Mental Health
Appendix F: Suicidal Behavior
Appendix F: Suicidal Behavior
Introduction
Suicide is a major public health problem in the United States and internationally. It affects LEOs in numerous ways. LEOs are often the first on the scene where a suicide is in process or has been completed. There is the phenomenon of “suicide by cop” where officers may be provoked to kill individuals who are seeking to die. There is suicidality among police officers, who face numerous occupational risks for suicidality and, typically, a culture which does not encourage protective activities such as seeking mental health care, and other assistance – which can mitigate risk.
Per WHO, the definition of suicide is “an act of self-harm taken with the expectation that it will be fatal.” “A suicide-attempt is a non-fatal act of self-harm, often with the aim of mobilizing help.”43Schneidman, a prominent American suicidologist, offers a useful, expanded definition of suicide:
“Suicide is a conscious act of self-annihilation, best understood as a multidimensional malaise in a needful individual who defines an issue for which suicide is perceived as the best solution.”44
Thoughts of suicide, or suicidal ideation, exists on a continuum from passive thoughts that ‘one is better off dead’ which may be fleeting, to fantasies of, or plans for, suicide with high levels of detail. Suicidal behaviors are behaviors, not diagnoses unto themselves. It is true they are commonly associated with mental health such as major depressive disorder, bipolar disorder, PTSD, substance use disorder, and borderline personality disorder. However, suicidality can also be precipitated by personal losses, humiliation, major medical illness, and other psychosocial stressors – even in the absence of a mental health disorder.
Treatment of suicide as a public health problem can be divided into three categories, prevention, intervention, and postvention.45As police physicians we may play a role in all three processes, but the focus of this guidance is to facilitate assessment of LEO safety and workability after they have expressed suicidal ideation, planning, or made an unsuccessful attempt.
Epidemiology
CDC data from 1999 through 2017 indicates suicide is among the top 10 causes of death for Americans of all age groups from 10-14 to 55-64, and for all ages. For age groups 10-14, 15-24, 25-34 suicide is the second leading cause of death. Heyman et al. observe that among LEOs, suicide rates hover close to the national rates in the U.S., 11-17 per 100,000, vs. civilian average of 13. An organization called Badge of Life which tracks media reports of Police Suicides identified 140 cases in 2017. This exceeded the number of line-of-duty deaths (127) for that year.46
Some studies have found that police suicide rates trail those of their communities. Marzuk looked at suicide rates for New York City police officers from 1977-1996, and found that they trailed demographically adjusted rates for New Yorkers as a whole. (14.9 vs. 18.3 per 100,000) However, methodological problems, biases of officers and departments probably lead to an underestimate of police suicides.47More recently, Violanti conducted a large proportional mortality study of suicide among US law enforcement workers between 1999 and 2007. He showed proportionate mortality ratios (PMRs) were higher for those in law enforcement professions – ranging from 133 to 388 depending on demographic and occupational factors.48
Police suicide rates are known to be elevated elsewhere in the world. A study of Italian police suicides from 1995-2017, found rates to be consistently in excess of rates for national resident population below age 65.49Grassi Loo performed a meta-analysis of studies of police suicide rates internationally and found great variability from 0-75.28 per 100,000, with the lowest rates in Asia, Africa and the Caribbean, and the highest rates in American and European countries. As in American studies, firearms were the predominant method.50
Suicide Mythology and Stigma:
| Fable | Fact |
| People who talk about suicide don’t commit suicide. | Of any 10 persons who kill themselves, 8 gave warning of their intentions. |
| Suicide happens without warning. | Studies show the suicidal person gives many clues and warnings regarding suicidal intentions. |
| Suicidal people are fully intent on dying. | Most suicidal people are undecided about living or dying, and they “gamble with death,” leaving it to others to save them. Almost no one commits suicide without letting others know how they are feeling. |
| Once a person is suicidal, he or she is suicidal forever. | Individuals who wish to kill themselves are suicidal only for a limited period of time. |
| Improvement following a suicidal crisis means that the suicidal risk is over. | Most suicides occur within about three months following the beginning of “improvement,” when the individual has the energy to put their morbid thoughts and feelings into effect. |
| Suicide strikes much more often among the rich – or, conversely, it occurs almost exclusively among the poor. | Suicide is neither the rich person’s disease nor the poor person’s curse. Suicide is very democratic and represented proportionally among all levels of society. |
| All suicides are mentally ill, and suicide is always the act of a psychotic person. | Studies of hundreds of suicide notes indicate that though the suicidal person is extremely unhappy, he/she is not necessarily mentally ill. |
Misinformation concerning suicide, its causes, and the behavior of suicidal people is pervasive and damaging to efforts to deal constructively with this problem. This is a longstanding problem. The table above, listing several common misconceptions, and the associated facts dates to 1967.51Their persistence speaks to a general societal failure to address suicidality. For medical professionals to be effective with suicidal patients we must start with the truth.
It is generally accepted that culturally, LEOs place a high value on self-reliance, and the ability to shake off the daily stresses and traumas associated with their work. Seeking help for personal mental health conditions, or suicidal thoughts does not conform to these standards. Bell and Eski note that fear of the consequences of non-conformance contributes significantly to LEOs’ reticence to come forward when in distress. LEOs believe that discussion of mental illness, suicidal thoughts, or even serious stressors may be “career ending.” 52
In contrast, Karaffa and Koch found that when individual officers were interviewed privately about their own attitudes, they had a relatively nuanced and more accepting attitude toward mental illness and suicidality. However, when asked what they thought their colleagues felt about these conditions, they described their views as harsher and more negative. In social psychology this is referred to as pluralistic ignorance – a situation in which a majority of group members privately reject a norm, but go along with it because they incorrectly assume that most others accept it.53
The stereotypical attitudes, and a potentially faulty belief in their true prevalence are important reinforcers of the stigma associated with mental health disorders and suicidality among LEOs. In the field of police suicidiology, these are part of what are referred to as the blue walls. Leenaars describes three phenomena in suicidal patients which are particularly relevant to the police physician.45 The first is masking, or dissembling, in which a suicidal patient seeks to conceal their intent, to prevent interference.
The second phenomenon is contagion. Among occupational groups, LEOs and other first responders are more likely to encounter suicidal people, while alive and after suicides have been completed. Contagion is said to occur when one suicidal event resonates with other suicidal people and causes them to think it may be a solution for them. In the year following comedian Robin Williams’ suicide by hanging – the frequency with which that method was used increased significantly. This was attributed to the publicity associated with his death. CDC has issued guidance on avoiding contagion with suicide reporting which is useful for departments in crafting their communications about these events.54 CDC Suicide is traumatizing for first responders, whether it is their own suicidal thinking, or the thoughts or actions of others, to whom they must respond. Contagion should be considered after any critical incident involving LEOs and suicide.
The third phenomenon is constriction of thought – for the suicidal person, their problems and the perceived solution becomes so prominent in their thinking that the rest of the world falls away. This irrational tunnel vision can be evident on interview.
Risk Factors and Protective Factors
Suicide risk is determined, in part, by the interplay of risk factors and protective factors – which differ in each individual case. Risk factors may be divided into individual and environmental factors. Some are chronic and or recurrent conditions, others are fleeting.
General Risk factors for Suicide in the General Population
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Leenaars notes that alcohol and other substance abuse is associated with police suicide in most studies.45Per Violanti, PTSD, depressive disorder, and substance use disorder are more prevalent that can be explained by chance alone in suicidal officers.55 Volanti 2004 Marzuk, in a study of New York police officers found marital/relationship problems, job suspensions, and alcoholism were commonly associated with police suicides.47
General Protective Factors in the General Population
- Protective Factors
- Family
- Living situation
- Friends
- Coworker relationships
- Therapist
- Trusted physician
- Pastor/church
- Knowledge base
- Financial standing
Protective factors reduce the likelihood of suicidality. As described below, evaluation of suicide risk involves consideration of relevant risk factors and protective factors. For a police physician engaged in longitudinal preventive care of LEOs, developing an understanding of these aspects of the officers’ histories could be useful in maintenance of mental wellness.
Access to firearms is a part of the job for most LEOs in the U.S. Firearms are likely used in the majority of police suicides. Firearms are an especially lethal means of suicide, especially in the hands of a trained person. For the general population firearms are used in only 5% of attempts, but are the means used in 53% of suicide deaths. At times it may be necessary to limit a LEO’s access to firearms. This should include unsanctioned access to weapons at while on light duty. Departments may also want to consider whether off duty officers should routinely carry their service weapons, as this significantly increases access.
Assessment of the Acutely Suicidal LEO
The police physician, will, from time to time, encounter a LEO with acute suicidal thoughts. Careful attention should be paid to safety and security. If the examination cannot be performed safely, the LEO should be referred to a facility, such as a psychiatric emergency room, where this can occur. The assistance of the department may be required.
If an evaluation can be conducted it is useful to have a structured clinical approach to initial assessment. The Suicide Assessment Five-step Evaluation and Triage (SAFE-T) card, is one such an approach.56 Steps 1 and 2 are the identification of risk factors and protective factors respectively. Step 3 involves conduct of a suicide inquiry. Step 4 is determination of risk level and selection of an appropriate intervention. Step 5 is documentation.
The suicide inquiry (Step 3) is a process of uncovering suicidal thinking and attempts by interview. Some useful questions:
- Sometimes people in your situation lose hope. I’m wondering if you’ve felt that, too?
- Have you ever thought things would be better if you were dead?
- Have you ever thought about hurting or killing yourself?
- Have you ever tried to kill yourself?
If suicidal thoughts are initially denied but you remain suspicious – it is OK to ask again. If the denial is convincing it is OK to stop.
If suicidal ideation is present, inquire about frequency, duration, and intensity:
- When did you begin having suicidal ideation?
- Did anything seem to set off your thinking?
- How often do you have these thoughts? How long do they last? How strong are the thoughts?
- What is the worst they’ve ever been?
- What do you do when you have suicidal thoughts?
Ask about suicide planning:
- Do you have a plan for how you would end your life? How would you do it? Where would you do it?
- Do you have the (drugs/gun/rope) that you would use? Where is it now?
- Do you have a timeline in mind? Is there something that would tell you it’s time?
Remember, asking about a patient’s suicidal thinking is not going to cause them to act on their thoughts.
Lastly, evaluate the patient’s level intent:
- What would you accomplish by ending your life?
- How confident are you that the plan would end your life?
- What have you done to begin carrying out the plan?
- Have you rehearsed or practiced?
- Have you made arrangements to take care of finances, family, pets?
- How likely do you think you are to carry out your plan?
The table below shows the process for using recorded risk/protective factors and assessed degree of suicidality to place the LEO in high-, moderate-, or low-risk categories and decide on a range of possible interventions.
This is useful when it is not possible to make a referral to a mental health professional for initial assessment. Clear documentation of the evaluative process is essential. For non-emergent cases, referral to EAP, peer counseling, may be appropriate acutely. Referral to the department’s mental health consultant for a more formal FFD evaluation is likely to be necessary in any high or moderate-risk case.
Role of Police Physicians, Departmental Management, and Mental Health Consultants in Managing Suicidality in Law Enforcement Agencies
|
Prevention |
|
|
Police Physician |
• Routinely explore mental health disorders, substance use, psychosocial stressors, suicide risk factors • Remind LEOs about available resources • Referrals when appropriate • Act on recommendations of mental health consultant in advising the department |
|
Department |
• Make mental health and resiliency a leadership priority • Institutionalized mental wellness and suicide prevention policies and practices • Agency campaigns to raise awareness • Invest in training re: mental health/resiliency/dealing with critical incidents (suicides, traumatic events) – focus on first-line supervisors • Provide family training and events |
|
Mental Health Consultant |
• Post-offer screening and recommendations. • Periodic mental health wellness screenings • Work with department and police physician in clinical management |
|
Intervention |
|
|
Police Physician |
• Be prepared to manage LEO suicidality from ideation to attempts • Referrals when appropriate • Act on recommendations of mental health consultant in advising the department • Consult with mental health consultant and department concerning needs intervention programs in context of specific events |
|
Department |
• Make mental health and resiliency a leadership priority • Establish intervention protocols for assisting officers at risk (for mental health crises, suicidal ideation of behavior • Audit psychological service providers to insure effective intervention. This includes peer providers. • Pay closer attention to at risk groups |
|
Mental Health Consultant |
• Fitness for duty assessments • Follow-up visits • Consult with police physician and department concerning needs intervention programs in context of specific events |
|
Post-Intervention |
|
|
Police Physician |
• Routinely explore: MHD, substance use, psychosocial stressors, suicide risk factors • Remind LEOs about available resources • Referrals when appropriate • Be prepared to assist department with family, agency, and community notification • Support department in post-incident counselling and agency-wide mental health awareness actions |
|
Department |
• Make mental health and resiliency a leadership priority • Institutionalized mental wellness and suicide prevention policies and practices • Agency campaigns to raise awareness • Invest in training re: mental health/resiliency/dealing with critical incidents – focus on first-line supervisors • Provide family training and events |
|
Mental Health Consultant |
• Post-event screening and recommendations. Focus on higher-risk LEOs. • Periodic mental health wellness screenings • Be prepared to assist department with family, agency, and community notification • Assist department with revision of agency trainings in context of event |