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thank you for joining us today for this discussion of suicide we have with us today dr. Kelly Posner who’s with the Center for suicide prevention and we also have Suzanne Laughlin our very own firestorm co-founder executive vice president chief administrative officer all the participants are on mute today as always so if you have questions and I suspect that you will during this discussion please use the question function that’s built into the program and we’ll we’ll try to get to them either at the end or will answer them individually following the presentation I like to give a special welcome today to our friends who woken up early to join us in Alaska and Hawaii we have people from Calgary and up in Calgary we wish you well hopefully your flooding is doing okay and once again we have round-the-world contacts in the UK and Australia and Ghana like to now turn it over to Susie Laughlin who will introduce give us our legal disclaimer and introduce participants thank you Susie thanks everybody for joining they were really excited about introducing you to one of firestorms expert council members dr. Kelly Posner and I think Kelly’s got a salade she’s going to switch to and am it for me and that first you know we we always have our legal disclaimer by the way yes the twitter hashtag for this session you can see it here has to have FS crisis or you can follow us on Facebook next slide and about firestorm as you guys know a lot of you have attended many of our webinars and presentations and our goal really is to help you position your firm to become prepared before disaster strikes before you have a crisis and to the extent there’s any critical decision support or assistance firestorm can provide we stand ready to do so next one so I am Susie Laughlin as bill said and today more importantly I would like to introduce dr. Kelly Posner as bill said she is the principal investigator of the Center for suicide risk assessment at Columbia University and which is also a New York state psychiatric institute and sorry and when in my office didn’t turn off something and so and dr. Kelly Posner is a expert in the area of suicide and depression the work that she has done actually was commissioned by the FDA she was commissioned to lead a study to develop improved methods of suicide risk assessment and you’re going to learn about that today the work is part of a national and international public health initiative that goes across healthcare surveillance and research and ranges from primary schools Corrections health care systems Veterans Affairs to refers responders and clergy of note numerous states and branches of the military have moves towards system-wide implementation names one of New York’s magazines both influential people dr. Posner continues to work with the FDA the CDC the NIH US military the US Department of Education and many other agencies on suicide assessments and surveillance I personally had the privilege of working with dr. Posner in the implementation of the CFS RS the scale which you’re going to learn a lot about today and it’s the project also involves training staff at an independent school the project was terrific I am confident that it has added value to the workplace violence prevention program of that institution and I look forward to you all learning about it today with the goal that that I believe you will you too will see the value and understand why it is an integral part of any workplace violence prevention program next slide Kelly so we as always we have to just state our disclaimer that the work provided by firestorm has to be read in conjunction with all guidance given by national regional and local authorities as well as your company personal counsel and the information should not be interpreted as legal advice or legal opinion okay and with that I’m going to turn it over to dr. Posner and let her get started okay thanks thanks Susie and I’m really excited to to be here with everybody so you know why why is this an important issue the fact is suicide is one of our world’s greatest public health crises it’s a leading cause of death across the world across ages it’s now become the number one cause of injury mortality in the in the United States surpassing car accidents every 15 minutes and in in this country somebody dies by suicide doctor and and many other places not just this country and the head of our National Institute of Mental Health

calls it the under-recognized public health crisis of suicide now the good news is it’s our one most preventable cause of death we actually can probably have a world where we don’t have to have this cause of death anymore in youth under 25 it used to be that every one hour every two hour in 11 minutes somebody under 25 would die by suicide it’s now 1 hour and 48 minutes it keeps it keeps narrowing and and under 25 again in 2010 as soon as I became the second leading cause of death 10 to 24 surpassing homicide for the first time in the last decade so you know just just some of these statistics are really startling so in 1980 to 1996 suicide doubled for African American males that were adolescents for African American girls hanging increased by two hundred and thirty eight percent in ten to fourteen year olds it increased 50 percent between 81 and 2005 so started out as a crisis and just just keeps keeps growing um and we’re gonna talk about this this is just a cross across the age span so that’s that that’s death by suicide but what about the precursors that we’re talking about you know suicide attempts suicide thinking did you know that when the CDC does Studies of your average high schooler across this nation about 10 percent say they’ve attempted suicide in the past year these are non depressed kids and we know these are growth under estimates before we’ve had better more comprehensive monitoring so that what that means is within any classroom it’s likely that you know three students one boy and two girls will have attempted suicide in the you’re at a minimum and it’s very much related to the school violence and of course workplace violence that we have all been very much you know focused on you know of almost 80% of shooters have well-documented suicidal ideation and and behavior and very often it’s actually a suicide in disguise they actually talk about it as their motive so you know we were taught thinking this way back at Columbine you know screen screen screen it not only will help address the terrible crisis of suicide it will also help prevent some of these tragic tragic episodes military you know we read about this all the time it’s surpassed combat deaths suicide in the National Guard literally doubled in 2010 in the US Army every single day there’s been a suicide in the VA they’re about 21 suicides per day a thousand attempts per month and many connected to systems of care which is a scene we’re gonna we’re gonna be talking about what what’s been striking to me is how it’s a crisis everywhere we look did you know that typically it’s the number one cause of death among police themselves right alongside car accidents so in 2012 almost as many police died as suicide as were killed in the line of duty rates right up there with the US Army so we work with police and first responders all the time but not only as a first responder also to screen and identify among themselves so for example you know in many places police want to be trained so they can recognize it in their partners and and and help avoid suicides corrections number one cause of death you know in in prisons and jails it’s about three times the rate of the general population and nearly 60 percent of inmates who die by suicide it have no clear have no psychiatric illness and no clear warning signs and in a rural areas it becomes our big itch challenged these are the highest rates these are large populations of course valid across great distances with less consistent access to any kind of care with the closest person maybe being several hours away high rates of poverty and gun ownership and with all this this kind of bad news we actually I think have a hopeful coming it has if you take suicide worldwide they’ve outnumbered death from war natural disaster and murder combined and you know the the World Health Organization estimates in a few years depression will be the second most debilitating disease in the world second and only to heart disease and again it this is not just because of the tragic loss of life and human suffering the the economic cost is is great and throughout the developed world we know that of harm now is the leading cause of

death 54:49 surpassing cancers heart disease and high income countries it trails only breast cancer as the killer of women in their early forties and has become the leading killer of women in their in their crisis has a very significant public health burden attached to it so I’m rich billion dollars a year in medical and work loss damages across the world in the US this was many years ago five billion a year I think it’s something like twelve now but the next statistic just startles me every time I think about it if you take a large corporation of about a hundred thousand employees every seven days every seven days an employee or a family member will die by suicide and every single day there will be three suicide attempts resulting in you know significant medical injury and disability which of course directly impacts health care costs particularly for self-insured company is so the other thing that’s related to this is that depression is the number one cause of work-related absence in in in business in general so you know when you’re screaming in businesses you’re not only taking care of your employees you’re also helping your bottom dollar very very dramatically you know in some states that we work with they were more suicides in the employee assistance program than in the impatience yeah at hospitals and you can see you know according to the to the Center for Disease Control you know we would say 1.2 million dollars for every every suicide we prevent you know also know that 90% of people who die by streeted mental illness 60% of which depression so I actually had the great fortune to give a speech to the leaders of the European Union on how to fight depression and suicide and I said you can put up barriers on bridges and do all these other things but if you want to maximize impact it’s about treatment and identification unfortunately most people who even don’t get it 50 to 75 percent of those in prevention absolutely depends upon approps of medicine and even if psychiatry has been challenged by a lack of clarity as to what to call things and corresponding to that we’ve had no well defined terminology so what ends up happening is the same exact occurrence is called 16 different things so you have no precision of communication and this clearly is going to have negative implication on how we manage if we can’t properly identify we certainly can’t understand manage or treat no matter where we’re trying to do so now you guys know all the controversies with whether medications cause people to be suicidal as was mentioned I was the person that led the team that was commissioned by the FDA to make sense of that so this problem that I’m describing has had profound impact on our safety regulatory questions and actually they asked for this scale now across most areas of Medicine but it but it of course limits our confidence also in epidemiological statistics right because if everybody’s defining things differently how can we compare across counties cities states countries now the good news is the CDC has adopted this now so we’re we’re making progress but this problem has it has had its tentacles in lots of different places this is a quote from the Institute of Medicine highlighting this very problem is one of our major impediments to suicide prevention efforts in general we also know that we’re gonna see suicidal issues across every medical disorder and well beyond into the general population as I indicated if you take any medical illness 25 percent will have a suicidal thought almost 9 percent will have made an attempt this is one study in cancer patients almost 18% independent of depression so no matter where we’re looking this is an issue and we know that we need to get it right and that’s actually how we we get through this this

scale you know people assume because the FDA asks for it that we created it for them but it actually happened many years before that we were running the first national study of treatment of suicide attempters in adolescents even though it’s the second or leading third leading cause of death in that age group there had never been a large intervention trial to look at how to help them so in this important national study we had every scale for suicide and depression and the experts said there’s nothing to do this there’s nothing to put ideation and behavior together or look at severity so we created it to fill this gaping hole in the field that had never been filled before it’s evidence-based and supported and it’s very low burden when you do what I call the whole thing because there’s a screening version too it takes just a few minutes and what we think it does is get you the most critical information you’d want to track in any setting you know we got together as authors and said what’s the minimal amount of information we’d want to track whether it’s an office a medical EDD and army base or a school and I would say that this is my favorite slide because it’s very hopeful this this shows where it’s being used across the world or requested to be used so you know health canada japanese national institute tribal nations fire departments Police Department’s primary care prisons homeless clergy Crisis Negotiation you basically name it and they’ve started to come to us and that and it started to come to us in a very bottom-up way for a very long time and we work with many states and countries and and you know one of the first top-down states made this very important point about the linking of systems when you’re doing the same thing workplace inpatient bridge outpatient community you’re going too quick and care to the people who need it you know Tennessee said it’s so important that the school nurse is going to be doing the same thing as the EMT as as the hospital in New York New York is one of those those states and we just got off the phone with with New York and in terms of their their act programs which are these you know outpatient treatment teams they were talking about what a huge difference it’s made in terms of the communication and the linking of systems and making care and and suicide prevention so much more more efficient and we know we work with the US Department of Education we had the great fortune to to consult with them a few times and it can be used across across every type of education from preschool through higher education and all types of gatekeepers as you’re gonna hear and this is this is what has happened in the military which is very exciting you know I you’ll see we’re up to about 11 States and I used to say New York’s going top-down but what about New Jersey and now we’re at about 11 States and it really relies on people finding out about it and it was the same thing with the military three National Guard’s how do we get the rest to know about it so that bottom-up really reflects its feasibility and a great need but as you all know probably top-down is where you get the most profound change so that’s why this is particularly exciting so the US Army is building it into their behavioral health data platform the National Guard the Air Force the Navy Marines total force rollout and this this is important this is how the Marines are doing it and this just reflects the scope of people and gatekeepers that can do it in any workplace any organization and it’s a great model so the Marines they’re total force roll-out they have gone are going to all 16 installations including Okinawa and training all support workers family advocacy victims advocates attorneys chaplain so every time an attorney meets with a marine they do the scale because it’s a vulnerable time and in fact legal issues have now surpassed everything else in terms of the number one precipitant for marine suicide so again this really illustrates the kind of scope of impact and youth and this is you know I’m gonna talk a lot about saving money and redirecting resources while uniquely identifying and this is what we’re hearing no matter where you go so for example this is a quote from somebody in a military setting valuable tool to ensure that necessary steps were taken to safeguard an individual or return them back home with support it can help avoid unnecessary hospitalization or save a life and those are the kind of counterparts that is that it’s the theme that I’m going to be going to be talking about and what this scale has really shown for the first

time is the ability according to many people the ability to predict and this is an ni MH quote saying you know to be able to determine clinically meaningful points at which a person may be at risk if something that is so important and that that other other methods have not been able to do and as they said New York State is one of those top-down states and why is it making a difference they feel that it separates the wheat from the shaft it focuses attention where it needs to be so in terms of how it can be helpful to your state to your system to your workplace this is kind of some of the details so you can see suicide screening told to be rolled out in Rhode Island this will be transformative for Rhode Island because it will improve care and allow us to focus resources where they most help people easy way to save lives by tying it to our electronic health records it becomes that much more streamlined into everyday care that goes back to the linking of systems again and this is Georgia this was one of the first big top-down states and what was so interesting is so you see this plan from crisis lines to homeless but what was amazing with Georgia is that the crisis lines actually came to us first and people were literally going up to Georgia leadership and saying you are going to require this aren’t you when when do you have something where people are asking for it to be mandated and again I just think that reflects the great need and the usefulness somebody else said oh I get it this is more than just filling out two other pieces of paper this is actually going to help people and this is what Georgia is doing and again this is a great model for any kind of system school or workplace provider by provider all services between services and in systems of care you can assessment intervention quality management and it’s not just the SSRS by the way they also do something called safety planning which is a beef crisis contact first time intervention and that’s the same thing that New York is doing so this kind of systems approach you know New York State did an assessment of all of their recent suicides and every one looked exactly the same no good risk assessment no safety plan and no warm handoff and that’s what these systems approaches are trying to address the leaf state is kind of different in New Jersey the original plan was all service all schools and all services that touch youth and young adults juvenile justice etcetera but the adult site is doing it as well Tennessee its Department of Mental Health it’s the crisis assessment tool for Tennessee all hospitals all schools and the new states are kind of can do it in all these ways Rhode Island has a statewide report for all first responders but again there’s no reason why all the new states can’t just do it in all of these different ways or systems so in Maine it’s part of the it will be part of the statewide health improvement plan and primary care and this is a county in Michigan and when they say top down this is what they mean bus drivers cafeteria workers Road Patrol and this is really important because when you have whole geographical locations or settings where there are no holes that will go a tremendous way towards prevention and when I said at the beginning that rural areas are our worst our greatest challenge but we have a hopeful response so this kind of blanket coverage becomes really critical so this is a quote that I think some some of it up very nicely ultimately it serves as an effective mobile crisis tool which gets to the right people at the right time and right place and helps to save lives and save public dollars and you know this was the Tennessee in which was you know I thought hopeful hope it last to break suicide silence but what I found so interesting was reading the blog on the newspapers website a leading cause of death I have my doubts maybe in some third-world oppressed countries are among some teenagers but certainly not in the u.s hope it lasts to break suicide silence I was not aware there was any and this was from a retired mental health editor of all people so I always say that even if we weren’t identifying better which we are I believe the fact that we’re having this conversation is of critical importance so that’s a lot about what its impact is and meaning and we’ll of course talk more about that but you know what is it it’s simply a 1 to 5 rating for suicidal thoughts of increasing severity it’s always as little as these two screen questions for suicidal thoughts so somebody gets asked have you wished you were dead or wished you could go to sleep and not wake up or have you actually had any thoughts of killing yourself the behavior section fixes the problems that we’ve seen in the past most most most importantly it covers the full range of behaviors for the first time you know it used to be that

traditionally we would just ask about a suicide attempt and then you miss the person that bought the gun yesterday or put the noose around their neck and change their mind or wrote the suicide notes things we absolutely cannot afford to miss and it’s the first thing with definitions you remember that comment from IOM about the importance of definitions and standardized questions for each category to guide the easiest and most improved identification so the way it happens is this is that one through five of increasing severity so only and only if really really only if if somebody says yes to that second question I just said it told you have you actually had thoughts of killing yourself then they go on to get asked have you been thinking about how you might do this have you had these thoughts and had some intention of acting on them or have you started to work out or worked out the details of how to kill yourself you can’t have a method intent or plan an intent if you don’t have a thought of killing yourself those are subcategories of it so the questions that we need to get at you know that we need four to determine if somebody’s at high risk only get asked you know when when when it they should be asked now every single thing on this scale is there because it it needs to be assessed if you just take one behavior we are talking about here what we call a preparatory behavior that’s buying a gun collecting pills writing a will or suicide note just that one behavior somebody’s eight to ten times more likely to end their life to die by suicide now the good news is these worrisome answers so we’re able to get at high risk people for the first time people say in a much more precise way and the good news is these high-risk people these worrisome answers are very rare this is a phone system delivery that I’m going to tell you about in a few minutes so the way it works is somebody picks up the phone and they get asked the questions electronically with a human voice and they press the buttons for the answers and it’s connected to two call centers and there’s immediate transfer of information to whomever needs it and if there’s a worrisome answer the bells and whistles don’t go off until there’s acknowledgement of receipt so look at with 50,000 administration’s we’re now up to a hundred thousand with this with this methodology with 50,000 less than 1% were worried some answers so they’re very rare but within that 1% only 13% of those answers were actual suicide attempts and all the rest almost 500 of them were these other behaviors that we were never asking about before so this really illustrates to me why we’re moving towards better prevention we also have scientific support now showing that each one of these behaviors in the full range is equally predictive to a suicide attempt in terms of showing us who’s gonna who’s gonna go on to make a short-term suicide attempt and this is the same kind of information out of a VA system in Detroit so very high risk population right vets they did a pilot with almost 3,000 vets who were going to see their psychiatrist the more high risk people only 14 out of 3,000 screened positive and only four or five of them needed acute care so we’re always talking about how this is reducing unnecessary things and really getting us to these much rarer high-risk people and this is another great example of how it’s beneficial to a system in terms of uniquely identifying and kind of reducing a lot of the noise so related to that people assume that when you start to ask these questions across primary care across a please across the school you’re gonna increase burden understandably but actually the data points in in the opposite direction so there’s there’s one particular scale that gets used all the time across the world which has one question for four for suicidal issues have you had thoughts that you’d be better off dead or of hurting yourself in some way this was developed in primary care and this is data out of Cleveland Clinic so Cleveland Clinic went policy with the CSO service a long time ago and look at look at these numbers they got almost twenty four percent positive screens according to that one question that people standardly used in in primary care versus 6.2 percent on the CSS RS with a few additional questions Wow while they uniquely identified cases that would have been missed so it’s a great example of the win-win nature of doing it dramatic reduction of false positives while uniquely identifying and similarly

these are obesity patients when they just relied on triggered responses you know not systematic asking the questions they got 452 occurrences when they moved to systematically using the CSS or s across everybody they got 12 a dramatic example of reduced burden now I’ve alluded to this a few times but I would say that one of the greatest contributions of this scale is its impact on care delivery and service utilization and the way that it does that is it has operationalized criteria for next steps whatever those next steps are specific parameters for triggering referral to a mental health professional for putting on one to one for you know whatever it may be and what that’s doing is leading to a tremendous amount of decrease of unnecessary interventions because in the past people didn’t know what to manage so they would hear any answer and they would walk to an ER or send home from a workplace or put on one to one or hospitalized and this is an example of how it’s triaging and streamlining so New York State as I said is one of those top-down states this is the electronic medical record from New York State and it’s not just the CSS RS that’s built into it it’s those high risk answers so if you get one of those rare high risk answers that we were talking about the big red suicide alert arrows go off and that travels with the person as they go through their their history this is another example this is the largest provider of behavioral healthcare in the United States something called center stones when you get these worrisome answers is when they have their highest level of alert and monitoring this is a hospital system when you get these answers that’s when you get the one-on-one psychiatric consult and then they have a version where the triage points for the nurse or the school are right there on the forum to know what the next steps are and this is an army base always the same formula just dependent on what the system is so if they get the worst answer which we call four or five emergent action necessary behavioral health consultation and then it decreases as you decrease in the severity of the answer and this is amended for whatever system it is a primary care office again a you know a workplace or a school and this is a it’s a research supported threshold and what that means is these particular high-risk answers have been shown to really significantly more significantly predict who was going to go on to make a suicide attempt and this this is really compelling you know in the in this when that phone system they have 35,000 non suicidal depressed adults when they have these certain ideation answers remember when we went through the questions and it said do you have intent to act or do you have a plan an intent those are those high-risk answers what we call a four or five if they had one of those they were significantly more likely to go on to make an attempt if they had that and the behavior they were nine times more likely to make an attempt so greet greet very meaningful prediction and then and the ability to predict again ultimately helps us do all these things those thresholds help us reduce a lot of unnecessary burden and unnecessary work while uniquely identifying high-risk people so this is one of the most important slides that I can show you you know I said it it’s leading to a lot of reduction of unnecessary intervention so this is the first system large hospital system that used it and you see those bars on the right those are their suicide watch or their one two ones so they’re one to ones decline steadily over the next quarters without anything tragic happening so you know people often say saving lives and saving money but I always add that this is not just about saving money this is also about getting care to the people who need it you know one one system said we had 20 suicide watches indicated but we didn’t have 20 people to to watch them so before we have this scale it was like playing it was like playing Russian roulette if everybody’s on high alert then then nobody is and this is a year more follow up on this system so you see the red line is where their suicide watches or their one-to-ones were prior to this CSS dress so they always stayed below that but one month the economy got much worse unemployment went up and you see your first spike in identification a year later same thing so what that tells us

we think is that the scale is doing what it needs to be doing picking up people when they when they need to be picked up which is what we need to do everywhere we’re looking and this is a quote from that hospital system it allowed us to identify those at risk and better direct limited resources in terms of psychiatric consultation services and patient monitoring and has also given us the unexpected benefit of identification of mental illness in the general hospital population which allows us to better serve our patience and our community and it doesn’t matter again where we’re looking Corrections California has one of the largest prisons and they said that they spent twenty million dollars in one year in these suicides on these suicide watches that they think will be halved and I have countless countless systems that come to us with the same the same dilemma and it’s reached a policy level so Rhode Island as I alluded to had a Senate Commission hearing on ER overuse and the state senators talked about the scale as the means to reducing er over youth because the first responders use it so this is Rhode Island’s statewide report statewide coordination and implementation this recommendation would be critical in assisting those in the field with an additional tools for everyday use and it’s a quote from the from the Rhode Island police officer about how meaningful it is and then schools you know there’s a tremendous amount of controversy across this nation about ER overuse by schools New York City did a four Hospital study and they found that 61 to 97 percent of their referrals did not require hospitalization this is a quote from the Department of Education the great majority of kids and teens referred by schools for psyche are eval are not hospitalized and do not require the level of containment cost and care entailed in the ER eval and evaluation in hospital based psyche ours is costly traumatic to kids and families and less effective probably and getting them where they need to go so cranes wrote their second article on the CSS RS and they talked about our pilot project with 38 middle schools training the nurses this was presented to the City Council they found a hundred kids that would have been missed while reducing the noise and yet you know in in Tennessee two weeks after training the school system for that state I got up my first email you know probably already saved a life while the other stuff is reduced so that the kid who sat in the principal’s office for nine hours waiting for the EMT to get there that never needed to be sitting there in the first place and again we all want to save lives but having secondary gain helps us do just that whether it’s saving money or protecting against liability so cranes in their first article they consulted with a malpractice attorney who said that asking these questions also provides legal protection and we hear from countless countless risk managers and insurance companies that that use it for that for that want that being one of the reasons and remember I said the CDC has adopted it so you can see a link to the scale in the new CDC document which is really great you know linking of systems and common language is terrific but this is also in the CDC document the unacceptable terms the terms that shouldn’t be used anymore and what this is doing us what this is doing we think it is moving us towards a more meaningful common language it can be used across the age span all special populations it’s been given millions of times across the world across ages with very good feasibility very good acceptance in practice and patient satisfaction and you don’t need to be a mental health professional to administer it so eight hundred and twelve nurses were trained at one system and they got 99% reliability even independent of education because there were a whole bunch of high school degrees in there so that means all types of gatekeepers can do it as I as I again alluded to before and you know I’d like to tell this story about the gatekeepers because I think it’s I think it’s really illustrative so I went to train a Hindu temple in Schenectady New York very disadvantaged population very high suicide rate I trained the priests and the grandmothers and the grandfathers and the high school kids and two weeks later there was an article in the newspaper this grandmother who was at the training her grandson walked in he didn’t look very good she asked the questions and it said probably saved his life the closer we can get to everybody everywhere all the time and this can be done in a self-report way which you’ll see you know the the more the closer we’re gonna get to doing away with all that this costs us in addition to in addition to lives

and it’s very important it’s as important as having the right questions having innovative delivery we need to be able to have feasible delivery so examples of this are laminated cards metal keychains apps on phones portable printers and EMT vehicles again because we need to have efficient delivery of the right questions and this is another one of those this is that phone system that I was talking about and I I do think this is an optimal a critical piece of an optimal prevention plan so again somebody picks up the phone they get asked the questions electronically with a human voice it’s a self-report they press the buttons for the answers there’s immediate transfer of information to whomever needs it and if there’s a worrisome answers they don’t stop until somebody acknowledges receipt now think about think about this this this is like pilots and surgeons with their checklist you never get a question missed and that increases that else’ ultimately save lives saves lives and you know most of you many of you probably know that when somebody’s discharged from a hospital it’s a time of great risk we haven’t really known how to monitor them very well to imagine somebody can actually call in from their bed one week post-discharge two week post discharge and we have a way to monitor that we’ve never been able to do before in New Jersey they talk about the summer as being increased time of increased risk for kids and you know a kid you know drinking taking drugs they don’t get to see them so imagine somebody can call in a kid can call in from their cell phone gives us a way to monitor you know we’re in a workplace somebody could sit at their desk you know and do it on the computer or pick up the phone and do it they can call in from at home when they’re absent when they’re not absent I mean this is a tremendous tremendously indicated and useful approach particularly in these kind of settings like like workplaces and this is another example of innovative delivery so this is a poster that a national guard did have you or someone you know and it gives the questions and that can be in a school in a primary care office again the more we kind of paper and plaster in many different ways the better off you know we’re gonna and and one of my final points is that you know it also is tailored for population specific questions so this is a pediatric version which adds a few additional ways to ask the questions for very young kids you know it says have you thought about how to make yourself not alive anymore you know six year olds don’t typically write write wills this was a suicide cluster in in Schenectady in New York again and it was a different demographic it was gang a gang-related precipitant and it was you know these girls were trying to get out of of gangs and they couldn’t so instead they were they were they were taking their labs and I said of different demographic it was african-american females and it was this gang-related precipitous so in this case we trained the police in the schools and the state wanted to know if it was you know related the subsequent issues we were assessing were related to that so we found a way to do that and this is what we do in the military they do the same ideation and behavior that a workplace would do but they had a few additional questions so for example financial troubles you see it says sometimes the person can feel that others close to them eg family would be better off financially if the person were no longer alive have you experienced this because people are taking their lives because of the finance in the Army for example because of the financial meaning it has there are prison examples you know when somebody misses a visit or a lawyer visit it’s a time of risk because this can be you know things can be added for any particular setting or population and you know III I want to say this as much as I can everywhere you know almost 50 percent of suicides see their primary care doctor the month before they die we should be asking these questions the way we monitor for blood pressure and we know that it will work and this is a you know an action Alliant National Action Alliance saying that we must do screening it’s one of the things we need to do to start to start preventing or to continue trying to increase prevention and we know that it works you know an author on the scale dr. Mann has a seminal article in JAMA showing that screening results in lowers suicide rates in adults this is american foundation of suicide prevention this college project screen project one suicide in four years post screening versus three suicides in four years pre-screening but I would bet my bottom dollar we’d see it everywhere we looked and you know college presidents are so worried understandably about the liability of suicide well a history of a suicide attempt is the number one risk factor ask a few questions when they come in for their health screens it will go a tremendous way towards towards prevention and we also know that monitoring is critical we need to be doing this all the time at every visit like like you know like we do blood

pressure god forbid the time the time you didn’t ask is the time you needed to ask and when you think about it it’s just a few questions so it ultimately is a very clear equation and you know I’ve alluded to this too that that ultimately sorry my ultimately it reduces burden people are always afraid that when you look under the can you when you look under the rock when you look under the rock that it’s gonna put you out of business and again it’s the opposite so you can see this of those thirty five thousand always the most most most prevalent is the least severe that you don’t have to do anything about and those those high risk answers are incredibly or you know are much rarer and then finally my final my really my final point is that it’s actually a really good thing that we’re all beginning to do one thing many thought leaders talk about this the science and the public health demand uniformity when you don’t do one thing you get in precision you get noise and we cannot afford this so on the bottom this is the FDA guidance that says you know they asked for the CSS RS and they say you know if you do some other things it will cause variability which is particularly problematic with suicidal issues and we just cannot cannot afford that so this is my email and I will we welcome any questions this is our website you can go and get trained on the website we work with systems all the time you know to help systems and states and other things so thank you thank you for your attention and Susie are you gonna yeah thanks Kellyanne I know I think bill does have a couple of questions you know before I turn it over to Bill to just ask a couple um you know once we Kelly that I wanted to bring up that that you know we often encounter when we talk about the topic of suicide is kind of a either a lack of understanding or or a worry that people have about bringing up the topic for fear that it might actually push someone over the edge who might not be there yet oh I talk glad you brought that up yeah so maybe you could just elaborate on that a little bit yeah no I would love to there is a lot of clinical or misunderstanding across the world that when you ask somebody to questions it’s going to cause them to be suicidal but actually the the the science points in the opposite direction so another author on the CSS or US has a seminal article in JAMA as well showing that when you ask these questions it does not cause distress for for suicidality when you ask these types of questions and then Kelly with that what’s your view from a baseline perspective in light of the staggering statistic you started with where we see that really it’s you know our failure to acknowledge the incredible risk that in the adolescent or it let’s use the school-age population do you recommend that a baseline be performed of all students or are any states doing that what is the current thinking on that point yeah the current thinking and what we very much believe is you cannot rely on what we call trigger you know the people the kids that you think you need to worry about the people you think you need to worry about because there are lots of people that are suffering in silence and the only way that you’re gonna find them is if you do this across everybody so you know that that that’s what we know needs to be done so when we’re talking about screening for example we’re talking about just asking everybody because people by the way who haven’t been suicidal or happens in depressed you know might become that way and it’s by asking the questions that we’re going to find out and you know I’ve been involved in organizations that did a lot of work after 9/11 and they what they realized after 9/11 by doing the kind of assessment for all the unmet mental health needs that existed that have existed always and again it’s only by systematically asking these questions that we’re gonna that we’re going to find these people who are suffering in silence yes Kelly first of all could you back up to the slide that shows your contact information I think it’s two slides back there yeah thank you here’s a person wants to know how do we get copies of the suicidal ideations is that on the website or how do we get that show you all the languages is available and including us Spanish it’ll have the different screening version and the scale so absolutely also on the website you can click on the link and get

trained you can get trained on the screening on a long you know there there are many many resources there and we are are continually a continual resource resource for anybody who needs anything but absolutely it’s on the website good how long does it take to Train gatekeepers in the process yep so we actually have a training now that is about seven minutes many gatekeepers have been trained using the regular you know the regular training which is 45 to an hour typically so it can be kind of whatever works okay how frequently should the screening take place this you know every year or every six months or um we very much believe that this would be done what we call every visit you know whatever that means so if you’re in a setting where you’re seeing people and it’s then you’re gonna do it like you do mental status or blood pressure in a primary care office every time they come in in a nurse’s office in this school every time they come in because again god forbid this time you didn’t ask it the time you needed to ask so in the general population as much as we can you know with with within reason you know an example that I won’t forget is the VA system in Detroit they hadn’t started asking the questions yet and I did a training their most recent suicides a 67 year old guy they found that upon his death that he was putting clothes and bags and labeling them for different charities and stockpiling food for his pet six months of preparations and it was very clear to the system that if they had been asking the questions like you monitor for blood pressure they would have had a better chance of of saving this guy’s life hmm and again when you think about the screening question which really is is is typically just a few questions it it’s so brief that it’s it more inset and remember I showed you when you don’t ask it systematically the 452 versus 12 so that kind of win-win reduction of burden by asking these questions you know helps us get that done okay how can the program be implemented or used by business or industry emergency responders yes well the same way we work with emergency responders all the time and the way it is is those people are trained to do it they have they have the questions they have the forms remember I was at talking about you know EMT printers and EMT vehicles or laminated cards or metal keychains are just a piece of paper on a clipboard or even the self-report version that somebody can be handed so emergency response people will do it the same way any other kind of gatekeeper is and it’s one of the most critical places I think and here’s a person kind of reiterating how do we get a list of the questions that on the website as well yes within the scale you can see the question and and if something’s not clear please email us and we’ll send it to you what about international usage are there any restrictions to use this in other nations the country agrees I mean I could go on and on and we work very closely with Canada in many different ways so it’s the same story though you know the hospitals and France are using it or the this for Greece uses it but the country next-door doesn’t know about it yet so if we actually really welcome and so appreciate any thoughts anybody has in terms of that dissemination I mean as I said we’re moving towards you know about eleven states but what about the other 39 that don’t know about it yet you know so I do that math right okay um and we depend on people you know to help us with that so you know any countries any states any systems that you could connect us with our appreciate it but yes tremendous amount of many years of international youth with excellent feasibility I don’t know if I mentioned this but it is available in 107 languages and that’s because it’s been used so much across the world it

seems such a simple thing to use I would think everyone would want to use it yes you know what and that’s what most people that’s what most people say and it’s the biggest challenge as I said the reason why we’re at 11 and not 50 yet or it’s these countries but not those it’s because people don’t know about it Kelly can I jump in and ask one more question than in the context of schools you know one of the statistics I always found alarming was that 80% of parents who children committed suicide that died by suicide did claim they were not aware that their children were depressed or had suicidal thoughts so to what extent is our parents being trained and do you recommend that oh I absolutely do so remember that as the more information the more training everybody everywhere all the time the better up we’re gonna be remember that example I gave in that that that Hindu temple and the grandmother right so without question so I think really you know one of the takeaways and I we’re gonna try to give everyone back their afternoon we want to thank you for joining us I know that for those of you who tuned in to our webinars weekly you’ll feel here firestorm methodology repeated predict plan and perform so today you heard quite a bit about the ability to predict the risk of suicide and we clearly understand based on all the specifics that doctor Kozma shared with us that that death by suicide or suicidal attempts are clearly a vulnerability at every workplace and every school must contend with in order to address the vulnerabilities we need plan and incorporating tools like the CSS RS are critical to the plan to prevent and then intervene with respect to any student or employee who may need assistance so we urge you to look further into the the information that’s been shared with you today to incorporate the use of the CSS RS and all the other information in your workplace violence prevention program and I know it’s going back to that term many of you may be saying well what does this really have to do with workplace violence but I’ll remind you of any other presentations we’ve done where we know that eight or nine out of ten school shooters have been known to be suicidal there is a direct link and we know that it is that with intervention if we understand what the early warning signs are and we use tools like this hopefully we can trevean mall before that person ever consciously causing harm to themselves or anyone else so thank you very much for listening in today and we look forward to continuing to share more information with you each week and if we can be of assistance to you in the research and the plans you are developing please please contact us we really look forward to working with you and dr. Posner thank you so much for giving your time today we know you’re very busy and you’re obviously a wealth of knowledge and we are very grateful so thank you very much thank you thanks to everyone for joining us today and we’ll give you your day back thank you all bye

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