Suicide and Depression

Evonne Edwards, PhDProfessional Practice Group Clinical DirectorPine Rest Christian Mental Health ServicesAdjunct Assistant Professor, Michigan State University

Suicide Deaths Are Rising Across the US1

• 10th leading cause of death in US• 2nd leading cause of death in ages 15-34• Large increases in rates between 1999 and 2016

• 32.9% increase in MI

Suicidal Ideation, Attempts, and Deaths

• 28 attempts for every death by suicide

• 20% of those who die by suicide had a known history of suicide attempts2

Michigan Suicides3

Michigan Suicides By County (Per 100,000)7

More Locally. . . West Michigan Counties

County Suicides per 100,000 Residents

Barry 16.0

Newaygo 15.0

Ionia 14.4

Calhoun 14.4

Montcalm 14.0

Van Buren 13.9

Oceana 13.7

Mecosta 12.4

Kalamazoo 12.1

Muskegon 11.9

Allegan 11.6

Kent 9.6

Ottawa 8.1

Suicide is the 8th leading cause of death in both Kent and Ottawa8,9

Attempt20%Suicidal

Thoughts5%

Ottawa County Adults8

Attempt39.8%

Suicidal Thoughts

15%

Youth

More Locally…Ottawa County10

Ottawa and Kent County Youth Assessment Surveys9,11

• 24% of Kent County middle school students and 32% of high school students

• 21% of Kent County middle school students and 16% of high school students

• 13% of Kent County middle school and high school students

• 8% of Kent County middle school students and 7% of high school students

How Common is Depression?• Past year prevalence: 10.4% of US adults

and 12.8% of adolescents12, 13

– 37% of adults and 60% of adolescents did not receive treatment

• Lifetime Prevalence: 20.6% 12

• Postpartum: 21.9% moms will experience depression within 1 year postpartum14

– Suicides account for 20% of postpartum deaths15

28% of Ottawa County Women age 18-44 have

been diagnosed with depression8

Who’s Most At Risk?• American Indian/Alaska Natives: Suicide rates are 2.8 times higher

than national rate16

• Veterans: MI veteran suicide rate in 2016 was >1.5 times greater than the state rate17

• Transgender Individuals: 40% of those identifying as transgender have attempted suicide18

– Moderated by family support: 37% who identify family as supportive have attempted vs 54% of those reported family is unsupportive18

– Pine Rest adolescent inpatient study: 5x greater odds of a prior suicide attempt for transgender patients than other adolescent patients19

• No difference from other patients when they report high adult support

• Middle-aged adults (35 – 64 years): Largest proportion of suicides (54%) in 201316

• Adolescents and young adults (10-24 years): Suicide was the 2nd leading cause of death in 201316

• Women are times more likely to attempt suicide; men are

times more likely to die by suicide20,21

Who’s Most At Risk?: Age & Gender Factors

• 78% of suicides in 2017 were white males20

• Suicide is the 2nd leading cause of death (LCOD) for white men ages 5-34 (3rd-4th LCOD for ages 45-64)22

• Those with medical conditions, particularly23:• Neurological disorders/Brain injury• Visual impairment• Chronic lung disease• Seizure disorders• Moderate to severe pain (back pain, migraines, etc.)• Cancer• Dementia• Sleep Disorders

• Substance use: 17-24% who die by suicide are acutely intoxicated at time of death24

Who’s Most At Risk?

Who’s Most At Risk?: Those with Mental Illness… Or Not???

90%Psychological autopsies find 90% of people who died by suicide likely had mental illness

• When there was a known mental illness2: • Depression (75.7%)• Anxiety Disorder (16.8%)• Bipolar Disorder (15.2%)• Problematic Substance Use (25-32%)

• Lifetime risk26:• 2-7% for eating disorder• 2-6% for mood disorders26

• 8.6% if hospitalized for suicidality27

• 3% for depression26, 28

• 5-8% for bipolar disorders26, 29

• 4-5% for schizophrenia26, 30

• 7% for alcohol dependence26

• 10% for borderline personality disorder 31

Depression and Suicide Suicide Depression

Untreated Mental Illness

– Of the 329,000 MI adults with serious mental illness, 54.1% did not receive treatment in 20156

– The median delay in seeking treatment amongst those that made treatment contact were the following32:• For Anxiety Disorders: 23.0 years (SE = 0.6) • For Mood Disorders: 4.0 years (SE = 0.2)• For Substance Use Disorders: 13.0 years (SE

= 1.2)

Who’s Most at Risk?: Psychosocial Factors

Research-Supported Interventions to Reduce Suicides

Training Primary Care Physicians to identify and treat depression33

– 66% of those who die by suicide saw their PCP within a month of death34

– 35-50% of older adults who died by suicide visited PCP within a week prior to death23

– Increased prescription rates for selective serotonin reuptake inhibitors (SSRIs) and other non-SSRI antidepressants are associated with decreased rates of suicide for both adults35 and adolescents36

Means Restriction:

Restricting access to highly lethal means has been found to decrease

suicide rates33, 34

• Recommended by numerous medical and governmental organizations (e.g., WHO, the American College of Physicians, and the CDC)

• American Association of Suicidology report concluded “making means restriction a standard of care across settings is an improvement that will save lives”37

• Connection to Impulsivity:– 9 out of 10 suicide attempts are not fatal and

most (80-95%) of those who survive suicide attempt don’t go on to die by suicide38

– BUT 9 out of 10 attempts using a gun are fatal38

– More than 55% of attempts are impulsive, with 40% reporting they contemplated suicide for less than 5 minutes38

6% of suicide attempts involve guns39

Means Restriction: Local ImplicationsCounty Suicides per

100,000 Residents

% of Suicides by Firearms

Barry 16.0 56%

Newaygo 15.0 59%

Ionia 14.4 55%

Calhoun 14.4 53%

Montcalm 14.0 54%

Van Buren 13.9 55%

Ocean 13.7 58%

Mecosta 12.4 67%

Kalamazoo 12.1 45%

Muskegon 11.9 50%

Allegan 11.6 50%

Kent 9.6 42%

Ottawa 8.1 39%

Gun41%

Hanging24%

Drug Overdose

19%

CO5%

Other11%

Kent County (2016)

Research-Supported Psychotherapy: Treating Depression vs Reducing Suicides

Treating Depression (APA-Therapy) Reducing Suicide

• Acceptance and Commitment Therapy• Behavioral Activation• Cognitive Behavioral Analysis System of

Psychotherapy• Cognitive Therapy• Emotion-Focused Therapy• Interpersonal Psychotherapy• Problem-Solving Therapy• Rational Emotive Behavior Therapy• Reminiscence Therapy• Short-Term Psychodynamic Therapy• Cognitive-Behavioral Therapy

• Cognitive Behavior Therapy for Suicide Prevention (CBT-SP)

• Suicide attempters were 50% less likely to re-attempt than attempters who received treatment-as-usual41

• Dialectical Behavior Therapy (DBT)• Reduced suicide attempts by 2/3• Patients receiving DBT also had fewer

emergency room visits and psychiatric hospitalizations42, 43

• Collaborative Assessment and Management of Suicidality (CAMS): A therapy framework found to be effective in decreasing suicidal thoughts44

Treating Depression40

• Acceptance and Commitment Therapy• Behavioral Activation• Cognitive Behavioral Analysis System of

Psychotherapy• Cognitive Therapy• Emotion-Focused Therapy• Interpersonal Psychotherapy• Problem-Solving Therapy• Rational Emotive Behavior Therapy• Reminiscence Therapy• Short-Term Psychodynamic Therapy• Cognitive-Behavioral Therapy

Research-Supported Interventions to Reduce Suicides

• Electroconvulsive therapy (ECT) reduces treatment-resistant depression (50% response rate), reduces suicidal thoughts/behaviors, and is recommended by the American Psychiatric Association45, 46

• Improve continuity of care34

– Highest risk is 1-2 weeks47 post-discharge from emergency department or inpatient psychiatric hospital; remains elevated for 1-5+ years37

• 10% of those who die by suicide were seen in ED in last 2 months

• 50-70% don’t go to 1st follow-up appointment post-discharge

• Contact post-hospitalization or emergency room discharge may reduce suicide attempts, self-harm, and suicides by 50%48, 49, 50

Preventing Suicide: A Community Effort

Residential ServicesAnd

Residential DetoxOutpatient ServicesPartial Hospitalization

• 6,580 hospital admissions in 2017• 9 units

• Child & Adolescent: 36 beds• Adolescent/Young Adult (13-24): 26 beds• Dual Diagnosis Adult Unit: 22 beds• Older Adult Unit: 26 beds• 4 Other Adult Units: 88 beds

Psychiatric Inpatient

Outpatient ServicesPsychiatric Inpatient

Partial Hospitalization• 1,871 partial hospital admissions in 2017

• Child & Adolescent• Mother & Baby• Adult

Residential ServicesAnd

Residential DetoxPartial Hospitalization

Outpatient ServicesPartial HospitalizationPsychiatric Inpatient

Residential Services• Adolescent Residential• Adult Crisis Residential Services• Adult Residential Treatment for adults with chronic

mental illness and substance use disorder or mild developmental disability (Pine Rest Christian Homes)

• Adult Long-Term Residential Services for developmentally disabled adults

• Adult Residential Treatment for Substance Use Disorder

Residential Subacute Detox: 12 beds

Residential ServicesAnd

Residential Detox

• Therapy and Psychiatry• Psychological Testing & Forensic Services• Electroconvulsive Therapy (ECT)• Transcranial Magnetic Stimulation (TMS)• Intensive Outpatient Program and Medication

Assisted Treatment (MAT) for Substance Use Disorders (SUD)

• Dialectical Behavior Therapy (DBT)• Group therapy for Depression, Anxiety,

LGBTQ Persons, Postpartum Adjustment, and SUD Recovery

• Street Reach• Community Case Management

Residential ServicesAnd

Residential DetoxPartial HospitalizationPsychiatric Inpatient Outpatient Services

17 Outpatient Clinics

Coming Soon: Psychiatric Urgent Care Center

• Opening in April 2019• Serving adults (18+)

with acute psychiatric symptoms

• 7 days/week• Multidisciplinary Clinical

Team

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2. Stone, D. M., Simon, T. R., Fowler, K. A., Kegler, S. R., Yuan,K., Holland, K. M., Ivey-Stephenson, A. Z., & Crosby, A. E. (2018). Vital Signs: Trends in state suicide rates-United States, 1999-2016 and circumstances contributing to suicide-27 States, 2015. CDC Morbidity and Mortality Weekly Report, 67(22), 617-624

3. American Foundation for Suicide Prevention (2018). State Fact Sheets: Suicide Facts & Figures: Michigan 2018. Retrieved from https://afsp.org/about-suicide/state-fact-sheets/#Michigan

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9. Jantz, R., & Saari, C. (2018). Kent County Community Health Needs Assessment 2017. Retrieved from https://accesskent.com/Health/pdf/2017KC_CHNA.pdf10. Ottawa County Department of Public Health (2018). Death by Suicide. Retrieved from

https://www.miottawa.org/health/OCHD/pdf/data/Special/OC_Suicide_FactSheet.pdf11. Ottawa County Department of Public Health (2018). Ottawa County Youth Assessment Survey 2017: Depression & Suicide. Retrieved from

https://www.miottawa.org/Health/OCHD/pdf/data/YAS/Depression-Suicide.pdf

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