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Tough legislative fight could be ahead for suicide prevention bill

Rep. Tina Orwall

Roughly 1,000 Washingtonians kill themselves every year, contributing to a suicide rate that is 15 percent above the national average. But if the state Senate passes and the governor signs a bill that passed the House 94-3 earlier this month, Washington will lead the nation in its efforts to prevent suicide. Granted, the bar has been set pretty low.

The bill now before the Senate would require suicide prevention training for doctors, nurses, naturopaths, chiropractors and other primary healthcare providers. (This training would take up six of the continuing education hours already required.) No other state has passed similar legislation. Two years ago, Washington became the first state to require suicide prevention training for counselors, social workers and other mental health professionals. A couple of other states have already followed suit.

Why is this happening here? "I was approached by [University of Washington assistant professor of social work] Jennifer Stuber," explains state Rep. Tina Orwall, the prime sponsor of both suicide prevention training bills. "Her husband had just completed suicide." (In suicide prevention circles, one doesn't speak of "committing" suicide. One "commits" a crime, which is what suicide has traditionally been considered. One does not "commit" a public health problem, which is how they want suicide to be seen now.)

Stuber's husband had seen professionals, says Orwall, but "the people he had sought help from really hadn't been trained." After her husband's death a few years ago, Stuber approached Orwall. Last year, Stuber co-founded the UW-based suicide prevention group Forefront, which has organized a lobbying day Tuesday in Olympia.

Before introducing any legislation, Orwall says, she and Stuber "really built a coalition." Two years ago, they introduced and passed the “Matt Adler Suicide, Assessment, Treatment and Management Act of 2012″— named in honor of Stuber's late husband — which required training for mental health professionals. But some professional groups, including doctors and nurses, didn't want the law applied to them at the time, and they were left out. "This year, we're taking the big step, which is around providers," Orwall says.

Although the bill sailed through the House with only three "no" votes, in the Senate, it faces "a fair amount" of pushback. She explains that professional associations still don't want anyone telling them what to do. And some conservative legislators don't like government telling anyone what to do. In House testimony, opponents also raised concerns about the costs.  

Some people have wondered if knowing the questions to ask potentially suicidal patients would increase a practitioner's liability for patients who killed themselves, says Lauren Davis of Forefront. Ironically, Davis says, "the reality is you're liable now if you don't ask."

The Washington State Psychiatric Association opposes the legislation. In an open letter, the association's president, Daniel Crawford, argues that given the number of people who kill themselves every year and the trauma their deaths cause survivors, "the option of inaction is unconscionable," but that "evidence for effective ways to prevent suicide remains frustratingly limited." Crawford quotes a nine-year-old Journal of the American Medical Association(JAMA) article which concluded that physician "education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates," but "[o]ther interventions need more evidence of efficacy."

As Crawford acknowledges, the statistics are pretty staggering. "Some 38,000 people killed themselves in the United States in 2010," the magazine Nature recently observed, citing a February report by the National Action Alliance for Suicide Prevention. "That’s more than were killed in traffic accidents (34,000) or by prostate cancer (29,000), and more than twice the number murdered (16,000)."  Nature also reported, "Since 2008, the suicide rate among soldiers has exceeded that of the general population, and in the past few years the army has lost more soldiers to suicide than to combat."

Rates have risen in the civilian workforce, too. Paul Quinnett, a psychologist who runs a Spokane-based suicide prevention training institute and has been a clinical assistant professor in the UW Medical School's department of psychiatry and behavioral science, observes that rates have gone up among people of prime working age, between 25 and 55 since the start of the recession. He says that every 1 percent rise in unemployment is matched by a 1 percent rise in suicides.

And the rate among veterans has been notoriously high. Yet . . . John Osborn, who served as chief of medicine at the Veterans Administration hospital in Spokane and still practices there, says that although vets are a high-risk group — he recalls a patient shooting himself in a VA bathroom — he personally never received training in suicide prevention.

Some argue that for a mature person facing bleak medical or other prospects, suicide may be a rational option. But virtually no one argues that it's rational for, say, a high school student whose girlfriend has just dumped him or a vet who's having trouble readjusting to civilian life or a person who has been trying to get medical help for depression.

There isn't always any way to know that a person is contemplating suicide. But often, spotting the signs isn't rocket science. People contemplating suicide frequently say things, but their listeners may not recognize the warning signs or know what to do. "They often say something obliquely," Quinnett explains. "The problem is the [people] hearing this communication don't know what they're hearing or they're afraid to ask because they don't want to put" the idea of suicide into the other person's mind.

The communication isn't always all that oblique. Quinnett says that not long ago, a teenage boy killed himself only three hours after posting on Facebook, "Leave the lights on for me Jesus, I'm coming home tonight."

Untrained friends and family aren't the only ones who fail to recognize the signs. "National statistics tell us that 60 percent of the people who commit suicide have seen a primary care provider in the past 30 days," Orwall says. And they may not have seen anyone else. "The most frequent last contact with a professional," Quinnett says, "is with a primary care provider." The person sees "a physician or a nurse who doesn't tumble to the fact that this person is about to kill himself." Frequently, he says, "someone in their 70s goes in to see a doctor. They're depressed, [so] they're given a prescription for a medication that in overdose can be fatal, and the next day they're dead," A lot of hints may be dropped in such visits, he says: "When people say, 'if I take all this medication would it kill a person,' they're not asking a chemistry question."

If you make it hard for a person to kill himself one way, won't he just find another? Maybe not. "Surprisingly," Nature observed, "many people intent on suicide abandon their plan if their chosen means is not available. Firearms account for about half of US suicide deaths, and modelling work carried out for the new report shows that almost 10% of all suicides could be prevented by restricting access to guns. In 2010, 735 people in the United States killed themselves with carbon monoxide from car exhausts; the report suggests that 600 of those deaths might have been prevented if car manufactures were required to install a sensor inside the vehicle that turns off the engine when carbon monoxide builds up."

And then there are the largely preventable deaths of depressed people already under professional care. Michigan's Henry Ford Health System has driven the percentage of its own depressed patients who kill themselves to zero over a two-and-a-half year periodl That shows it can be done. Now, Quinnett says, "there's a [broader] movement to target zero suicides in behavioral health care" a goal that would have been unthinkable 10 years ago.

There are real-life difficulties, however, notes Dale Reisner, M.D., head of the Washington State Medical Association, who notes that simply getting suicidal people into mental health care can be a problem. "If a person who's at risk doesn't say [that he or she is contemplating suicide], you have no ability to admit them," she says. And there aren't enough facilities. "It's all about money," she says.

In the wider world, Quinnett likens suicide prevention to ordinary citizens using CPR to help people having heart attacks. Our aproach to suicide prevention should be "based on that same premise that early intervention saves lives," he says. But before you can expect anyone to intervene, "you have to teach people what those warning signs are."

You also have to teach them that it's OK to talk about suicide. A lot of people still don't want to use the "s" word. Reisner talks about the need to overcome "the shame and silence" that inhibit public discussion. "Historically," Quinnett notes, "it's been a sin. It's been a crime. It's been punished as a crime."

A person who killed himself couldn't be buried in consecrated ground. And his whole family suffered. If the authorities decided his death had been a suicide, the state would confiscate the family property. This religion-based approach to suicide "actually drove Western thought until the suicide prevention movement got started about 50, 60 years ago," Quinnett says. He has been working on suicide prevention in Ireland, where he says the last flogging of a child for a suicide attempt was only in 1955.

Osborn suggests that the reluctance to even talk about suicide has a familiar ring. "I've been through this with HIV," he says. "We couldn't talk about it." The taboo lasted for years. "It wasn't until people like Rock Hudson and Magic Johnson contracted and [in Hudson's case] died from HIV" that people started discussing it openly. He says it's groundbreaking that Washington state is having a conversation about suicide and has even passed the earlier law that requires training in suicide prevention. "This has not happened any place else," he says.

"I see this as a first step," Rep. Orwall says. "At the end of the day, this [current] bill is about people getting help." If it succeeds, "I would really in my heart like to believe this will save lives."

Quinnett is optimistic. "If Washington passes this bill," he says, "I think it will make a huge difference."

For exclusive coverage of the state government, check out Crosscut's Under the Dome page.

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