|



 
 

|
|  
   
 

The Ohio Suicide Prevention Foundation

O
  

 
O

O

 uStill the effort seems unhurried. Every 17
minutes in America, someone commits
suicide. Where is the public concern and
outrage?µ

Kay Redfield Jamison

Author of [

 


  

á
 

 
 Training Goals
· ›earn about local suicide prevention efforts, how these
efforts connect with your practice and patients
· Understand the pivotal role of medical personnel in the
treatment of depressed patients and in reducing suicide
risk
· Increase awareness of suicide risk characteristics in
patients who may not present as depressed/suicidal
· ›earn a brief suicide risk assessment model
· ›earn to ask the uSµ question

á
 

 
 Why Do We Need To Improve Suicide
Prevention Efforts?
· Suicide is the last taboo
· We can talk about sex, alcoholism, cancer, but not suicide
· People need to understand the impact of depression and
other mental illnesses, and how they lead to suicide
· Suicide is a preventable death
· Integrating medical staff into the efforts of suicide prevention
coalitions to reduce deaths, increase awareness, and reduce
stigma seems critical to local, state, and national efforts to
change our approach to this age-
age-old problem

á
 

 
 ½hanging Our Approach:
Depression Is An å
· Suicide has been viewed for countless generations
as:
X A moral failing, a spiritual weakness
X An inability to cope with life
X uThe coward·s way outµ
X A character flaw
X This cultural view of suicide is not validated by our
current understanding of brain chemistry and it·s
interaction with stress, trauma and genetics on mood
and behavior
á
 

 
· The research evidence is overwhelming-
overwhelming- what we think of
as depression is far more than a sad mood. It includes:
1. Weight gain/loss
2. Sleep problems
3. Sense of tiredness, exhaustion
4. Sad mood
5. ›oss of interest in pleasurable things, lack of motivation
6. Irritability
7. ½onfusion, loss of concentration, poor memory
8. Negative thinking
9. Withdrawal from friends and family
10. Sometimes, suicidal thoughts
(DSMIVR, 2002)

á
 

 
20 years of brain research teaches that what we
are seeing is the J
  result of:
å         
J 
   J 
    
    
    J 
Depressed people suffer from a physical illness
within the brain ² what we might consider
ufaulty wiringµ
(Braun, 2000; Surgeon General·s ½all To Action, 1999, Stoff & Mann,
1997, The Neurobiology of Suicide)

á
 

 
 Faulty Wiring?
· ›iterally, damage to certain nerve cells in our brains
· The result of too many stress hormones ² cortisol, adrenaline and
testosterone
· Hormones activated by our Autonomic Nervous System to
protect us in times of danger
· ½hronic stress causes changes in the functioning of the
ANS, so that a high level of activation occurs with little
stimulus
· ½auses changes in muscle tension, imbalances in blood
flow patterns leading to illnesses such as asthma, IBS, back
pain and depression
(Goleman, 1997, Braun, 1999)

á
 

 
 Faulty Wiring?
· Without a way to return to rest, hormones
accumulate, doing damage to brain cells
· Stress alone is not the problem, but how we
interpret the event, thought or feeling
· People with   
  ,, placed in a
highly  
 will experience
damage to brain cells from stress hormones
· This leads to the cluster of  
    we call depression
(Goleman, 1997; Braun, 1999)

á
 

 
Where It Hits Us

á
 

 
 One of Many Neurons
‡Neurons make up the brain and
cause us to think, feel, and act
‡Neurons must connect to one
another (through dendrites and
axons)
‡Stress hormones damage dendrites
and axons, causing them to
ushrinkµ away from other
connectors
‡As fewer connections are made,
more and more symptoms of
á
 

 
depression appear
· As damage occurs, thinking changes in the predictable
ways identified in our 10 criteria
· uThought constrictionµ can lead to the idea that
suicide is the only option
· How do antidepressants affect this ubrain damageµ?
· May counter the effects of stress hormones
· We know now that antidepressants stimulate genes
within the neurons (turn on growth genes) which
encourage the growth of new dendrites

(Braun, 1999)

á
 

 
· Renewed dendrites:
· increase the number of neuronal connections
· allow our nerve cells to begin connecting again

· The more connections, the more information

flow, the more flexibility and resilience the brain
will have
· Why does increasing the amount of serotonin, as
many anti-
anti-depressants do, take so long to reduce
the symptoms of depression?
· It takes 4-
4-6 weeks to re-
re-grow dendrites & axons
(Braun, 1999)

á
 

 
 Why Don·t We Seek Treatment?
· We don·t know we are experiencing a brain
disorder ² we don·t recognize the symptoms
· When we talk to doctors, we are vague about
symptoms
· We believe the things we are thinking and
feeling are our fault, our failure, our weakness,
not an illness
· We fear being stigmatized at work, at church, at
school
á
 

 
 No Happy Pills For Me
· The stigma around depression leads to refusal of
treatment
· Taking medication is viewed as a failure by the
same people who cheerfully take their blood
pressure or cholesterol meds
· Medication is seen as altering personality, taking
something away, rather than as repairing damage
done to the brain by stress hormones
á
 

 
 Therapy? Are You Kidding? I Don·t
Need All That Woo-
Woo-Woo Stuff!
· How can patients seek treatment for something
they believe is a personal failure?
· Acknowledging the need for help is not popular
in our culture (Strong Silent type, ½owboy)
· People who seek therapy may be viewed as weak
· Therapists are viewed as crazy
· They·ll just blame it on my mother or some
other stupid thing
á
 

 
 How Does Psychotherapy Help?
· Medications may improve brain function, but do not change how
we   stress
· Psychotherapy, especially cognitive or interpersonal therapy, helps
people change the (negative) patterns of thinking that lead to
depressed and suicidal thoughts
· Research shows that cognitive psychotherapy is as effective as
medication in reducing depression and suicidal thinking
· ½hanging our beliefs and thought patterns alters our response to
stress ² we are not as reactive or as affected by stress at the
physical level (›ester, 2004)

á
 

 
 What Therapy?
· The standard of care is medication and
psychotherapy combined
· At this point, only cognitive behavioral and
interpersonal psychotherapies are considered to
be effective with clinical depression (evidence-
(evidence-
based)
· Doctors should make referrals to a cognitive or
interpersonal therapists
á
 

 
· Yet most people do not understand the physical
aspects of mental illness, as you have no doubt
found in talking with your patients

· Suicide is strongly linked with certain mental

illnesses, and most people do not understand this
connection
· Your county Suicide Prevention ½oalition is
attempting to D   attached to
mental illness, increase  J


,, and
    ! 
  
á
 

 
 Suicide Prevention Efforts
· First national effort established at NIMH in 1969
· Surgeon General issued a call to action to prevent
suicide in 1999
· In 2001, a National Strategy for Suicide Prevention
½ommittee developed future goals and objectives
· An Ohio Suicide Prevention Plan was developed in
May, 2002, and grants for local coalitions were given
out in November of 2002

á
 

 
 Development Of
Prevention Efforts
· Over the past 20 years, we have acquired valuable
information on risk and protective factors, methods for
preventing suicidal behavior, and improved research
methods
· An increase in suicide prevention programs in schools
· The rapid development of suicidology as a
multidisciplinary sub-
sub-specialty
· Establishment of centers for the study and prevention of
suicide
á
 

 
 Framework For Prevention
· Public health approach to prevention in contrast to
clinical approaches used in the past

· The prevailing model is the Universal, Selective, and

Indicated model (WHO, 2002)

· Focuses attention on defined populations, from

everyone, to specific at-
at-risk groups, to specific high
high--risk
individuals
á
 

 
 Is Suicide Really a Problem?

· m people complete suicide every day

· r
r people in 2004 in the US
· Over º

 suicides worldwide (reported)
· This data refers to completed suicides that are
documented by medical examiners ² it is
estimated that 2-
2-3 times as many actually
complete suicide

(Surgeon General·s Report on Suicide, 1999)

á
 

 
 The Unnoticed Death
· For every 2 homicides, 3 people complete
suicide yearly²
yearly² data that has been constant
for 100 years
· During the Viet Nam War from 1964-1964-
1972, we lost 55,000 troops, and 220,000
people to suicide

á
 

 
 Who Is At Risk?
· Most people assume young people
are more likely to complete suicide,
· It is the 3rd largest killer of youth ages 15-
15-24
·    from r  actually complete suicide
at a far greater rate than youth
· The elderly are at significant risk; among those
over 75, 1 out of 4 attempts end in death because
the elderly tend to use more lethal means
(Surgeon General·s call to Action, 1999)

á
 

 
½  
D "
#|#| 
· Rates per 100,000 population
· National average - 11.1 per 100,000*
· White males - 18
· Hispanic males - 10.3
· African--American males
African - 9.1 **
· Asians - 5.2
· ½aucasian females - 4.8
· African American females - 1.5
· Males over 85 - 67.6
· Annual Attempts ² 811,000 (estimated)
· 150--1 completion for the young - 4-1 for the elderly
150
(*AAS website),**(Significant increases have occurred among African Americans in the
past 10 years - Toussaint, 2002)
á
 

 
 |D $º



  ëëëëë

ë



ë

ë

 
 
 



 
 
 

r
 
  
 



á
 

 
 Suicide Rates Among The Elderly
‡ The elderly have the highest suicide rate of any group.
‡ Depression in late life affects six million people, one out of six patients
in a general medical practice
‡ However, only one of those six patients is diagnosed and treated
appropriately
‡ The majority of these people have seen their primary care physician
within the last month of life
‡ There is evidence that the majority of elderly suicide victims die in the
midst of their first episode of major depression
‡ Depression is not a normal consequence of aging and can alter the
course of other medical conditions
(Empfield, 2003)
á
 

 
 P½P·s And Diagnosis Of Depression

· Seniors have often visited a health-

health-care provider before
completing suicide
· 20% of elderly (over 65 years) who complete suicide visited a
physician within 24 hours
· 41% within a week
· 75% within one month
· Patients may not use the words depression or sadness
· Because of the stigma that is still attached to this diagnosis,
somatic symptoms may become the focus of complaint
· There may be much denial and minimizing of affective
symptoms
(Empfield, 2003)
á
 

 
%  " &  ½ 
'
· Increased risk for inappropriate medication
treatment (Bartels, et al., 1997, 2002)
> 1 in 5 older persons given an inappropriate
prescription (Zhan, 2001)
· The elderly are less likely to be treated with
psychotherapy (Bartels, et al., 1997)
· ›ower quality of general health care is associated
with increased mortality
(Druss, 2001)
á
 

 
 Depression Associated With Worse
Health Outcomes
· Depression is common among older patients with certain
medical disorders
· Associated with worse health outcomes
· Greater use and costs of medications
· Greater use of health services
· Medical illness greatly increases the risk for depression
particularly in:
· Ischemic heart disease (e.g. MI, ½ABG)
Stroke ½ancer ½hronic lung disease Alzheimer>>s disease
Alzheimer
Parkinson>>s disease
Parkinson
Rheumatoid Arthritis
á
 


(Empfield, 2003) 
· In ½ancer, depression leads to
· å & ( 
·   
· !  
·   
· Increased mortality rates for
· &  
· ½ D 
·   å  

· å     
   

   ) 

( Frasure-
Frasure-Smith 1993, 1995; Mossey 1990; Penninx et al. 2001; Katz 1989,
Rovner 1991, Parmelee 1992;Ashby1991; Shah 1993, Samuels 1997)
á
 

 
 Rates Of Depression
Among Elders With Illness
· ½ognitively intact nursing home patients shown to
have symptoms consistent with depressive
disorders ² 60%
· ½hronically ill outpatients in a primary care
practice - 25%
· Hospitalized patients - 20%
· In nursing homes, regardless of physical health,
major depression increases the likelihood of
mortality by 59% in one year
á
 

 (Empfield, 2003)

Benefits Of Treatment For Depression
In The Elderly
· Depression is one of the few medical conditions in
which treatment can make a rapid and dramatic
difference in an elderly person·s level of function and
quality of life
· Treatment may help patients accept medical treatment
that they otherwise might refuse because of feelings of
hopelessness or futility
· Treatment also helps enhance or recover coping skills
needed to deal with the inevitable losses associated with
chronic medical illness
(Empfield, 2003)
á
 

 
 What Factors Put
Someone At Risk?
· Many things increase one·s risk for suicide-
suicide- biological,
psychological, social factors all apply
· The single greatest risk factor for suicide completion -

 
#
· 90% of reported US suicides are experiencing depression
· The 2nd biggest factor - having an 
J.. However, many people with alcohol and drug
J
problems are significantly depressed, and are self-
self-
medicating
(›ester, 1998)
á
 

 
·  :
"   :
· Previous suicide attempts
· A family history of suicide - increases our risk by 6 times
· A significant loss by death, divorce, separation, moving, or
breaking up with a loved one. Shock or pain, even long term
lower level stress, can affect the structure of the brain,
especially the limbic system
· 30 years of research confirms the relationship between
and
 and suicide, across diagnoses
· Impulsivity, particularly among youth, is increasingly linked
to suicidal behavior
· Access to firearms ² 70% of completed suicides used
firearms
(Surgeon General·s call to Action, 1999)

á
 

 
· $   
· Biological changes are associated with
both completed and attempted suicide
· ½hanges include abnormal functioning of
the Hypothalamic-
Hypothalamic-Pituitary-
Pituitary-Adrenal axis,
a major component of the way we adapt to stress
·    
· ½hanges in thinking (constricted thought) leading to the belief
that suicide is the only answer; negative automatic thoughts that
lead to sadness, hopelessness, loss of pleasure, inability to see a
future, low self-
self-esteem
· Suicidality, although clearly overlapping the symptoms of
associated MH disorders, does not appear to respond to
treatment in exactly the same way
· In some cases, depressive symptoms can be reduced by
medication without a reduction in suicidal thinking
á
 

 
 Protective Factors
· Stigma reduction programs, especially
among youth, increase help-
help-seeking behavior
· Resiliency and coping skills to reduce risk can be taught
(Dialectical Behavioral Training)
· Spirituality improves defenses against suicidal thinking
· Social support ² those with close relationships cope better
with various stresses, including bereavement, job loss, and
illness
· Social disapproval of suicide reduces rates
*(Berman & Jobes, 1996; Beck, 1985; Rush et al, 1992, Surgeon General·s ½all To Action, 1999)

á
 

 
 Treatment
· Treatment of suicidality has improved dramatically
in the last 20 years
· Evidence is clear that lithium treatment of bi-
bi-polar
disorder significantly reduces suicide rates*
· A correlation has been noted between an increase in
prescription rates for SSRI·s and a decline in suicide
rates**
(*Baldessarini, et.al, 1999, **NIMH, 2002)

á
 

 
· However, medication alone is insufficient to reduce suicidal ideation
· Psychotherapy can reduce suicidality by helping people learn to
interpret the stresses in their lives more effectively, reducing the level
of stress hormones in the body
· Psychotherapy provides a necessary therapeutic relationship that
reduces risk through increased hope and support
· ½ognitive--behavioral approaches that include problem-
½ognitive problem-solving training
reduce suicidal ideation and attempts more effectively than other
approaches
· Medication combined with psychotherapy is the current standard of
care for clinical depression
,
(Beck, 1996 Quinnett, 2000, Macintosh, 1996)

á
 

 
 Barriers To Treatment
· Fragmentation of services and cost of care are the most
frequently cited barriers to treatment
· About 67% of people with significant mental disorders 
receive treatment
· Psychological autopsy studies reveal that less than 14% of
completers were receiving adequate treatment, and fewer than
17% were being treated with psychiatric medications
· However, 50-
50-70% had contact with health services in the
weeks before their death

· Surgeon General·s ½all To Action, 1999; Empfield, 2003

á
 

 
· ½urrently, no psychological test, clinical technique or biological
marker is sensitive enough to accurately and consistently predict
suicide
· Primary care has become a critical setting for detection of the two
most common factors: depression and alcoholism*
· Depression is the second most common chronic disorder seen by
P½P·s
· According to the AMA, a diagnostic interview for depression is
comparable in sensitivity to laboratory tests commonly used in
diagnosis, but currently, less than 50% of adults with diagnosable
depression are accurately diagnosed by P½P·s*
· uPhysicians are often reticent to talk with patients about suicide
intent or ideation, and patients seldom spontaneously report itµ**
(*Surgeon General·s ½all to Action, 1999; **Quinnett, 2000 )

á
 

 
 What Is Your ½ounty Doing?
· Suicide prevention coalitions have been developed over the
past 3 years across the state with grants from Ohio Dept. of
Mental Health
· In many counties, the Mental Health Board is spearheading this
process, with help
from all areas of the community,
including health care providers, mental
health professionals, suicide survivors,
clergy, school personnel, human resource
personnel, police/sheriff dept, health
department, and many others

á
 

 
 How Do We Know Suicide
Prevention ½oalitions Work?
· In 1996 the U.S. Air Force decided to mount an assault
on it·s high suicide rate
· They targeted help-
help-seeking behavior, stigma, and
awareness
· After 5 years of a major collaborative effort within the
service, suicide rates dropped 78%
· ½omparable rates in the other 4 armed services
remained the same

á
 

 
 How ½an You Help?
· Medical personnel are the front line of defense against
this insidious killer - assess your patients for suicidal
ideation when depressive symptoms arise
· Specifically ask your patients if they are experiencing
suicidal ideation ² They may not volunteer the
information
· Train staff in depression awareness, and in asking the uSµ
question
· We must gain confidence in asking people if they are
thinking about dying
(Surgeon General·s ½all To Action, 1999)

á
 

 
½omfort And ½ompetence ›ead To
Hopefulness
· A study by Dr. Paul Quinett, a long-
long-time
researcher and clinician in suicide, indicates that
patients who felt their clinician was comfortable
asking questions about their suicidal thoughts
and feelings reported much higher levels of
hope about the future
· The best outcome of asking the 'S question is
immediate relief for the patient
(Quinnett, 2001)
á
 

 
· Hopelessness is the most immediate risk factor
for suicide, so instilling hope is essential
· If your patient is on anti-
anti-depressant or anti-
anti-
anxiety medication, refer them to a psychologist
or counselor who can work with them on the
maintaining causes of depression
· ½onsider using a risk assessment format to
ensure you ask the right questions

á
 

 
 What To Ask?
· Except for psychiatrists, routine
questioning about suicidal ideation
is not the current standard of care
· If you have a patient with depressive symptoms or
other mental health disorders (especially anxiety)
· ›earn to Ask the uSµ question
· Not ² you aren·t thinking of suicide are you?
· But - Some people who experience the amount of pain you·re
in think about killing themselves. Have you ever thought
about it?

(›ester, 1998)
á
 

 
 Use Of A Structured Interview
· Many patients will not overtly acknowledge common
symptoms of depression, focusing more on vague pain
· You may wish to develop or purchase a guided clinical
interview for use with suicidal clients
· A structured form assesses current risk, sets up a
management plan, and ensures that all the right
questions are asked
· Most take just a few minutes to complete, and people
are surprisingly honest

á
 

 
 Screening Recommendations
· The U.S. Preventive Services Task Force reviewed new evidence that
patients fare best when medical professionals recognize the symptoms of
depression and make sure they receive appropriate treatment
· The USPSTF issued new depression screening recommendations in May,
2002, asking P½P·s to routinely screen adult patients for depression
· Medical professionals should have systems in place to assure accurate
diagnosis, effective treatment, and follow-
follow-up if patients are to benefit
from screening
· The journal of AAFP offers the article uScreening for Depression across
the ›ifespan: A review of Measures of Use in Primary ½are settingsµ to
help medical professionals make appropriate choices of screening tool
(Sharp and ›ipsky, 2002)

á
 

 
 Possible Depression Scales
· Beck Depression Inventory
· ½hildren·s Depression Inventory
½ES--D½ (½enter for Epidemiological Studies
· ½ES
Depression Scale)
· Edinburgh Post-
Post-Natal Depression Scale
· Geriatric Depression Scale
· QPRT - Question, Persuade, Refer or Treat -QPR
Institute - www.qprinstitute.com
· Zung Depression Inventory

á
 

 
 uQPRµµ ² Or, How To Ask
›earning uQPR
The uSµ Question
· It is essential, if we are to reduce the number of suicide
deaths in our country, that community
members/gatekeepers learn u%D u%Dµµ
· First identified by Dr. Paul Quinnett as an analogue to
u%Dµµ consists of
½PR, u%D
ƒ %uestion ² asking the uSµ question
ƒ ersuade
ersuade²² Getting the person to talk, and to seek help
ƒ Defer ² Getting the person to professional help
ƒ Medical staff can learn this method in a very short time
(Quinnett, 2000)

á
 

 
 Intervention
· Once a patient has told someone they are thinking of
suicide, you need a thorough suicide assessment
· In your area, what mental health facilities with
emergency services are available?
· Sending a suicidal patient  to the emergency room
could be a mistake
· Most mental health agencies have crisis workers who
can come to your office to interview your patient š
suicidal people should never be left alone!

á
 

 
 Psychiatric Hospitalization
· The actual prediction of suicide is, essentially,
impossible
· The base rates are too low, and risk level changes from
day to day
· Statistically, you could almost always bet that no given
individual will complete suicide
· Other risks are managed by understanding what risk
factors exist, and limiting as many of them as possible,
like wearing sunscreen
· It is imperative that medical professionals know risk
factors for suicide
(MacIntosh, 1993)
á
 

 
 The Top Ten Risk Factors When
Thinking Of Hospitalization
· Previous Suicide attempt(s)
· Mental disorders (especially depression, bipolar)
· ½o--occurring mental and A›/SA disorders
½o
· Family history of suicide
· Hopelessness (should this be first?)
· Impulsive/aggressive tendencies
· Barriers to accessing mental health treatment
· Relational, social, work or financial loss
· physical illness (esp. with chronic pain)
· Easy access to lethal methods, especially guns
General>s ½all to Action to Prevent Suicide, 1999)
(Surgeon General>
á
 

 
 Voluntary Hospitalization
· patient>s sense of
Best choice š less hard on the patient>
self--worth š a way to buy time (to think it over,
self
get sleep, etc.)
night>s
· Safety is the main message š a good night>
sleep, a start on medications, talk with doctors,
put things on hold for awhile
didn>t want to, but
· Allows them to save face š I didn>
insisted

they insisted

á
 

 
 Sharing Knowledge Of Hospitals
· Ease the transition by addressing their fears
· Facts: hospital stays tend to be short
· Staff are well-
well-trained and know about suicidal
suffering
· E½T cannot be given without patient permission
· Patients rights are guaranteed
· Modern hospitals are not snake pits

á
 

 
 Know Your ›ocal Resources And
Agencies
· Where to hospitalize
· Who do you call
· Have your risk assessment information ready
· Help to overcome barriers to hospitalization
such as child care, pets, transportation, calls to
work, etc.

á
 

 
 ›ocal Professional Resources
Your ›ocal Mental Health ›ocal ½risis Hotlines
Agencies National ½risis Hotlines
Your ›ocal Mental Health School nurses
Board 911
School Guidance ›ocal Police/Sheriff
½ounselors
›ocal ½lergy
Your Hospital Emergency
Room

á
 

 
 uSuicide is a
   
to a
Jµµ
 J

Edwin Schneidman, MD.

Founder of Suicidology

á
 

 
"|
  
The Ohio State University, ½enter on Education
and Training for Employment
1900 Kenny Road, Room 2072
½olumbus, OH 43210

614--292-
614 292-8585

á
 

 
 A Brief Bibliography
· Anderson, E. uThe Personal and Professional Impact of ½lient
Suicide on Mental Health Professionals. Unpublished Doctoral
dissertation, U. of Toledo, 1999
· Berman, A. ›. & Jobes, D. A. (1996) Adolescent Suicide: Assessment
and Intervention.
Intervention.
· Blumenthal, S.J. & Kupfer, D.J. (Eds) (1990). Suicide Over the ›ife
½ycle: Risk Factors, Assessment, and Treatment of Suicidal Patients.
American Psychiatric Press.
· Empfield, Maureen MD( 2002) PSY½HIATRY FOR THE
PRIMARY ½ARE PHYSI½IAN  |  #
D
È Goldberg, I. SSRI·s and Suicide: Results of a ME›INE Search. At:
ttp://www.psycom.net/depression.central.ssri--suicide.html
ttp://www.psycom.net/depression.central.ssri
· Jacobs, D., Ed. (1999). The Harvard Medical School Guide to
Suicide Assessment and Interventions. Jossey
Jossey--Bass.

á
 

 
· Jamison, K.R., (1999). Night Falls Fast: Understanding Suicide.
Alfred Knopf
· ›ester, D. (1998). Making Sense of Suicide: An In- In-Depth ›ook at
Why People Kill Themselves. American Psychiatric Press
· Oregon Health Department, Prevention. Notes on Depression and
Suicide:
ttp://www.dhs.state.or.us/publickhealth/ipe/depression/notes.cf
m
· President·s New Freedom ½ouncil on Mental Health, 2003
· Quinnett, P.G. (2000)
2000). ½ounseling Suicidal People.
People. QPR Institute,
Spokane, WA
· Shea, ½., 2000.
2000. A Practical Interviewing Strategy for the Elicitation
of Suicidal Ideation.
Ideation. Journal of ½linical Psychiatry (supplement 20
20))
59
59:: 58
58--72
72,, 1998

á
 

 
· Smith, Range & Ulner. uBelief in Afterlife as a buffer in suicide
and other bereavement.µ Omega Journal of Death and Dying,
1991--92, (24)3; 217-
1991 217-225.
· Stoff, D.M. & Mann, J.J. (Eds.), (1997). The Neurobiology of
Suicide.. American Academy of Science
Suicide
· Schneidman, E.S. (1996)
1996). The Suicidal Mind.
Mind. Oxford University
Press..
Press
· Styron, W. (1992)
1992). Darkness Visible.
Visible. Vintage Books
· Surgeon General·s ½all to Action (1999). Department of Health
and Human Services, U.S. Public Health Service.
· Tang, T.Z. & De Rubeis, R.J. ((
((1999
1999)). uSudden Gains and critical
sessions in cognitive-
cognitive-behavioral therapy for depressionµ
depressionµ.. Journal
of ½onsulting and ½linical Psychology 6767:: 894-
894-904.
904.

á