Other Topic: Lethal Means Safety

Suicide and Older Adults: On-Demand

Suicide and Older Adults: On-Demand

Dr. Jobes and his special guest expert Dr. Yeates Conwell discuss suicide among older adults with an eye to research and evidence for effective approaches to its prevention.

The suicide rate among older adults is higher overall than at other points in the life course and poses particular challenges for prevention. Older adults take their own lives with high lethality of intent and utilize firearms more often than younger age groups. Suicide attempts are also less frequent and older adults less often express suicidal ideation than younger adults. While interventions must be aggressive in the actively suicidal older person, the lethality of suicidal behavior in older adults underscores the need for relatively greater emphasis on upstream preventive interventions.

In addition to access to deadly means, risk factors for completed suicide in later life can be characterized as “the 5 Ds”: demographic characteristics (male, older, unmarried), depression, disease (physical illness), disablement, and disconnectedness. Because older adults who take their own lives are more likely to be seen in primary care than mental health care settings, primary care-based integrated care models hold promise for reducing suicide in this age group. Social disconnectedness, which is made worse by the “social distancing” required by the coronavirus pandemic, is also a modifiable state for which community-based services and supports should be mobilized.

At the conclusion of this webinar, participants will understand the scope of the problem of suicide in older adults, factors that place older people at increased risk for suicide, and evidence for effective approaches to its prevention.

Dr. Yeates Conwell

About Dr. Yeates Conwell

Yeates Conwell, M.D. received his medical training at the University of Cincinnati and completed his Psychiatry Residency and a Fellowship in Geriatric Psychiatry at Yale University School of Medicine. He is now Professor of and Vice-Chair of Psychiatry, University of Rochester School of Medicine and Dentistry, where he is Director of the Geriatric Psychiatry Program and the UR Medical Center’s Office for Aging Research and Health Services, and Co-Director of the UR Center for the Study and Prevention of Suicide. In addition to teaching, clinical care, and service system development, Dr. Conwell directs an interdisciplinary program of research in aging, mental health services, and suicide prevention.

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Challenges of Assessing and Treating Youth Suicide: A Solution in CAMS-4Teens®

The news of rising teen suicide rates is difficult to ignore. Every few months, the media reports on another study that documents how much teen suicide rates have increased in the past 20 years. Rates jumped from 6.8 deaths per 100,000 people in 2000 to 10.6 deaths per 100,000 people in 2017.1 Suicide is now the second-leading cause of death for 15- to 24-year-olds, with only motor vehicle accident deaths outnumbering it. Researchers have noticed trends in suicide rates among girls and young women increasing, as well as for young black men.1,2

Researchers and mental health professionals are struggling to identify causes for these trends and to quickly identify effective prevention and treatment strategies to address this major public health concern. While many research studies report on trends in rates among certain gender and ethnic groups, it is extremely difficult to identify causes for rising suicide rates. Our best educated guesses about this alarming trend relate to added stress caused by:

  • addiction in families (as seen in the opioid crisis),
  • the use of social media and the associated feelings of inadequacy, loneliness, and the pressures of “keeping up” with friends,3
  • lack of access to mental health resources in schools and communities,
  • lack of suicide-specific training for mental health professionals, and
  • evidence that the current generation of youth experience more depression, anxiety, and stress in general than prior generations4.

All of these issues combined with easier access of searching, finding, and being exposed to media that depict or offer information on suicide may be impacting the increase.

Obstacles to Treatment

A major obstacle to reducing the rise of suicide rates across all age groups is the lack of evidenced-based care available for individuals who are suicidal5. Funding for research on suicide treatment lags far behind other health issues. For decades, researchers and mental health professionals did not include suicidal individuals in studies that tested promising new treatments because it was considered too risky. These barriers have brought us to our current state of feeling far behind in terms of knowing what works best for treating suicide. The National Institute of Mental Health has identified research on suicide as an area of priority, and more studies are being funded to help evaluate what methods work best for prevention, screening youth for suicide risk, and finding the best possible treatments.6

There are many layers of prevention and treatment that can be implemented for youth suicide. Many states have suicide prevention centers within their public health departments, which are tasked with implementing prevention programs in communities and schools and training mental health professionals in their state on best practices for working with suicidal patients. Within schools, Signs of Suicide has been found to be an effective gatekeeper training program that teaches teens about recognizing suicide risk in their peers and the steps they should take to connect their friends with resources.7 The Good Behavior Game is a classroom-management system that is used for second-graders and focuses on minimizing aggressive and disruptive behavior, and amazingly has shown long-term reductions in suicidal behavior as kids move through adolescence.8

Existing Treatment Programs

From a treatment standpoint, few treatments specific to suicide exist that have been shown to provide best clinical care for suicidal teens. Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) are both used for teens with suicide risk. CBT works well as a treatment for depression and anxiety-related disorders, and it can also be used to help someone understand their thoughts about suicide and their feelings of hopelessness.9 DBT specifically addresses self-harming behavior and teaches teens important coping skills to use in place of self-harm.10

Safety-planning interventions and crisis response plans are useful when used in conjunction with DBT or CBT, as they provide concrete steps for teens and their families to follow when the teen is in crisis or thinking seriously about suicide.11,12

Advantages of CAMS with Youth and Teen Suicidality

Collaborative Assessment and Management of Suicidality (CAMS) is a therapeutic assessment and treatment framework that combines all elements from these treatments into one approach. First, CAMS provides a thorough risk assessment in the first session and uses the Suicide Status Form (SSF) to gather valuable information about a teen’s current experience and overall suicide risk.

With CAMS, the entire assessment approach is collaborative. The therapist sits next to the teen (if they are comfortable with it), encouraging the feeling that they are literally on the same page. Because many adolescents may be hesitant or suspicious of the treatment process, CAMS emphasizes transparency and empathy. Instead of a therapist sitting across from the teen with a clipboard and taking notes (that the teen can’t see) while asking questions, the teen is either writing their responses on the Suicide Status Form themselves (first page), or they are watching the therapist write down their responses (second page). The therapist and the teen write the treatment plan together, identify the top two drivers together, and create the stabilization plan together.

We have seen the CAMS approach work very well with teens (CAMS-4Teens), both in our own practices and with consultation and case presentations from other clinicians, as well as in research. A recent study found that the Suicide Status Form works just as well for assessing teen’s suicide risk as it does with adults. Teens in the study were able to understand and rate constructs like psychological pain, hopelessness, and self-hate in a way that was helpful to determining their overall level of distress and suicide risk.13

Once the therapist and teen identify the top two drivers for the treatment plan, the therapist explains what the goals and objectives will be, and which interventions they will use to help achieve those goals. Many teens have some version of self-hate as a driver for suicide. Therapists can make simple goals of decreasing self-hate and identify interventions to target that driver. Examples of interventions may be CBT interventions for increasing self-esteem or behavioral activation for getting teens out of the house and connected to the community and causes they care about (e.g., mentoring younger kids, animal shelters, volunteer work). Furthermore, elements from CBT, DBT skills, problem-solving, interpersonal therapy, and many other methods can be integrated into the CAMS Treatment® plan to target and treat drivers.

Especially for teens in an acute suicidal state, sometimes it is extremely helpful to first identify the problem. The CAMS Assessment® provides a guided walk-through of the teen’s life at that moment, and if a particular stressor or issue is uncovered as being related to the current suicidal thoughts, it can be addressed quickly in treatment. Teens can be overwhelmed with situational factors that feel unsurmountable. We have observed CAMS to be very useful in breaking down these factors into more manageable pieces that the teen can then recognize as treatable.

Tips for Using CAMS with Teens and Adolescents (CAMS-4Teens)

We have assembled some general tips for using CAMS with teens that may be helpful. Before making any major modifications to the Suicide Status Form (SSF) for use with teens, we decided to test it in its existing form. Our hunches were correct: we discovered that CAMS does not need to be radically changed for use with youth (ages 12-17).13

However, other slight procedural recommendations are helpful to keep in mind. First, some youth may need slower pacing for the assessment. It may take more time to explain concepts like psychological pain and agitation. Also, it may take some time to think about how to explain these concepts in a variety of ways.

Second, if the assessment is taking longer than usual, it is beneficial to prioritize getting the stabilization plan completed and in place. As much as possible and practical, intensive outpatient treatment is the goal of CAMS. This is largely achieved by having a solid stabilization plan/safety plan in place. It is very helpful to identify any supportive adults in the teen’s life that they can list on their stabilization plan as someone they can contact in a crisis. You may need to be creative in identifying these adults (e.g., parents, older siblings, other relatives, coaches, pastors, school counselors, etc.).

Third, some youth may respond better with a “parallel assessment” in which you are still gathering the information for the SSF while they are engaging in some other activity (coloring, fidget toys, etc.).

The last tip is focused on how to work with parents and caregivers during the course of CAMS Treatment. It is essential that other adults in the teen’s life are aware of the stabilization plan, understand how to respond to the child in a crisis, and can help assure access to lethal means are limited. We recommend completing the SSF with just the teen present, and then inviting the caregivers into the session at the end to review the stabilization plan. Caregivers may have a wide variety of emotional reactions to their suicidal teen, and it’s important to provide education on suicide in general, and the process of CAMS. Parents and caregivers may need their own support via therapy or community support groups.

In Conclusion

Thus far we have confidence from recent research results that the SSF is appropriate for teens,13 and that CAMS is a promising evidence-based treatment for suicidal teens.14,15 We know that CAMS is an effective treatment for adults,16 and that many clinicians are using CAMS with youth ages 12+ with success.

Our consultants provide on-going support to clinicians using CAMS with teens, and the overwhelming response from clinicians has been positive. They describe CAMS as useful with all types of teens – from those who are very expressive and talkative as CAMS helps organize their thoughts and feelings, to those who may be more reserved as CAMS allows them to express themselves through the SSF without needing to verbalize everything.

The next phase of CAMS-4Teens research includes randomized clinical trials (RCT), which are the gold standard in treatment research, to gather more evidence for the effectiveness of using CAMS with youth. We see a bright future in which CAMS will be available as an evidenced-base intervention for suicidal youth, a group for which having effective treatment will make a big impact and save lives.

    1. Curtin, S. C., & Heron, M. (2019). Death rates due to suicide and homicide among persons aged 10–24: United States, 2000–2017. NCHS Data Brief, no 352. Hyattsville, MD: National Center for Health Statistics.
    2. Miron, R., Yu, K-H., Wilf-Miron, R., & Kohane, I. S. (2019). Suicide Rates Among Adolescents and Young Adults in the United States, 2000-2017. JAMA, 321, 2362-2364.
    3. Twenge, J. M. (2017). Have smartphones destroyed a generation? The Atlantic, https://www.theatlantic.com/magazine/archive/2017/09/has-the-smartphone-destroyed-a-generation/534198/.
    4. Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019). Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005-2017. Journal of Abnormal Psychology, 128, 185-199.
    5. Jobes, D. A., & Joiner, T. E. (2019). Reflections on suicidal ideation. Crisis, 40, 227-230.
    6. Research Prioritization Task Force. (2014). A prioritized research agenda for suicide prevention: An action plan to save lives. National Action Alliance for Suicide Prevention.

http://actionallianceforsuicideprevention.org/sites/actionallianceforsuicideprevention.org/files/Agenda.pdf

  1. Seltine, R. H., James, A., Schilling, E. A., & Glanovsky, J. (2007). Evaluating the SOS suicide prevention program: a replication and extension. BMC Public Health, 7, 161.
  2. Wilcox, H. C., Kellam, S. G., Brown, C. H., Poduska, J. M., Ialongo, N. S., Wang, W., & Anthony. J. C. (2008). The impact of two universal randomized first- and second-grade classroom interventions on young adult suicide ideation and attempts. Drug and Alcohol Dependence, 95 (s1), s60-s73.
  3. Stanley, B. Brown, G., Brent, D. et al. (2009). Cognitive Behavior Therapy for Suicide Prevention (CBT-SP): Treatment model, feasibility, and acceptability. Journal of the American Academy of Child and Adolescent Psychiatry, 48, 1005-1013.
  4. McCauley, E., Berk, M. S., & Asarnow, J. R. (2018). Efficacy of Dialectical Behavior Therapy for adolescents at high risk for suicide. JAMA Psychiatry, 75, 777-785.
  5. Stanley, B., & Brown, G. K. (2012). Safety Planning Intervention: A brief intervention to mitigate suicide risk. Cognitive and Behavioral Practice, 19, 256-264.
  6. Bryan, C. J., Mintz, J., Clemans, T. A., Burch, T. S., Leeson, B., Williams, S., & Rudd, M. D. (2017). Effect of Crisis Response Planning on patient mood and clinician decision making: A clinical trial with suicidal U.S. soldiers. Psychiatric Services, 69, 108-111.
  7. Brausch, A. M., O’Connor, S. S., Powers, J. T., McClay, M. M., Gregory, J. A., & Jobes, D. A. (2019, early on-line). Validating the Suicide Status Form for the Collaborative Assessment and Management of Suicidality in a clinical adolescent sample. Suicide and Life-Threatening Behavior. DOI: 10.1111/sltb.12587
  8. O’Connor, S. S., Brausch, A. M., Ridge Anderson, A., & Jobes, D. (2014). Applying the Collaborative Assessment and Management of Suicidality (CAMS) to suicidal adolescents. The International Journal of Behavioral Consultation and Therapy, 9, 53-58.
  9. Jobes, D. A., Vergara, G. A., Lanzillo, E. C., & Ridge-Anderson, A. (2019). The potential use of CAMS for suicidal youth: Building on epidemiology and clinical interventions. Children’s Health Care, 48, 444-468.
  10. Jobes, D. A. (2015). Managing suicidal risk: A collaborative approach (2nd edition). New York: Guilford.

About the Author

Amy Brausch Ph.D.

Amy Brausch Ph.D.
Dr. Amy Brausch is an Associate Professor of Psychological Sciences at Western Kentucky University where she founded the Risk Behaviors and Suicide Prevention Laboratory in 2011. She completed her Ph.D. in clinical psychology at Northern Illinois University in 2008, following her clinical internship at Utah State University Counseling and Psychological Services Center. Dr. Brausch’s research program broadly focuses on youth suicide risk assessment, prevention, and treatment. Specifically, her work has also focused on the overlap between nonsuicidal self-injury and suicide risk, the overlap between body image, disordered eating, and self-harm, and the role of emotion dysregulation in NSSI and suicide risk. Her work has been funded by the Kentucky Biomedical Research Infrastructure Network and the National Institute of Mental Health. Dr. Brausch has collaborated with Dr. Jobes on research related to CAMS-4Teens, including a validation study of the Suicide Status Form for adolescents. As a Senior Consultant with CAMS-care, LLC, Dr. Brausch has provided training in CAMS to mental health providers in the United States and Australia at community mental health centers, university counseling centers, school districts, and local and state mental health suicide prevention organizations.

See More Articles by this Author

About Amy Brausch Ph.D.

Amy Brausch Ph.D.
Dr. Amy Brausch is an Associate Professor of Psychological Sciences at Western Kentucky University where she founded the Risk Behaviors and Suicide Prevention Laboratory in 2011. She completed her Ph.D. in clinical psychology at Northern Illinois University in 2008, following her clinical internship at Utah State University Counseling and Psychological Services Center. Dr. Brausch’s research program broadly focuses on youth suicide risk assessment, prevention, and treatment. Specifically, her work has also focused on the overlap between nonsuicidal self-injury and suicide risk, the overlap between body image, disordered eating, and self-harm, and the role of emotion dysregulation in NSSI and suicide risk. Her work has been funded by the Kentucky Biomedical Research Infrastructure Network and the National Institute of Mental Health. Dr. Brausch has collaborated with Dr. Jobes on research related to CAMS-4Teens, including a validation study of the Suicide Status Form for adolescents. As a Senior Consultant with CAMS-care, LLC, Dr. Brausch has provided training in CAMS to mental health providers in the United States and Australia at community mental health centers, university counseling centers, school districts, and local and state mental health suicide prevention organizations.

Gun Safety and Suicide Prevention

Perhaps you’ve personally known someone, or treated someone, who attempted suicide using a firearm. Chances are, it was a man – and chances are, the attempt was fatal.

Guns and Suicide in the United States

Studies show that 76% of those who die by suicide in the U.S. are men, and 60% of male suicides are by firearm. Tragically, death is the result of over 80% of firearm suicide attempts. Since men are more likely to use firearms in suicide attempts, and since using a firearm results in a higher likelihood of death than other methods (such as overdose or suffocation/hanging), overall more men than women die as a result of suicide. For instance, approximately 77% of those who die by suicide during their first attempt are men and most of these deaths are by firearm.1

Addressing the Intersection of Firearms and Suicide:

Regardless of the gender of suicide-by-firearm victims, increased awareness of firearm safety can go a long way in preventing gun deaths and reducing suicide rates. Here are some ways that we can help to prevent suicide by firearms in our communities:

Access to Firearms for At-Risk Individuals: Trigger Locks, Gun Safes & More

While most gun owners feel that guns make them safer2, this is likely not true if a person in the household is suicidal. In fact, studies show that access to a firearm increases the risk of death by suicide by as much as three times for everyone in the household.3

One major action that can help save lives is to provide information about removing firearms, or installing trigger locks, firearms safes, and other methods of securing to not only individuals at risk for suicide but also to their loved ones.

Provide Counseling on Firearm Safety

CAMS-care, which uses an evidence-based therapeutic framework for suicide-specific assessment and treatment of a patient’s suicidal risk, recommends a collaborative discussion between a healthcare provider and patient (and ideally the patient’s family or other support network) about how to stay safe. The CAMS-care assessment includes questions about access to firearms as well as personalized discussion of how to be safe with them. Recommendations for safety are not prescriptive; they are decisions made via collaborative problem solving. For some, the solution may be to remove firearms from the house altogether. For others, it may mean securing firearms in a gun safe with ammunition stored separately, and for others putting a picture of a loved one by the firearm is the only agreed upon deterrent.

Increase Public Awareness of Firearm Safety to Prevent Suicide

They say “it takes a village to raise a child,” and the same could be said of preventing suicide. Public awareness campaigns about firearms safety in suicide prevention can reduce the number of deaths by suicide in our communities.

Campaigns launched by law enforcement, medical professionals, and gun shop owners can also help prevent suicide. For example:

  • Police and other law enforcement agencies can expand existing gun licensing and safety training requirements for new or prospective gun owners to include suicide prevention information.
  • Firearms dealers, gun range owners, or retailers can offer suicide prevention-specific information in sponsored gun safety courses.
  • Physicians and other medical professionals can discuss firearms safety and suicide risk with patients.

The Role of Gun Control Laws

Grass-roots efforts by concerned citizens to raise awareness of firearms safety and suicide prevention can also help make our communities safer. However, it’s important to recognize that individual efforts are most effective when complemented by comprehensive gun control laws that address firearm accessibility and ownership. Implementing stricter gun regulations and background checks can serve as pivotal measures in preventing impulsive acts of self-harm. By combining the power of community-driven initiatives with formal legislation, we create a more comprehensive approach for addressing gun deaths.

How Gun Safety Can Promote Suicide Prevention

The road to preventing firearm suicides through gun safety is not a straight path, but by embracing responsible firearm ownership, education, and community collaboration, we can collectively move towards a safer society. By fostering open discussions, advocating for gun safety policies, and promoting mental health awareness, we can help reduce firearm suicides in the U.S.

—

Over half of the adults in America know someone who has died by suicide.4 Perhaps with greater awareness of the role that firearms safety can play in suicide prevention, our loved ones and patients will have a better chance of surviving a suicide attempt, or even ultimately avoiding suicidal behavior altogether.

 

References:

1 Bostwick, J. M., Pabbati, C., Geske, J. R., & McKean, A. J. (2016). Suicide attempt as a risk factor for completed suicide: even more lethal than we knew. American journal of psychiatry, 173(11), 1094-1100.

2 Igielnik R, Brown A. Key takeaways on Americans’ views of guns and gun ownership. Pew Research Center. June 22, 2017. https://pewrsr.ch/2sZzPjv.

3 Anglemyer A, Horvath T, Rutherford G. The accessibility of firearms and risk for suicide and homicide victimization among household members: A systematic review and meta-analysis. Annals of Internal Medicine. 2014; 160: 101–110.

4  https://www.rasmussenreports.com/public_content/lifestyle/general_lifestyle/september_2017/more_than_half_of_americans_know_someone_who_committed_suicide

For more information

To learn more about how gender and gender identification affects suicidality, read “The Gender Paradox of Suicide: How Suicide Differs Between Men, Women, and Transgender/Gender Diverse Individuals” by Dr. Raymond P. Tucker.

About the Author

Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.

See More Articles by this Author

About Raymond P. Tucker Ph.D.

Raymond P. Tucker Ph.D.
Raymond is an Assistant Professor of Psychology at Louisiana State University (LSU) where he founded the Mitigation of Suicidal Behavior (MOSB) Laboratory in 2017. He also is a Clinical Assistant Professor of Psychiatry at Louisiana State University Health Sciences Center /Our Lady of the Lake Medical Center. He finished his Ph.D. in clinical psychology from Oklahoma State University in 2017 following his clinical internship at VA Puget Sound. Raymond's research broadly focuses on the enhancement of theoretical models of suicide and suicide risk assessment tools, particularly in underserved populations (e.g., Veterans, Transgender and Gender Diverse adults). Raymond began his tenure as a CAMS consultant in 2019 after receiving a state-level grant to implement CAMS across the Our Lady of the Lake Regional Medical Center in Baton Rouge L.A. He is a former board member of the American Association of Suicidology and is a current faculty member at the National Suicidology Training Center.