There Are No Simple Solutions

Hi Jerry,

I very much enjoyed your blog post and found you covered so many different aspects of the challenges and complexities both for suicide and mental health.  You mention so many important points, both that suicide is on the rise in certain areas, but on a decline in others and most importantly - what would have happened had all these amazing organizations/agencies not had the National Strategy in place and created so many outstanding programs for those in need.

I'm in Canada, we are still without a National Suicide Prevention Strategy, but are close to having it finally after a private member's bill was brought forward and relentless work done to make our government wake up and get one in place.  It's my understanding that Canada played a major role in the creation of the strategy that has been adopted by many countries, yet we ourselves are still without one.  Pretty mind boggling!

I lost my late husband Rob to suicide in Dec. 2000 and have since become a very passionate advocate for suicide prevention and mental illness.  It takes everyone getting involved to educate on these issues and I applaud SPRC for all they do.  I share tons of posts on suicide both post and prevention, mental illness, bullying, and many other areas that relate on my Facebook fanpage "Suicide Shatters".  It's something I felt compelled to do, that it was my purpose or passion to take what I had experienced and learned to heal from and help others do the same.  Getting good information out and educating others is critical I believe.

Almost 1 million worldwide die by suicide each year, it's my understanding that for every 1 completed suicide there are 10-20 attempts and those numbers are absolutely shocking realizing how many are walking around on this planet trying to figure out how to cope with suicide and the struggles of mental illness that is 90% present in suicide. 

I loved your 2nd last paragraph stating "it's time for genuine and intentional cross-sector, cross-discipline and cross-funded approaches that will act synergistically to bring the best we know to the complex problem of suicide."  It takes each and every person coordinating efforts to help those who so desperately need it before as well as after suicide has entered their lives.

I've shared your wonderful blog post on my page!  Thank you!

Dear Mr. Reed,

I enjoyed your thoughtful comments regarding national efforts in suicide prevention.  It's truly mind boggling that some 33,000 Americans end their lives each year.  I suspect, though there have been significan efforts made to support returning veterans, their mental health challenges combined with their return during a stressed economy with decreased mental health support will be especially difficult in the years ahead for our country.

My suggestion is a simple one, and one which has motiviated me to work  with established state prevention committees in NH.  I currently serve on the Youth Suicide Prevention Assembly, the Suicide Prevention Council (established by the NH legislature), the Public Policy Sub-Committe of the SPC, and participate in a consultation group for mental health treators working with the refugee population in NH.  Most of my career was spent working as a secondary guidance counselor at Manchester High School West.  Manchester is the largest city in the state with a population of over 100,00; the city is also a refugee receiving center.  After attaining a CAGS in Mental Health Counseling, I spent two years working as a fee for service clinician at a local mental health center.

Having given you a bit of my background, let my share my suggestion.  Adolescent depression, suicidal ideation, suicidal attempts, and completed suicides are serious and documented issues in that age group.  To address these issues, I humbly suggest that DEPRESSION EDUCATION/SUICIDE AWARENESS BE A MANDATED UNIT OF INSTRUCTION IN ALL PUBLIC HIGH SCHOOLS IN THE UNITED STATES.  In NH, this could easily be integrated within the health curricular; all public high schools in NH must teach health.  Though I am not certain that this requirement exists in all states, my guess is that it does in many.

The content of the mandated unit would emphasize:  (1) how to know if you or a peer may be depressed (2) it is a strength, not weakness,  to seek help for yourself or peer you are concerned about  (3) there is no confidentiality when there are concerns about safety; thus giving adolescents permission to come forward about friends (4) All high school staff/faculty will be instructed that if a student approaches them concerned about him/herself or a peer, they are to report the concern immediately to a guidance counselor.

I believe the beauty of this suggestion is it's simplicity and minimal cost to implement.  Units to cover the topics could easily be developed by "experts", the mechanism to implement is already is in place for those states that require health be taught in high school, and since the approach is educational and NOT clinical, certified teachers could safely deliver the information

This suggestion comes out of my work 'in the trenches" and not in the ivy tower.  I would be most interested to learn your response to my comment.

Sincerely yours,

Nancy Dorner, M.Ed., CAGS

23 Rossini Rd.

Londonderry, NH 03053

I appreciate Jerry's post, "There Are No Simple Solutions." As a Physician-Pediatrician who lost my 21 year old son to suicide, I am a "survivor." It has given me a remarkable new perspective on what we do (and don’t do) for depression and grief in our communities. For sure, it “takes a village,” a community, and needs to begin as children, with education.  Certainly, Dr. Regina Benjamin is sincere, as our nation’s Surgeon General, in eliminating Suicide with the Action Alliance for Suicide Prevention task force. The task force can be the catalyst for societal transformation in reversing the discrimination that exists in getting mental health care help before it becomes a crisis, starting with more aggressively dealing with depression. With my new perspective, on the ‘other side of the mirror,’ I believe the solution to our “suicide problem” is less complicated than we are making it out to be. It’s a “Pandora’s Box” we frankly don't want to deal with as a society, putting processes in place to actively overcome the obstacles to identifying suicidal risk and then instill programs in our communities providing the safety net needed for this most vulnerable sub-set of our society. Prior Task Force findings and recommendations, the DoD’s included, have given us insight, but haven’t caused us to change our behaviors. The National Strategy for Suicide Prevention must deal with why suicide happens in any industrialized evolving society. I would like to be a part of the work of the task force to be completed by this summer. I recently retired as an Army COL working transformation to Patient-Centered and Family-Focused Healthcare. Now I have time and energy to give to the project. While we have been involved in wars for over 10 years, with PTSD and TBI complicating the picture, this isn’t new. Wars have come and gone for decades. This problem is the same over generations. Many self-proclaimed experts lament, "You just can't prevent all suicides." I suggest this is defensive posturing, playing into cognitive dissonance and group think, not a mind set for eliminating suicide.

Has our "knowledge of suicide prevention" really increased, or have we just documented more of them, and put them on the news, thereby raising public awareness? True, there are more individuals and organizations dedicated to advancing suicide prevention, a good thing, as long as we are not duplicating services that are not effective. We must look for desired outcomes and the programs that are getting them today. The Henry Ford Clinic in Detroit and the Kristin Brooks Hope Center “I’m Alive” Crisis Line come to mind. The Air Force did a great job in the early 2000’s leading the DoD, but have fallen back to pre-existing levels. Why? Our approach to resource support must change capitalizing on known successes. It seems funding hasn’t gotten at the root causes for this epidemic. Frankly, too many of our crisis lines have taken a 'legalistic' approach, calling the police (or SWAT Team…see recent articles) too soon, putting the caller in jail, or worse yet, death-by-cop, further alienating and generating mis-trust of all crisis lines. I agree, "We must challenge ourselves to apply increased understanding of suicide on a much broader scale.”

For the Departments of Veterans Affairs and Defense to really reverse the suicide rate, we must deal with the ingrained stigma and discrimination inherent with any mental health diagnosis, especially suicidal ideation. Unfortunately, an admission of need makes a troop 'non-deployable,' suspect, thereby increasing the depression and feeling of burdensomeness and alienation that got them to that state of mind in the first place. A culture of trust is missing. Coming forward too often leads to abandonment and a real fear of administrative separation for the active duty troop and/or veteran, despite our motto – “No troop left behind.” Further, the emphasis on the ‘Battle Buddy’ being responsible for recognizing an impending crisis with his Buddy, admitting the ‘Battle Team’ is defective, must be reconsidered. Denial is strong, and guilt is produced when they do 'turn them in,' only to see them released without effective treatment. Too often, the guilt produces two casualties.

What we need is full transparency and accountability, to examine the root cause of every loss of life by suicide with an honest and open reassessment of our processes, learning from every surviver, be they the attempter or the grieving family members. Are our processes patient-centered or do they protect the bottom line and legal status quo? Provide funding for programs providing true preventive education and individualized therapy on the patient's terms and needs, ones that address childhood issues that lead to adult depression and dysfunctional behaviors, with processes supporting warm hand-offs in crisis with continuous care and integrated collaborations, case management and close continuous follow-up.

True, it could be worse without all we have done to date, but we must listen not only to "the stories of lives saved" but also lives lost. Rather than asking for more behavioral health workers, we must integrate those we have within primary care clinics where patients initially raise physical symptoms indicating stress, anxiety, and depression, harbingers of future suicide. Currently, most programs place time and barriers in between a depressed person and follow-up with a mental health colleague with referral processes based on health plan and contract business rules rather than patient need. This standard of care is certainly contributing to today's suicide rate. It certainly did in my son’s case. It we are to provide true proactive care coordination and case management utilizing the ‘Army of volunteers’ available in the patient’s community and environment, must invite them to participate and include them from the start. We need them, as the patient is unable to muster the resolve to carry out the instructions and processes, especially with the many barriers our system(s) place in the way of making appointment follow ups. To eliminate this complication, provide those services at the point of recognition of need, same day, rather than at a separate referral site. This multi-disciplinary same day continuous therapy can, of course, be done virtually, by tele-conference or phone initially, and then continue face-to-face with help of the patient’s family and loved ones who do have the resources to check on the patient and get them to follow-on care, assisting the medical system in placing a true safety net around them. Successes to date have taught us this is required, every time, if we are to succeed in eliminating suicide. To be able to work as a team, we must enlist our legal colleagues in correcting misplaced concern for patient privacy with 'need-to-know' information exchange policies, having every patient sign a release form while they are healthy, before they are in crisis and making life-threatening decisions to isolate themselves.

We will know we are "thinking and acting differently" when we have integrated public health and mental health within primary care processes, combining appointment systems and case management follow-up to produce desired results.  “Moving upstream (to) prevent the onset of suicidal behavior” must begin in grade school, as you said, with programs that address root causes, and include families in the discussion, proactively. Certainly, addressing spiritual and emotional fitness in everyday clinic practices is crucial for the transformation to occur, along with the usual physical and mental health practices, addressing individuals in crisis by inviting families and close colleagues and friends to be part of the care plan earlier in the process, educating communities to expect this culture shift of inclusion.

The time is now to move ahead, absolutely, in the right direction and with lessons learned. Integrate traditional specialty care into primary care clinic processes, including pharmacy, behavioral health, and pain management in the medical home. I suggest "the answers (and) solutions to suicide are (not that) complex." Rather, point out we can eliminate suicide at its root addressing why our most creative and sensitive individuals feel alienated, unappreciated, and a burden on the very society they are so concerned about fitting into. Certainly, identifying mental health disorders earlier and involving families in the treatment care plan for them is also crucial. Yes, "genuine and intentional cross-sector, cross-discipline, and cross-funded approaches (acting) synergistically" is the right approach, but this will require a cultural change, especially in how we pay for the time and procedures it takes to do this right, provided by resourced primary care teams with continuity, responding at the first sign of depression and risk-taking behavior. The 'complexity' will remain if we don't incent the right behaviors. The commitment to eliminating suicide is the right answer, not just preventing it. Thank you.

Dr. George Patrin

210-833-9152

patrin.george@gmail.com

We would like to bring your attention to a four minute YouTube video which pertains to legislation NAMI introduced in the South Carolina legislature. At the end of this e-mail there is a web link to take you to the video. Please watch it and forward the link to all your friends.

The legislation, Senate Bill 1015 and House Bill 4569, is to improve communication in healthcare. It is really very simple. A provider will offer a release to patients so they may designate a person(s) to be involved in their health care. A patient is not obligated to designate anyone.

Regretfully, the South Carolina Medical Association and the South Carolina Hospital Association are opposing NAMI’s legislation.

Their position does not make sense to me. Why should I be denied easy availability of a form which permits me, the patient, to authorize someone(s) of my choosing to talk with my doctor or know about my treatment?

1. After watching the video, please forward the link to everyone you know.
2. If you agree treatment should not be this difficult or perhaps you have personally experienced similar circumstances to the video, please contact your South Carolina Senator and Representative and tell them this legislation is important to you and ask them to vote for it.
3. As you see your healthcare providers or enter a hospital, please ask for a Release if you are not offered one. Until this legislation is passed, this may be the only way to get the Release Form.

Now, Click on this Link to view the Video. http://www.youtube.com/watch?v=QvcwrvjLqwc

Also NAMI Mid-Carolina recently published a booklet that is FREE on our website "What Hurts/What Helps". Dr. James Hayes says WHWH should be required reading for anyone in the medical professions... www.NAMIMidCarolina.org  Please feel free to download and use.

What else is going to change in care?

Better communicaitons is what a corporation would do when faced with "healthcare" situation.

I recall the authoritative (if rather simplistic) response, of an experienced university lecturer qualified to doctoral level, to my intention in 1999 to initiate qualitative research into the predicament of survivors of bereavement by suicide: "Is that not just a special form of bereavement?" they said, inferring (wrongly) that there was nothing much to research there. Over 10 years later, I have completed a research master's (2001) and a research doctorate (2010) investigating that particular aspect of suicidology..

Having lost close relatives to suicide, on reflection and after 13+ years of study, it seems to me that, while 'suicide prevention' must be an urgent priority for individuals, families, communities, neighbours and nations, there appear to be  obstacles, insurmountable to date, that render such an urgent priority, though laudable in the extreme, as for example the elimination of world poverty, unlikely to be achieved anytime soon.

Our local Irish experience illustrates this disappointing truth. In Northern Ireland, a government funded suicide prevention strategy has been in place since 2006 with the following aim:

Par 3.9 This Strategy incorporates the following targets .........

(i) to obtain a 10% reduction in the overall suicide rate by 2008; and

(ii) to reduce the overall suicide rate by a further 5% by 2011. 

(Accessed on 25 March 2012 from Par 3.9, "Protect Life - the Northern Ireland Suicide Prevention Strategy and Action Plan" 2006-2011 - at http://www.dhsspsni.gov.uk/phnisuicidepreventionstrategy_action_plan-3.pdf  ) 

The following statement qualifies the above targets in par 3.9 "Progress towards these targets will play an important part in measuring the success of the Suicide Prevention Strategy."

No such reductions were achieved and a government study, published in 2010, reviewed the evidence base for the 'Protect Life' strategy. This study included the following comment at page 48:

"Other factors that may complicate the evaluation of the Protect Life on the basis of only one primary target, such as the reduction in the overall suicide rate are that in terms of absolute numbers, suicide is considered a relatively rare phenomenon, and therefore can show strong year-by-year fluctuations." (Accessed on 25 March 2012 from page 48 "Review of the Evidence Base for Protect Life - a shared vision, the Northern Ireland Suicide Prevention Strategy - at http://www.dhsspsni.gov.uk/review-evidence-base-protect-life.pdf  ).

To some extent, Jerry Reed's above comment:

 "We may be disheartened by the rising numbers and rates [of suicide] and wonder why we have not seen more reductions.  On the other hand, I wonder what we might be experiencing if we did not have this infrastructure in place and had not made the investments we have made.  We often do not hear the stories of lives saved."

strikes at the core of 'the trouble with suicide' (Tomlinson, 2007). And this is that suicide is complicated, multidimensional, multifaceted and obscure. Indeed it sometimes seems that its complexity is - at present - beyond the scope of our currently accessible human, intellectual and scientific understanding.

The occasional successes that psychiatric medicine achieves in preserving and enhancing the quailty of human life of patients suffering incomprehensible cognitive and behavioural issues, e.g via librium, offers an alternative pathway for suicidology in achieving a lessening in the loss of human life by suicide. Psychiatry does not know why or how librium 'works' but indeed it often does in 'quality of life' outcomes. Might it be that the 'holy grail' of effective suicide prevention might rest in its infrequency rather than anywhere else. In other words might we in suicidology be much better off focusing upon and facilitating 'reasons for living' (Linehan et al. 1983) rather than upon the conditions for suicide (Joiner, 2005) in our life saving work.

For me it has been more important to comfort those bereaved by suicide, and to help them to avoid a similar fate, than in speculation about what might or might not have caused particular death/s by completed suicide. In so doing I look after myself, both as a survivor and as a psychotherapist, and perhaps become a modest exemplar of the inestimable value of life and living, for those who know me and who know of me.