Whether you are a doctor, teacher, parent, coworker, friend or anyone else — the first step is asking the right questions.
Suicide
among young people is once again at the forefront of our national
consciousness with the news two weeks ago that the Washington State
quarterback Tyler Hilinski was found dead of a self-inflicted gunshot wound. Halfway across the country, in Perry Township,
Ohio, a 15-year-old became the sixth teen in the school district there
to kill themselves in the last six months, three occurring just
in January. And the swimming legend Michael Phelps said recently that
his ongoing bouts of depression, which began when he was a teenage
phenomenon, led him to “contemplate suicide … I didn't want to be in the sport anymore ... I didn't want to be alive anymore."
Suicide is a growing public health crisis. The Centers for Disease Control reported recently that suicide rates for teenage girls in the United States have hit a 40-year high. The suicide rates
doubled among girls and rose by more than 30% among teen boys and young
men between 2007 and 2015, according to the CDC report. Today suicide
is the number one killer of teenage girls worldwide and the second leading cause of death in teenagers in the U.S. (only accidents cause more deaths).
Nine out of 10 youth who die by suicide have a mental health condition, while four out of five give clear warning signs. Nearly 3 in 100 high school students report having made such a serious attempt to take their own life
during the past year that they required medical treatment. Twice as
many report an attempt at suicide that didn't require treatment.
These
statistics should serve both as a shock to our collective being and an
urgent call for national action. We simply cannot offer heartfelt
condolences and then go about our normal daily activities anymore. Just
as the opioid crisis has spurred a call to action at the local,
state and national levels, the suicide crisis requires an immediate and
comprehensive response.
The very good
news is that we know how to do away with this preventable and tragic
loss of life. The first step is to change and expand the way we talk
about suicide. We know that more than half of all people who die by
suicide visit their primary care doctor within a month of their deaths.
For
the most part, however, a discussion of suicide is not part of the
average examination. Nor is depression, which is the psychiatric
diagnosis most commonly associated with suicide and is projected to be
the second leading component of the global disease burden
by 2020. We must start asking about suicide (i.e., screening) like we
monitor for blood pressure. If not, we will not find the people who are
suffering in silence.
In my work with communities
across the globe, I have seen first-hand the great need for and benefits
of asking a few questions to identify those at risk for suicide.
I
once travelled to a Hindu temple in upstate New York that served a
disadvantaged population with a high suicide rate. I trained the entire
community on a brief suicide screening we developed — the Columbia
Suicide Severity Rating Scale (CSSRS) — which incorporates a few simple
questions that can be asked in a consistent way. The questions help
determine whether a person is experiencing suicidal thoughts (“Have you
actually had any thoughts of killing yourself?”), and if so, whether the
thoughts include method (“Have you been thinking about how you might do
this?”) and intent (“Have you had these thoughts and some intention of
acting on them?”).
A history of suicide attempts is
the number one risk factor for suicide. Therefore, asking about a
person’s attempt history and other serious suicidal behaviors (e.g.,
“Have you taken any steps towards making a suicide attempt or preparing
to kill yourself, such as collecting pills, getting a gun, giving
valuables away, or writing a suicide note?”) is essential to identifying
his or her level of risk.
Two weeks after my visit
to the Hindu temple, there was an article in the local newspaper. A
grandmother who had been at the training had noticed that her grandson
wasn’t looking so good, asked him the questions, and said that doing so
probably saved his life. Whether you are a doctor, teacher, parent,
coworker, friend, relative or anyone else — the first step is asking.
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Using such a screen process works. The most evidence-based tool of its kind is being used in 45 countries
on six continents with significant success. And anyone can use this
life-saving tool. We have worked with every type of organization
— the military; veterans; schools, colleges and universities; health
care institutions; first responders; and many government agencies and
have witnessed the dramatic impact on suicide rates where talking openly
about suicide has been embraced and these helpful simple questions are
put in everyone’s hands.
A “total force” roll out
in the Marines of the screening program, putting it in the hands of all
support workers including legal assistants, financial aid counselors,
clergy, etc., helped lead to a 3.5% reduction in suicide in the three
years since it's use started in 2014. The Defense Suicide Prevention
Office is now rolling the effort out to non-medical personnel in the
other Armed Forces branches.
These individuals are
often the first to encounter at-risk servicemen and women and are now
able to provide lifesaving screening. The power of asking was again
illustrated when Utah reported that using the questions and putting them
in everyone’s hands helped the state reverse their suicide rate for the first time in years.
And
since its implementation, screening efforts helped reduce suicide rate
from 3.1 suicides per 10,000 people to 1.1 in 20 months in the Tennessee programs of Centerstone, one of the nation’s largest not-for-profit providers of outpatient community behavioral healthcare.
I recently helped
Princeton University put it in the hands of all the athletic coaches so
they can hopefully identify athletes like Tyler before it is too
late. Thanks to the simplicity of screening, numerous school systems
have done the same.
But we still have a long way to
go. One of the biggest problems is that most people who need treatment
do not get it — 50% to 75% of those in need receive inadequate treatment
or no treatment at all. This is partly due to stigma and access-to-care
barriers, but, in the end, few avert the problem of under-treatment:
Nearly 80% of college students who die by suicide receive no consistent treatment prior to their deaths.
Suicide
can be prevented — which sets it apart from other sources of pain and
suffering in the world. We need to get to a place where everybody,
everywhere asks the questions that help identify at-risk individuals and
get them the help that they need. Together, we can prevent these
unnecessary tragedies.
Kelly Posner is a
clinical professor in the department of Child and Adolescent Psychiatry,
Vagelos College of Physicians and Surgeons at Columbia University and
the founder and director of the Columbia Lighthouse Project.
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