Suicide Statistics
Every year, 34,000 people will die by suicide in the U.S., and another 500,000 will be seen in the emergency department for treatment of self-inflicted injuries. Ninety Americans take their lives daily, and many experts believe that suicide deaths are widely underreported and that the extent of the problem is much larger. No culture, religion, gender, profession, degree of wealth, success or fame is invulnerable. Every 15 minutes, another life is lost, and the emotional toll on friends and families is overwhelming and eternal.
Suicide is a complex problem that is difficult to understand and hard to predict. Mental suffering leading up to death is private and can be inexpressible. The choice of death is rationalized as the only solution to intolerable psycholog-ical pain.
Those suffering often feel a narrowing of choices, with death seen as the only logical answer to escape the pain. Suicide is rarely spontaneous. Rather, it often results from the effects of it wearing on a person’s ability to cope over a long period of time.
Suicide affects both genders, but men are four times more likely to complete it. A previous history of suicide attempts or a family history of suicide increases the risk, and substance abuse and alcoholism are factors in 30% of such deaths. Mental health disorders, such as schizophrenia, mood disorders and depression, can also increase the risk.
Depression is the leading psychiatric diagnosis associated with people attempting suicide. More than 60% of people who die by suicide suffer from major depression. Treatment for depression is highly effective, but many people never seek help prior to their death.
Although there are no official statistics on attempted suicides, it’s generally estimated that 25 attempts occur for each completed suicide. Most individuals who are suicidal exhibit warning signs, such as social isolation, expression of a plan and access to lethal means or methods. These are important indicators, and suicide ideation or self-reported thoughts of engaging in suicidal behavior can be a precursor to an attempt. Dramatic mood changes, withdrawing from society, uncontrollable anger, recklessness and hopelessness are also signals.
Effects on First Responders
First responders interact with suicidal people on a regular basis. Responding time and again to attempted and completed suicides can be emotionally disturbing and requires dangerous rescues or body recoveries.
Responders may carry intrusive sights, sounds, smells and memories of these violent and often gruesome deaths with them for their whole careers. The grief and sorrow expressed by the surviving family can “splash over” onto emergency personnel, causing critical incident stress.
Most EMS providers have little or no training in suicide crisis intervention. Few standardized training programs or response guidelines address what to do or say to someone attempting suicide or how to support the surviving family of those who have completed suicide.
In 2001, the U.S. Department of Health and Human Services released the National Strategy for Suicide Prevention, Goals and Objectives (NSSP). This document was a milestone in suicide awareness, prevention and education.
Part of the strategy was to implement training for key gatekeepers of society: teachers, clergy, nursing home staff, primary healthcare providers, mental healthcare professionals, police officers and emergency medical personnel.
The thought behind this was that these people have daily, face-to-face contact with large numbers of the community, so they should be trained to identify at-risk suicidal behavior. NSSP recommended suicide awareness training that EMS agencies incorporate into basic educational and training curriculums.
Communications specialists should also be well trained to interact with suicidal callers. All suicidal situations are volatile, and every threat should be taken seriously. The dispatcher should determine the exact location of the caller if unknown. Every effort should be made to build a rapport with them.
The dispatcher should gather as much information as possible and talk specifics, such as whether the caller has the means, method and a plan to take their life. The conversation should focus on the reality and finality of the caller’s potential decision while also bringing positive reinforcement into the discussion.
Responses to threats of and attempted suicides should be handled cautiously by first responders, allowing law enforcement to first stabilize the scene. Introduce yourself and state the reason for your presence while observing the person’s body language and hand position. Take charge of the situation and avoid physical confrontations by not violating the individual’s personal space. Establish a rapport by using good listening skills. Show compassion and understanding, and don’t be judgmental. Always show empathy and respect for the person and their situation, no matter how bad it appears.
Assess lethality by questioning the person directly about a suicide plan, means and method of injury. Look for a suicide letter or indications that the person has made final arrangements. Everyone who threatens suicide should be transported for physical and psychological evaluation.
During transport, evaluate for evidence of injury, previous suicide attempts and signs of depression or substance abuse. Before leaving the scene, responders should encourage the family to remove all lethal means from the home, especially firearms and medication, prior to the person’s hospital discharge.
Suicide Scene Safety
All completed suicides should be considered a crime scene, and immediate access should be restricted from family and pets. The body and surrounding environment shouldn’t be disturbed unless it’s necessary to declare death. Confirm the identity of the deceased, and note the position and manner of death. Medical control should be consulted as local protocol requires.
A detailed patient care report should include time of death given by medical control, environment conditions, body position, location of weapons, types of injuries, presence of a suicide letter and any information that will aid in the investigation.
Efforts to support the surviving family should be a priority. You should realize the effect your words and actions can have on them, and you should ensure that they’re not further traumatized. Introduce yourself, and assign a crew member to assist the family as needed. Validate the family’s personal loss and support their immediate needs. Help survivors mobilize their own support network, such as family, friends and clergy. Prepare survivors for what will occur when law enforcement investigators and the coroner arrive.
You should also be sure to leave a business card, so the family can contact you later if necessary, and a suicide resource brochure with important telephone numbers and websites.
In the Line of Duty
The effect of suicide on society is substantial. It’s estimated that each suicide intimately affects a minimum of six people who may suffer subsequent mental health problems, guilt, pain and personal agony—sometimes those people are the emergency responders.
The effect of emergency work on EMS providers is difficult to measure because most don’t talk about their feelings and generally aren’t the type of people to voluntarily seek help. Stress is expected in a profession where death, disfigurement, long shifts, sleepless nights, poor nutrition, dangerous working conditions and guilt (e.g., “Did I do everything possible to help this patient?”) are constant companions.
It’s no surprise that mental-health issues emerge as a critical factor in performance, retention and quality of life for EMS providers, but consistent occupational mental health statistics within the EMS and fire service remain elusive.
What isn’t obscure is that suicide completion among EMS providers could be more prevalent than previously thought. For example, in 2009, the Chicago Fire Department had an above-average number of suicide attempts and completions among its members. Since December 2009, the Phoenix Fire Department alone has experienced four suicide completions. Are these departments a microcosm of a larger, more widespread problem nationwide?
The number and availability of mental-health programs for fire and EMS providers are limited and restricted by a culture of “machismo,” which implies that it’s a sign of weakness to seek help for mental-health issues. Additionally, the popular mental health model of Critical Incident Stress Management (CISM), developed by Jeffrey Mitchell, PhD, in the 1980s, is considered controversial by a number of researchers.
Resiliency Education
EMS providers and firefighters exposed to traumatic events can develop stress-induced thoughts, dreams and behaviors, which may lead to post traumatic stress disorder (PTSD). CISM, once thought to minimize these problems has been shown to have controversial results.
A new approach, substantiated by research data, has been having a positive effect in behavioral health intervention for people experiencing the effects of traumatic situations. This new methodology focuses on a holistic, preventive process capable of being taught in a non-clinical academic setting.
The concept, termed “resiliency,” is defined as “the ability to bounce back from adverse events and cope with stressors in a healthy manner.” Research literature clearly substantiates that resilient people are far less likely to experience the effects of PTSD. In fact, not only are resilient people more capable of dealing with stress, but they also thrive and grow as a result of stressful experiences.
A resiliency curriculum, known as the Supportive Education for Returning Veterans (SERV) has been developed by Michael Marks, MD, lead psychiatrist for the outpatient PTSD clinic at the Veteran’s Administration Hospital in Tucson, Ariz., and Phil Callahan, MD, NREMT-P, a professor at the University of Arizona. The SERV curriculum has received national recognition by the Veteran’s Administration as an evidence-based program that works, producing profound results within the military veteran population.
On completion of the SERV program, veterans were less likely to develop PTSD, demonstrated improved dietary and physical fitness habits, strengthened their social support system and were more likely to remain enrolled in higher education. In fact, students successfully completing SERV resiliency education as a prerequisite to enrollment in college-level courses were 15 times more likely to remain enrolled in college compared with students who didn’t enroll in a resiliency training program.
The resiliency curriculum consists of teaching responders to identify, measure and subsequently improve their abilities to cope with home and work stress. Initially, each responder establishes a baseline of their current ability to cope with personal and professional stress. Next, the responder is taught how to improve their physiological and psychological resiliency skills.
Physiological resiliency includes the following:
- Proper nutrition, including establishing a nutritional baseline and the importance of a balanced diet based on an individual’s basal metabolic rate;
- An emphasis on the importance of physical exercise using the frequency, intensity, time spent and type of exercise (FITT principle); and
- Good sleep hygiene, with an emphasis on how to use cognitive behavioral approaches to eliminate or minimize nightmares.
Psychological resiliency teaches responders to do the following:
- Relax, using proper breathing techniques and progressive muscle relaxation;
- Change self-defeating thought patterns into positive, realistic thinking;
- Learn empathetic communication and the power of perspective; and
Know the importance of establishing—and maintaining—a strong social support system.
A significant difference between CISM and resiliency education focuses on when responders are exposed to each. The CISM process takes place after the fact, with the bad event being the trigger. Resiliency education, on the other hand, occurs at the beginning of a provider’s career, an inoculation if you will, to the horrific events all responders eventually are exposed to. Regular reinforcement of resiliency concepts then occurs after the initial training, such as the beginning of a physical fitness program or the daily practice of relaxation techniques.
Both Marks and Callahan believe the results seen thus far with veterans can transfer into the world of EMS and fire, assisting providers to minimize the effects of stress and its cumulative effects.
Currently, an advisory group consisting of leaders within the fire service, EMS and academia has been formed to determine if resiliency education can produce measurable improvements in the reduction of stress, PTSD and rates of suicides within the fire/EMS profession. Pilot testing of the curriculum for the EMS and fire service will occur later this year in at least four sites nationwide.
The resulting data will be compared to those of military veterans. If favorable, resiliency education will be expanded to organizations looking for a proven methodology to assist emergency personnel experiencing issues related to mental health.
Caring for Our Own
Suicide is treatable and preventable. As gatekeepers of society, it’s part of our fundamental mission to save these lives, especially when some of them are our own.
The first step starts with collecting accurate data on work-related stress, suicide attempts and completions to help identify trends within our industry. Good data will be difficult to acquire until we reduce the stigma surrounding help-seeking behavior and encourage our fellow responders to come forward and get the help they may need.
Development of a comprehensive suicide prevention strategy, improving access to mental-health counseling and developing a responder support network is paramount to saving our brothers and sisters.
Teamwork is the foundation of EMS. What affects one individual will likely have some influence on others, and ultimately it will affect the team’s performance. Identifying mental-health risk factors and promoting individual health and well-being through education is critical to the success and evolution of our profession.
Resources
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