By Tara Bannow

The Bulletin

Warning signs for suicide

• Talking about or making plans for suicide.

• Expressing hopelessness about future.

• Displaying severe/overwhelming emotional pain or distress.

• Showing worrisome behavioral cues or marked changes in behavior, particularly in the presence of other warning signs, including:

• Significant withdrawal from or changes in social connections/situations.

• Changes in sleep (increased or decreased).

• Anger or hostility that seem out of character or context.

• Recent increased agitation or irritability.

For youth assessing warning signs in peers:

• Are they talking about wanting to die or be dead, or about suicide?

• Are they cutting or burning themselves?

• Are they feeling as though things may never get better?

• Do they seem to be in terrible emotional pain (as though something is wrong deep inside but they can’t make it go away)?

• Are they struggling to deal with a big loss in their life?

• Is your gut telling you to be worried because they have withdrawn from everyone and everything, have become more worried or on edge, seem unusually angry or just don’t seem normal to you?

Source: Oregon Health Authority 2016-2020 Youth Suicide Intervention and Prevention Plan

Before Dr. Kristi Nix’s brother killed himself, he saw his primary care doctor. He went to the emergency room. He called a crisis hotline.

“He did all those things,” said Nix, a pediatrician with High Lakes Health Care in Bend. “The disconnect was he did all those things at various times but it never really came together in a coordinated effort and there wasn’t anybody following up with that.”

A new plan to address youth suicides in Oregon will attempt to tackle the issue from multiple angles, but one of the main focuses will be to increase communication between health care providers — primary care physicians, mental health providers, hospitals, crisis lines — when patients show warning signs of suicide.

The Oregon Health Authority’s 2016-20 Youth Suicide Intervention and Prevention Plan carries the aspirational goal of bringing the number of suicides to zero among Oregonians ages 10 to 24. It’s the second-leading cause of death in Oregon among that age group.

The “Zero Suicide” model has shown dramatic results in other areas, said Ann Kirkwood, OHA’s youth suicide intervention coordinator and leader of the dozens of people who helped create the plan, including health care providers, nonprofit leaders, education and local government officials, veteran and LGBTQ advocates, suicide survivors and family members of people who died by suicide.

“They actually have reduced suicides among health system patients in some areas by 80 to 100 percent by initiating zero suicides,” Kirkwood said.

Deschutes County is among four counties specifically highlighted in the plan for both their high rates of suicide and readiness to begin addressing the issue. In Deschutes County, 33 people between 10 and 24 killed themselves between 2003 and 2012; in all age groups during that time, there were 290 suicides .

While 10- to 24-year-olds don’t see the highest rate of suicide in Oregon — that’s among 45- to 64-year-olds — the Legislature in 2014 directed the state to focus on the younger age group because that’s where suicide first surfaces as an issue, Kirkwood said.

“The plan also looks at comprehensive mental health and substance abuse services, which — if we can make those available to youth — the downstream consequences when they become adults should be much more positive and we have a good chance of reducing the suicide rate in the future among older folks,” she said.

Under the plan, the county will receive $65,000 per year for the next five years from a federal grant to carry out some of the initiatives. Among those are new practices to ensure youth released from emergency rooms and inpatient psychiatric care receive appropriate follow-up treatment from community providers. County providers will implement the new practices by Sept. 30, 2017, and the OHA will publicize outcomes by March 2018.

A theme running throughout the new plan is to spread the responsibility of suicide intervention to everyone in communities instead of just those who work in health care.

Aimee Johnson, lead suicide prevention coordinator for the Portland VA Healthcare System, said one of the important things she does is distribute educational materials to people in communities, including family members, professors and others who interact with veterans, to let them know the warning signs of suicide. Often when someone goes to the hospital or a psychiatric facility, that information isn’t reported to the VA.

“It’s not something the VA can do alone,” she said.

The report highlights veterans as one of the groups at increased risk of suicide. It was the second-leading cause of death among young Oregon veterans between 2008 and 2012. Other groups at high risk include people who have attempted suicide, people who have lost a loved one to suicide, LGBTQ individuals, people with disabilities, Native Americans and older males.

Professionals can only do so much. Coordinating care among providers is crucial, but not everyone who kills themselves sees a provider beforehand, which makes it crucial that everyday people be informed about warning signs and feel a sense of responsibility for one another, said Carol Palmer, a registered nurse and licensed professional counselor in Bend who specializes in grief and trauma.

“It takes a village to raise a child and it takes a village to save a child — and an adult,” she said. “I’m concerned about adult suicides also.”

Palmer’s 21-year-old son, Mark, did not see any doctors before he killed himself. She doesn’t recall him telling anyone about his struggle or showing any signs he was thinking about suicide.

Almost all suicides have some warning, however, Palmer said. In most cases, it’s just that people around the person either did not recognize the signs or did not know what to do. In some cases, a person will drop several hints to different people, but each of them doesn’t realize it on their own.

Palmer recalled the case of a man who killed himself and afterward several co-workers remembered him saying unusual things, but none of them thought to ask him whether he was thinking of suicide. For example, he had told one person he had been out target practicing over the weekend. The co-worker thought that was unusual because he had never talked about guns before.

An important point Palmer and Johnson agree on: If someone shows a warning sign, it’s always OK to ask, ‘Are you thinking about suicide?’ Johnson said she wants to dispel the myth that asking the question will plant the idea of suicide in a person’s head.

If the person indicates he or she is considering suicide, don’t brush it off, Palmer said.

“Don’t just give them a platitude, like, ‘Oh, you’ll feel better tomorrow,’ or ‘You really don’t mean that,’” she said. “You don’t say that. You say, ‘Wait a minute. Boy, that sounds serious.’ You look up at them. You engage them. You act concerned.”

For those who know someone showing warning signs or indicating he or she is considering suicide, they should do everything in their power to get the person help, said David Visiko, Deschutes County’s suicide prevention coordinator. That could mean calling either the Deschutes County Crisis Line or the National Suicide Prevention Lifeline, encouraging them to seek professional help or, if immediate action is necessary, calling 911.

Visiko encourages community members to get training through programs like Question, Persuade and Refer or Applied Suicide Intervention Skills Training. QPR teaches people to recognize the warning signs of suicide, how to ask about it and how to persuade someone to seek help. ASIST helps caregivers learn how to recognize warning signs and intervene in cases where suicide may be imminent.

Nix, a member of the steering committee that wrote the new plan, said she likes the plan focuses on teaching primary care providers to ask about suicide warning signs. Most are already asking about depression, but they’re not well trained when it comes to responding to patients who say they’re considering suicide.

“I don’t think it’s an uncommon approach to have a child show up, admit being suicidal and the response is, ‘Well, you have to go to the emergency room for evaluation,’” she said.

When that happens, emergency rooms become overwhelmed, she said. The new plan strives to create a community of resources that communicate with one another to ensure they’re each playing a role.

The plan’s goal of zero suicides highlights the fact that suicides are preventable. For Nix, that notion triggers feelings of guilt and shame because of her brother’s death.

“But there is also this really beautiful aspect of, ‘It’s a public health problem,’ and really all of us can contribute in a meaningful way to preventing suicide,” she said.

— Reporter: 541-383-0304,