SAVING LIVES: Understanding Depression And Suicide In Young People – A Training For School Personnel Sponsored by the Ohio Department of Mental Health.

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

Suicide In Young People – A Training Suicide In Young People – A Training ForFor

School Personnel School Personnel

Sponsored by the Ohio Sponsored by the Ohio Department of Mental Health in Department of Mental Health in

Partnership with the Ohio Partnership with the Ohio Suicide Prevention FoundationSuicide Prevention Foundation

Developed by Ellen Developed by Ellen Anderson, Ph.D., SPCC, Anderson, Ph.D., SPCC,

2003-20082003-2008

Youth Depression and SuicideYouth Depression and Suicide 22

Training ObjectivesTraining Objectives

Increase knowledge about the impact Increase knowledge about the impact of suicide within the communityof suicide within the communityLearn the connection between Learn the connection between depression and suicidedepression and suicideDispel myths and misconceptions Dispel myths and misconceptions about suicideabout suicideLearn risk factors and signs of Learn risk factors and signs of suicidal behavior in youth suicidal behavior in youth Learn to assess risk and find help for Learn to assess risk and find help for those at risk – Asking the “S” those at risk – Asking the “S” questionquestion


Suicide Is The Last Taboo – Suicide Is The Last Taboo – We Don’t Want To Talk We Don’t Want To Talk

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

Understanding suicide helps communities Understanding suicide helps communities become proactive rather than reactive to a become proactive rather than reactive to a suicide once it occurssuicide once it occurs

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 Ignoring suicide means we are helpless to stop itit


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

It is the 3It is the 3rdrd largest killer of youth ages 10-24 largest killer of youth ages 10-24Up to 25% of adolescents consider suicide Up to 25% of adolescents consider suicide seriously at some point in their livesseriously at some point in their livesNo 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 riskA suicide attempt is a desperate cry for help A suicide attempt is a desperate cry for help to end excruciating, unending, overwhelming to end excruciating, unending, overwhelming pain, sometimes called psychache pain, sometimes called psychache

(Schneidman, 1996)(Schneidman, 1996)


The Gender IssueThe Gender Issue

Women perceived as being at higher risk Women perceived as being at higher risk than menthan men

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

These ratios are similar for girls and boysThese ratios are similar for girls and boys

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


Youth SuicideYouth Suicide

Persons under age 25 accounted for Persons under age 25 accounted for 13.6% of all suicides in 200313.6% of all suicides in 2003Every year we lose more than 4,000 Every year we lose more than 4,000 young people to suicide, and 90% of young people to suicide, and 90% of them are experiencing depression- a them are experiencing depression- a preventable diseasepreventable diseaseIn 2 NW Ohio counties, 27% of high In 2 NW Ohio counties, 27% of high school students admitted to experiencing school students admitted to experiencing significant suicidal thoughts within the significant suicidal thoughts within the past yearpast year

(President’s New Freedom Council Report, 2003)(President’s New Freedom Council Report, 2003)


What Factors Put A KidWhat Factors Put A Kid At Risk For Suicide? At Risk For Suicide?

Factors include biological, psychological, and Factors include biological, psychological, and social issuessocial issuesA A family historyfamily history of suicide increases risk by 6 of suicide increases risk by 6 timestimesAccess to firearmsAccess to firearms – people who use firearms – people who use firearms in their suicide attempt are more likely to diein their suicide attempt are more likely to dieA A significant losssignificant loss by death, separation, divorce, by death, separation, divorce, moving, or breaking up with a boyfriend or moving, or breaking up with a boyfriend or girlfriendgirlfriend– Shock or pain can affect the brain, Shock or pain can affect the brain, increasing stress increasing stress

related hormones that damage the brainrelated hormones that damage the brain


Social IsolationSocial Isolation: people who are rejected : people who are rejected because they are “weird”, because of their because they are “weird”, because of their sexual orientation, or because they just don’t sexual orientation, or because they just don’t fit infit in

AggressivenessAggressiveness or or impulsiveness-impulsiveness-people withpeople with these traits may not stop and think about the these traits may not stop and think about the

real consequences of their deathreal consequences of their deathThe 2nd biggest risk factor is having an The 2nd biggest risk factor is having an alcohol or drugalcohol or drug problem. However, many problem. However, many people with alcohol and drug problems are people with alcohol and drug problems are significantly depressed, and are self-significantly depressed, and are self-medicating for their painmedicating for their pain

(Surgeon General’s call to Action, 1999, Berman & Jobes, 1992)(Surgeon General’s call to Action, 1999, Berman & Jobes, 1992)


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

Having a Depressive IllnessHaving a Depressive Illness

Someone with clinical depression often feels Someone with clinical depression often feels helpless to solve his or her problems, leading to helpless to solve his or her problems, leading to hopelessnesshopelessness

At some point, suicide seems like the only way out At some point, suicide seems like the only way out of the pain and sufferingof the pain and suffering

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

90%90% of suicide completers have a of suicide completers have a depressive illnessdepressive illness

(Lester, 1998)(Lester, 1998)

Youth Depression and SuicideYouth Depression and Suicide 101010Gatekeeper Training- Dr. Ellen

Anderson

What Is Mental Illness?What Is Mental Illness?

Prior to our understanding of illness Prior to our understanding of illness caused by bacteria, most people caused by bacteria, most people thought of any illness as a spiritual thought of any illness as a spiritual failure or demon possessionfailure or demon possession

Contamination meant spiritual Contamination meant spiritual contaminationcontamination

People were frightened to be near People were frightened to be near someone with odd behavior for fear someone with odd behavior for fear of being contaminatedof being contaminated


Anderson


What do we say about someone who is What do we say about someone who is odd?odd?– Looney, batty, nuts, crazy, wacko, lunatic, Looney, batty, nuts, crazy, wacko, lunatic,

insane, fruitcake, psycho, not all there, bats insane, fruitcake, psycho, not all there, bats in the belfry, gonzo, bonkers, wackadoo, in the belfry, gonzo, bonkers, wackadoo, whack jobwhack job

Why would anyone admit to having a Why would anyone admit to having a mental illness?mental illness?So much stigma makes it very difficult So much stigma makes it very difficult for people to seek help or even for people to seek help or even acknowledge a problemacknowledge a problem


Anderson


We know that illnesses like epilepsy, We know that illnesses like epilepsy, Parkinson's and Alzheimer’s are Parkinson's and Alzheimer’s are physical illness in the brainphysical illness in the brain

Somehow, clinical depression, Somehow, clinical depression, anxiety, Bi-Polar Disorder and anxiety, Bi-Polar Disorder and Schizophrenia are not considered Schizophrenia are not considered illnesses to be treatedillnesses to be treated

We confuse brain with mindWe confuse brain with mind

Youth Depression and SuicideYouth Depression and Suicide 1313Gatekeeper Training- Dr. Ellen Gatekeeper Training- Dr. Ellen

AndersonAnderson 1313

The Feel of DepressionThe Feel of Depression

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


Anderson

8383 people complete suicide every day people complete suicide every day32,46632,466 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?


AndersonAnderson

Depression Is An Depression Is An IllnessIllnessSuicide 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


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

9.9. Withdrawal from friends and familyWithdrawal from friends and family

10.10. Sometimes, suicidal thoughtsSometimes, suicidal thoughts(DSMIVR, 2002)(DSMIVR, 2002)


AndersonAnderson

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 Changes in the physical structure Changes in the physical structure

of the brainof 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)


AndersonAnderson

Faulty Wiring?Faulty Wiring?Damage to nerve cells in our brains - the result Damage to nerve cells in our brains - the result of too many stress hormones – cortisol, of too many stress hormones – cortisol, adrenaline and testosterone – the hormones adrenaline and testosterone – the hormones activated by our activated by our AAutonomic utonomic NNervous ervous SSystem to ystem to protect us in times of dangerprotect 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 very little stimulusactivation occur with very little stimulus

Creates changes in muscle tension, imbalances Creates changes in muscle tension, imbalances in blood flow patterns leading to certain in blood flow patterns leading to certain illnesses such as asthma, IBS and depressionillnesses such as asthma, IBS and depression

(Braun, 1999)(Braun, 1999)


Faulty Wiring?Faulty Wiring?Every time something upsets us it causes the Every time something upsets us it causes the ANS to activate – without a way to detach and ANS to activate – without a way to detach and go back to a baseline of rest, stresses go back to a baseline of rest, stresses accumulate and keep us in a state of high accumulate and keep us in a state of high arousal – stress hormones build uparousal – stress hormones build up

People with People with genetic predispositionsgenetic predispositions, placed , placed in a highly in a highly stressful environmentstressful environment will will experience damage to brain cells from stress experience damage to brain cells from stress hormoneshormones

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)


AndersonAnderson

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


AndersonAnderson

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 the brain will havethe 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)


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)


Renewed dendrites:Renewed dendrites:– increase the number of neuronal increase the number of neuronal

connectionsconnections– allow our nerve cells to begin connecting allow our nerve cells to begin connecting

againagain

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)


How Does Psychotherapy How Does Psychotherapy Help?Help?

Stress alone is not the problem, but our Stress alone is not the problem, but our interpretation of events as stressfulinterpretation of events as stressfulMedications may relieve suffering and improve brain Medications may relieve suffering and improve brain function, but do not change how we function, but do not change how we interpretinterpret stress stressPsychotherapy, 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 thoughtsthoughtsResearch 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 thinkingChanging 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 level affected by stress at the physical level



How Does Psychotherapy How Does Psychotherapy Help?Help?

Changing our beliefs and thought patterns Changing our beliefs and thought patterns alters our response to stress – we are not as alters our response to stress – we are not as reactive or as affected by stress at the physical reactive or as affected by stress at the physical levellevel


More recent research is leading to a better More recent research is leading to a better understanding of just how “plastic” the adult understanding of just how “plastic” the adult brain isbrain is– What and how we think can cause connectors to What and how we think can cause connectors to

grow and expand in the areas those thoughts usegrow and expand in the areas those thoughts use– Thinking negatively leads to an increase in the part Thinking negatively leads to an increase in the part

of the brain where those thoughts occurof the brain where those thoughts occur


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

Woo Stuff!Woo 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


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

Increased school problems – lowered Increased school problems – lowered grades, behavior problems, tardiness grades, behavior problems, tardiness and absenteeismand absenteeism

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)


Depression is a medical illness that Depression is a medical illness that will likely affect the youth later in life, will likely affect the youth later in life, even after the initial episode improveseven after the initial episode improves

Youth who experience a major Youth who experience a major depressive episode have a 70% depressive episode have a 70% chance of having a second major chance of having a second major depressive episode within five yearsdepressive episode within five years

Many of the same problems that Many of the same problems that occurred with the first episode are occurred with the first episode are likely to return, and may worsenlikely to return, and may worsen

(Oregon SHDP)(Oregon SHDP)


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 fluoxetine or any other SSRI. In fact SSRI treatment may reduce aggression toward self or treatment may reduce aggression toward self or others”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 unnecessarily increasing the concerns of depressed patients who are prescribed depressed patients who are prescribed antidepressants” antidepressants” (Goldberg, 2003)(Goldberg, 2003)

Newsweek, Jan, 2008 – prescription rates Newsweek, Jan, 2008 – prescription rates for teens cut in half in 03 and 04 – for teens cut in half in 03 and 04 – completion rates rise 18% in those yearscompletion rates rise 18% in those years


What Should TeachersWhat Should Teachers Be Looking For Be Looking For

1. Depressed or irritable mood—look for:1. Depressed or irritable mood—look for:

Directly and indirectly says "I hate my life" Directly and indirectly says "I hate my life"

Easily irritated Easily irritated

Rebellious behavior Rebellious behavior

Seldom looks happy Seldom looks happy

Frequent crying spells Frequent crying spells

Wears somber clothes Wears somber clothes

Listens to music or has themes in writing with Listens to music or has themes in writing with depressive or violent undertones depressive or violent undertones

Has friends who appear depressed or irritableHas friends who appear depressed or irritable


2. Marked decrease in 2. Marked decrease in interest or pleasure in interest or pleasure in activities—look for:activities—look for: Frequently says "I’m Frequently says "I’m bored" bored" Withdraws or spends much Withdraws or spends much time in his or her bedroom time in his or her bedroom Declining hygiene Declining hygiene Changes to a more Changes to a more troubled peer group troubled peer group

3. Psychomotor agitation 3. Psychomotor agitation or slowing— look for:or slowing— look for: Agitated, always moving Agitated, always moving Mopes around the house or Mopes around the house or school school

4. Significant change in 4. Significant change in appetite or weight—look appetite or weight—look for:for: BecomesBecomes a picky eater a picky eater Snacks frequently and eats Snacks frequently and eats when stressed when stressed Quite thin or overweight Quite thin or overweight compared to peers compared to peers

5. Significant changes in 5. Significant changes in sleeping habits— look for:sleeping habits— look for: Takes more than an hour to Takes more than an hour to fall asleep fall asleep Multiple awakenings Multiple awakenings Wakes in early morning Wakes in early morning hours and can’t return to hours and can’t return to sleep sleep Sleeps more than normal Sleeps more than normal



6. Fatigue or loss of energy—6. Fatigue or loss of energy—look for:look for:

Too tired to do schoolwork, Too tired to do schoolwork, play or work play or work

Comes home from school Comes home from school exhausted exhausted

Too tired to cope with conflict Too tired to cope with conflict

7. Feelings of worthlessness 7. Feelings of worthlessness or inappropriate guilt—look or inappropriate guilt—look forfor::

Describes self as "bad" or Describes self as "bad" or "stupid" "stupid"

Has no hope or goals for the Has no hope or goals for the future future

Always trying to please others Always trying to please others

Blames self for causing Blames self for causing divorce or a death, when not divorce or a death, when not to blame to blame

8. Decreased 8. Decreased concentration or concentration or indecisiveness —indecisiveness —look for:look for:

Often responds "I Often responds "I don’t know" don’t know"

Takes much longer to Takes much longer to get work done get work done

Drop in grades Drop in grades

Headaches, Headaches, stomachaches stomachaches

Poor eye contact Poor eye contact



Depression May Look Depression May Look Different In TeensDifferent In Teens

It is important to understand that the brain It is important to understand that the brain determines one’s mood, thoughts, actions and determines one’s mood, thoughts, actions and judgmentjudgment

Many adults view youth who are irritable or who Many adults view youth who are irritable or who act out as behavior-problem youth, without being act out as behavior-problem youth, without being aware that a very treatable underlying cause such aware that a very treatable underlying cause such as depression may be affecting the youthas depression may be affecting the youth

While youth must be held accountable for their While youth must be held accountable for their actions, it is equally important that depression, if actions, it is equally important that depression, if present, be recognized, evaluated and treatedpresent, be recognized, evaluated and treated

(Schneidman, 1996)(Schneidman, 1996)


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 actedactedThey accounted for 60% of medically They accounted for 60% of medically treated suicidal actstreated suicidal actsCompared 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 sixA 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)


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 suicideWe have reviewed what a depressed We have reviewed what a depressed person looks likeperson looks likeNot all depressed people are suicidal – Not all depressed people are suicidal – how can we tell?how can we tell?Suicides don’t happen without warning Suicides don’t happen without warning - verbal and behavioral clues are - verbal and behavioral clues are present, but we may not notice thempresent, but we may not notice them


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


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 injury; Having several accidents resulting in injury;

"close calls" or "brushes with death""close calls" or "brushes with death"


– Preoccupation with death/violence; TV, Preoccupation with death/violence; TV, movies, drawings, books, at play, musicmovies, drawings, books, at play, music

– Risky behavior; jumping from high Risky behavior; jumping from high places, running into traffic, self-cuttingplaces, running into traffic, self-cutting

– School problems – a big drop in School problems – a big drop in grades, falling asleep in class, grades, falling asleep in class, emotional outbursts or other behavior emotional outbursts or other behavior unusual for this studentunusual for this student

– Wants to join a person in heavenWants to join a person in heaven

– Themes of death in artwork, poetry, etcThemes of death in artwork, poetry, etc

Further Behaviors Often Seen Further Behaviors Often Seen in Kidsin Kids


What On Earth Can What On Earth Can II Do? Do?We are reluctant to ask questions of We are reluctant to ask questions of depressed people depressed people Depression is an illness, like heart Depression is an illness, like heart disease, and disease, and suicidal thoughts are a suicidal thoughts are a crisis, like a heart attackcrisis, like a heart attackIf you saw someone having a heart attack If you saw someone having a heart attack you would make you would make somesome attempt to attempt to administer CPRadminister CPRAnyone can learn to ask the right Anyone can learn to ask the right questions to help a depressed and suicidal questions to help a depressed and suicidal personperson


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”

Most are fearful of getting a yes answerMost are fearful of getting a yes answer

What if we could recognize depression What if we could recognize depression symptoms like we recognize symptoms of a symptoms like we recognize symptoms of a heart attack?heart attack?

What if we could ask for help for ourselves, What if we could ask for help for ourselves, our parents, our children, without shame?our parents, our children, without shame?

What if we recognized feelings of despair What if we recognized feelings of despair and hopelessness as symptoms of a brain and hopelessness as symptoms of a brain disorder?disorder?


Reduce StigmaReduce StigmaStigma about having mental health Stigma about having mental health problems keeps students from seeking help problems keeps students from seeking help or even acknowledging their problemor even acknowledging their problemReducing the fear and shame we carry Reducing the fear and shame we carry about having such “shameful” problems is about having such “shameful” problems is criticalcriticalPeople must learn that depression is People must learn that depression is atreatable disorder– not something to be atreatable disorder– not something to be ashamed ofashamed ofLearning about suicide (and teaching our Learning about suicide (and teaching our students) makes it possible for us to students) makes it possible for us to overcome our fears about asking the “S” overcome our fears about asking the “S” questionquestion


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 It is essential, if we are to reduce the number of suicide deaths in our country, number of suicide deaths in our country, that community members/gatekeepers learn that 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” questionPPersuade– getting the person to talk, and to ersuade– getting the person to talk, and to

seek helpseek helpRRefer – getting the person to professional helpefer – getting the person to professional help

(Quinnett, 2000)(Quinnett, 2000)


Ask Questions!Ask Questions!

You seem pretty down You seem pretty down

Do things seem hopeless to you? Do things seem hopeless to you?

Have you ever thought it would be easier to Have you ever thought it would be easier to be dead? 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 already suicidal by talking about it. If they are already thinking of it they will probably be relieved thinking of it they will probably be relieved that the secret is out.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 questions few more questions


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?


Do . . .Do . . .Talk openly- reassure them that Talk openly- reassure them that they can be helped - Try to instill they can be helped - Try to instill hope hope

Listen without passing judgmentListen without passing judgment

Make empathic statementsMake empathic statements

Use warning signs to get helpUse warning signs to get help

early for the individualearly for the individual

Stay calm, relaxed, rationalStay calm, relaxed, rational


Don’t…Don’t…Make moral judgments– don’t argue or lectureMake moral judgments– don’t argue or lectureEncourage guiltEncourage guiltPromise total confidentiality/offer reassurances that Promise total confidentiality/offer reassurances that may not be truemay not be trueOffer empty reassurances – “you’re luckier than Offer empty reassurances – “you’re luckier than most people” won’t helpmost people” won’t helpMinimize the problem/offer simplistic solutions(e.g. Minimize the problem/offer simplistic solutions(e.g. “all you need is a good night’s sleep”)“all you need is a good night’s sleep”)Dare the suicidal person (e.g.“You won’t really do Dare the suicidal person (e.g.“You won’t really do it.”)it.”)Use reverse psychology (e.g. “Go ahead and kill Use reverse psychology (e.g. “Go ahead and kill yourself.”)yourself.”)Leave the youth aloneLeave the youth alone


Never Go It Alone!Never Go It Alone!

Collaborate with othersCollaborate with others– The person him/herselfThe person him/herself– Family and friendsFamily and friends– School Personnel or Co-workersSchool Personnel or Co-workers– Community AgenciesCommunity Agencies– Family doctorFamily doctor– Crisis HotlineCrisis Hotline


Getting HelpGetting Help

Refer for professional helpRefer for professional help– When youth exhibit signs of depressionWhen youth exhibit signs of depression– When risk is present (e.g. specific plan, available When risk is present (e.g. specific plan, available

means)means)

Know your community resourcesKnow your community resources– Maintain collaboration with treating agency to Maintain collaboration with treating agency to

provide behavioral information to therapistsprovide behavioral information to therapists– Yes, it is true the therapist may be unable to share Yes, it is true the therapist may be unable to share

information with you, but they are bound by law information with you, but they are bound by law to maintain silence without express permission to maintain silence without express permission from the clientfrom the client

– However, they will be glad to hear from you about However, they will be glad to hear from you about what you are seeing and hearingwhat you are seeing and hearing


Bereavement After Bereavement After A Suicide LossA Suicide Loss

Compared with homicide, accidental death or Compared with homicide, accidental death or natural death, suicide death is the most difficult natural death, suicide death is the most difficult for family members and friends to resolvefor family members and friends to resolveFriends of youth who complete suicide may Friends of youth who complete suicide may experience:experience:– Great painGreat pain– More difficulty finding meaning in the deathMore difficulty finding meaning in the death– More difficulty accepting the deathMore difficulty accepting the death– Less support and understandingLess support and understanding– More need for mental health careMore need for mental health care

Teachers are often the only source of support Teachers are often the only source of support for friends of suicide completersfor friends of suicide completers

(Smith, Range & Ulner, 1991)(Smith, Range & Ulner, 1991)


Helping Your Students Helping Your Students Through A Suicide At Your Through A Suicide At Your

SchoolSchoolSuicidal death is so stigmatized Suicidal death is so stigmatized

that many people never talkthat many people never talk

about it, creating a “conspiracy about it, creating a “conspiracy

of silence” that keeps people hurtingof silence” that keeps people hurting

Teach your students about the Teach your students about the seriousness of untreated depression – seriousness of untreated depression – help them understand they are not at help them understand they are not at fault if a friend diesfault if a friend dies

(Anderson, 1999)(Anderson, 1999)


Help them understand about the Help them understand about the unendurable psychache their friend unendurable psychache their friend experienced so they can resolve experienced so they can resolve some of their angersome of their anger

Assist other people in supporting the Assist other people in supporting the family, since lack of support is the family, since lack of support is the biggest problem survivors of suicide biggest problem survivors of suicide faceface

Reduce the stigma against Reduce the stigma against depression in your school, so kids depression in your school, so kids will feel safer talking about their losswill feel safer talking about their loss


Teachers Are Also SurvivorsTeachers Are Also SurvivorsRemember, you too, are a survivorRemember, you too, are a survivor

and it can be difficult to maintainand it can be difficult to maintain your professional stance whileyour professional stance while trying to help your studentstrying to help your students

Many professionals know the pain ofMany professionals know the pain of losing a young person to suicide, and the losing a young person to suicide, and the

struggle to be supportive to those who struggle to be supportive to those who depend on you while you are hurtingdepend on you while you are hurtingDo not be too hard on yourself if you are Do not be too hard on yourself if you are not sure what to do or say – we are all not sure what to do or say – we are all strugglingstruggling


Consider A School-wide Consider A School-wide Suicide Prevention ProgramSuicide Prevention Program

Impact the entire school environment by:Impact the entire school environment by:

DevelopingDeveloping written written policiespolicies and procedures for and procedures for responding to suicidal warning signs, gestures, responding to suicidal warning signs, gestures, threats, attempts, and completionsthreats, attempts, and completions

TrainingTraining every member of the school every member of the school staffstaff, not , not just teachers and counselors, in how to recognize, just teachers and counselors, in how to recognize, respond to, and refer youth at high suicide riskrespond to, and refer youth at high suicide risk

Educating parentsEducating parents to take all talk of suicide to take all talk of suicide seriously and to know how to help their childseriously and to know how to help their child

Giving studentsGiving students the knowledge to get help for a the knowledge to get help for a suicidal friendsuicidal friend


Permanent Solution-Permanent Solution-Temporary ProblemTemporary Problem

Remember a depressed person is physically Remember a depressed person is physically ill, and ill, and cannotcannot think clearly about right or think clearly about right or wrong, wrong, cannot cannot think logically about their think logically about their value to friends and familyvalue to friends and familyYou would try CPR if you saw a heart attack You would try CPR if you saw a heart attack victim. Don’t be afraid to “interfere” when victim. Don’t be afraid to “interfere” when someone is dying more slowly of depressionsomeone is dying more slowly of depressionMost kids, when treated, are able to Most kids, when treated, are able to overcome their suicidal thoughts, and recover overcome their suicidal thoughts, and recover from their depressionfrom their depressionDepression is a treatable disorderDepression is a treatable disorderSuicide is a preventable deathSuicide is a preventable death


Websites For Additional Websites For Additional InformationInformation

Ohio Department of Ohio Department of Mental HealthMental Health

www.mh.state.oh.uswww.mh.state.oh.us NAMINAMIwww.nami.orgwww.nami.orgNational Institute of National Institute of Mental HealthMental Healthwww.nih.nimh.govwww.nih.nimh.govAmerican Association American Association of Suicidologyof Suicidologywww.suicidology.orgwww.suicidology.org

Suicide Awareness/Voice Suicide Awareness/Voice of Educationof Education

www.save.orgwww.save.org

American Foundation for American Foundation for Suicide PreventionSuicide Prevention

www.afsp.orgwww.afsp.org

Suicide Prevention Suicide Prevention Advocacy Network Advocacy Network

www.spanusa.orgwww.spanusa.org

Suicide Prevention Suicide Prevention Resource Center Resource Center www.sprc.orgwww.sprc.org


A Brief BibliographyA Brief BibliographyAltesman, R., 2005. Altesman, R., 2005. Statement from the American Academy of Statement from the American Academy of Child and Adolescent Psychiatry for the Food and Drug Child and Adolescent Psychiatry for the Food and Drug Administration Joint MeetingAdministration Joint Meeting : : http://www.altesman.medem.com/ypol/user/userUploadHandouthttp://www.altesman.medem.com/ypol/user/userUploadHandout

Anderson, E. “The Personal and Professional Impact of Client Anderson, E. “The Personal and Professional Impact of Client Suicide on Mental Health Professionals. Unpublished Doctoral Suicide on Mental Health Professionals. Unpublished Doctoral dissertation, U. of Toledo, 1999dissertation, U. of Toledo, 1999

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

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

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

Jacobs, D., Ed. (1999). Jacobs, D., Ed. (1999). The Harvard Medical School Guide to The Harvard Medical School Guide to Suicide Assessment and Interventions.Suicide Assessment and Interventions. Jossey-Bass. Jossey-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 Psychiatric PressAmerican Psychiatric 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/depressttp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cfmion/notes.cfm

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

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

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


Signs of Depression in Youth.Signs of Depression in Youth. Oregon State Dept. of Oregon State Dept. of Health. Health. http://http://www.dhs.state.or.us/publichealthwww.dhs.state.or.us/publichealth//

ipe/depression/signs.cfmipe/depression/signs.cfm

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 Science. American Academy of Science

Styron, W. (1992). Styron, W. (1992). Darkness VisibleDarkness Visible. Vintage Books. Vintage Books

Surgeon General’s Call to Action (1999). Department of Surgeon General’s Call to Action (1999). Department of Health and Human Services, U.S. Public Health 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 for and critical sessions in cognitive-behavioral therapy for depression”. depression”. Journal of Consulting and Clinical Journal of Consulting and Clinical Psychology 67: 894-904.Psychology 67: 894-904.

SAVING LIVES: Understanding Depression And Suicide In Young People – A Training For School Personnel Sponsored by the Ohio Department of Mental Health.

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