attempts, and possibly deathattempts, and possibly death

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


2323

How Do I Know If How Do I Know If Someone Is Suicidal?Someone Is Suicidal?

• Now we understand the connection Now we understand the connection between depression and suicidebetween depression and suicide

• We have reviewed what a depressed We have reviewed what a depressed person looks likeperson looks like

• Not all depressed people are suicidal Not all depressed people are suicidal – how can we tell?– how can we tell?

• Suicides don’t happen without Suicides don’t happen without warning - verbal and behavioral clues warning - verbal and behavioral clues are present, but we may not notice are present, but we may not notice themthem


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Verbal ExpressionsVerbal Expressions• Common statementsCommon statements

– I shouldn't be hereI shouldn't be here– I'm going to run awayI'm going to run away– I wish I were deadI wish I were dead– I'm going to kill myselfI'm going to kill myself– I wish I could disappear foreverI wish I could disappear forever– If a person did this or that…., would If a person did this or that…., would

he/she diehe/she die– Maybe if I died, people would love me Maybe if I died, people would love me

moremore– I want to see what it feels like to dieI want to see what it feels like to die


2525

Some Behavioral Warning Some Behavioral Warning SignsSigns• Common signsCommon signs

– Previous suicidal thoughts or attemptsPrevious suicidal thoughts or attempts– Expressing feelings of hopelessness or guiltExpressing feelings of hopelessness or guilt– (Increased) substance abuse (Increased) substance abuse – Becoming less responsible and motivatedBecoming less responsible and motivated– Talking or joking about suicideTalking or joking about suicide– Giving away possessionsGiving away possessions– Having several accidents resulting in Having several accidents resulting in

injury; "close calls" or "brushes with death"injury; "close calls" or "brushes with death"


2626

What Stops Us?What Stops Us?• Most of us still believe suicide and Most of us still believe suicide and

depression are “none of our business” depression are “none of our business” and fearful of getting a yes answerand fearful of getting a yes answer

• What if: we could respond to “yes”?What if: we could respond to “yes”?– We could recognize depression symptoms We could recognize depression symptoms

like we recognize symptoms of a heart like we recognize symptoms of a heart attack?attack?

– We were no longer afraid to ask for help for We were no longer afraid to ask for help for ourselves, our parents, our children?ourselves, our parents, our children?

– We no longer had to feel ashamed of our We no longer had to feel ashamed of our feelings of despair and hopelessness, but feelings of despair and hopelessness, but recognized them as symptoms of a brain recognized them as symptoms of a brain disorder?disorder?


2727

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 designed by Dr. Paul Quinnett as an First designed 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” questionPPersuade– getting the person to talk, and to ersuade– getting the person to talk, and to

seek helpseek helpRRefer – getting the person to professional efer – getting the person to professional

helphelp(Quinnett, 2000)(Quinnett, 2000)


2828

Ask Questions!Ask Questions!• You seem pretty downYou seem pretty down• Do things seem hopeless to youDo things seem hopeless to you• Have you ever thought it would be easier Have you ever thought it would be easier

to be dead?to be dead?• Have you considered suicide?Have you considered suicide?• Remember, you cannot make someone Remember, you cannot make someone

suicidal by talking about it. If they are suicidal by talking about it. If they are already thinking of it they will probably be already thinking of it they will probably be relieved that the secret is outrelieved that the secret is out

• If you get a yes answer, don’t panic. Ask a If you get a yes answer, don’t panic. Ask a few more questionsfew more questions


2929

How Much Risk Is There?How Much Risk Is There?

• Assess lethalityAssess lethality– You are not a doctor, but you need You are not a doctor, but you need

to know how imminent the danger to know how imminent the danger isis

– Has he or she made any previous Has he or she made any previous suicide attempts? suicide attempts?

– Does he or she have a plan?Does he or she have a plan?– How specific is the plan? How specific is the plan? – Do they have access to means?Do they have access to means?


3030

Local Professional Local Professional ResourcesResourcesYour Hospital Your Hospital

Emergency RoomEmergency Room

Your Local Mental Your Local Mental Health AgenciesHealth Agencies

Your Local Mental Your Local Mental Health BoardHealth Board

School Guidance School Guidance CounselorsCounselors

Local Crisis HotlinesLocal Crisis Hotlines

National Crisis National Crisis HotlinesHotlines

Your family physicianYour family physician

School nursesSchool nurses

911911

Local Police/SheriffLocal Police/Sheriff

Local ClergyLocal Clergy


3131

Permanent Solution-Permanent Solution- Temporary Problem Temporary Problem

• Remember a depressed person is Remember a depressed person is physically ill, and physically ill, and cannotcannot think clearly think clearly about the morality of suicide, about the morality of suicide, cannot cannot think think logically about their value to friends and logically about their value to friends and familyfamily

• You would try CPR if you saw a heart You would try CPR if you saw a heart attack victimattack victim

• Don’t be afraid to “interfere” when Don’t be afraid to “interfere” when someone is dying more slowly of someone is dying more slowly of depressiondepression

• Depression is a treatable disorderDepression is a treatable disorder• Suicide is a preventable deathSuicide is a preventable death


3232

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


3333

Websites For Additional Websites For Additional InformationInformation• Ohio Department of Ohio Department of

Mental healthMental health www.mh.state.oh.us www.mh.state.oh.us • NAMINAMI

www.nami.orgwww.nami.org• Suicide Prevention Suicide Prevention

Resource CenterResource Centerwww.sprc.orgwww.sprc.org

American association of American association of suicidologysuicidologywww.suicidology.orgwww.suicidology.org

• Suicide Suicide awareness/voice of awareness/voice of educationeducationwww.save.orgwww.save.org

• American foundation American foundation for suicide preventionfor suicide preventionwww.afsp.orgwww.afsp.org

• Suicide prevention Suicide prevention advocacy networkadvocacy networkwww. www. spanusa.orgspanusa.org

• QPR institute QPR institute www.qprtinstitute.orgwww.qprtinstitute.org

http://www.spanusa.org/

http://www.spanusa.org/


3434

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

• Beck, A.T., Steer, R.A., Kovacs, M., & Garrison, B. (1985). Beck, A.T., Steer, R.A., Kovacs, M., & Garrison, B. (1985). Hopelessness, depression, suicidal ideation, and clinical Hopelessness, depression, suicidal ideation, and clinical diagnosis of depression. diagnosis of depression. Suicide and Life-Threatening Suicide and Life-Threatening BehaviorBehavior. 23(2), 139-145.. 23(2), 139-145.

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

• Braun, S. (2000). Braun, S. (2000). Unlocking the Mysteries of Mood: The Unlocking the Mysteries of Mood: The Science of HappinessScience of Happiness. Wiley and Sons, NY.. Wiley and Sons, NY.

• Calhoun, L.G, Abernathy, C.B., & Selby, J.W. (1986). The Calhoun, L.G, Abernathy, C.B., & Selby, J.W. (1986). The rules of bereavement: Are suicidal deaths different? rules of bereavement: Are suicidal deaths different? Journal Journal of Community Psychology, 14of Community Psychology, 14, 213-218., 213-218.


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• Doka, K.J. (1989). Doka, K.J. (1989). Disenfranchised Grief: Recognizing Disenfranchised Grief: Recognizing hidden sorrowhidden sorrow. Lexington, MA: Lexington Books.. Lexington, MA: Lexington Books.

• Dunne, E.J., MacIntosh, J.L., & Dunne-Maxim, K. (Eds.). Dunne, E.J., MacIntosh, J.L., & Dunne-Maxim, K. (Eds.). (1987). (1987). Suicide and its aftermath Suicide and its aftermath. New York: W.W. . New York: W.W. Norton.Norton.

• Empfield, M & Bakalar, N. (2001) Empfield, M & Bakalar, N. (2001) Understanding Understanding Teenage Depression: A guide to Diagnosis, Treatment Teenage Depression: A guide to Diagnosis, Treatment and Management.and Management. Holt & Co., NY. Holt & Co., NY.

• 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: Understanding Night Falls Fast: Understanding Suicide.Suicide. Alfred Knopf . Alfred Knopf .

• Krysinski, P.K. (1993). Coping with suicide: Beyond the Krysinski, P.K. (1993). Coping with suicide: Beyond the three day bereavement leave policy. three day bereavement leave policy. Death Studies: 17Death Studies: 17, , 173-177.173-177.

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


3636

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

• President’s New Freedom Council on Mental President’s New Freedom Council on Mental Health, 2003.Health, 2003.

• Rosenblatt, P. (1996). Grief that does not end. Rosenblatt, P. (1996). Grief that does not end. In D. Klass, P. Silverman, & S. Nickman In D. Klass, P. Silverman, & S. Nickman (Eds.), (Eds.), Continuing Bonds: New Continuing Bonds: New Understandings of griefUnderstandings of grief (pp 45-58). (pp 45-58). Washington, D.C.: Taylor & Francis.Washington, D.C.: Taylor & Francis.

• Rowling, L. (1995). The disenfranchised grief Rowling, L. (1995). The disenfranchised grief of teachers. of teachers. Omega, 31Omega, 31(4), 317-329.(4), 317-329.

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


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• 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

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

• Sheskin, A., & Wallace, S.E. (1976). Differing Sheskin, A., & Wallace, S.E. (1976). Differing bereavements: Suicide, natural, and accidental bereavements: Suicide, natural, and accidental deaths. deaths. Omega 7Omega 7, 229-242., 229-242.

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

• Styron, W. (1992). Darkness Visible. Vintage Styron, W. (1992). Darkness Visible. Vintage BooksBooks

• Surgeon General’s Call to Action (1999). Surgeon General’s Call to Action (1999). Department of Health and Human Services, U.S. Department of Health and Human Services, U.S. Public Health Service.Public Health Service.

• Thompson, K. & Range, L. (1992). Bereavement Thompson, K. & Range, L. (1992). Bereavement following suicide and other deaths: Why support following suicide and other deaths: Why support attempts fail. attempts fail. Omega 26Omega 26(1), 61-70.(1), 61-70.

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