RESOURCES FOR AT-RISK VETERANS AND THE PRACTICING BAR: THE SUICIDE EPIDEMIC
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RESOURCES FOR AT-RISK
VETERANS AND THE PRACTICING
BAR: THE SUICIDE EPIDEMIC
CLE Credit: 1.0
Sponsor: KBA Military Law Committee and KYLAP
Wednesday, June 12, 2019
11:50 a.m. – 12:50 p.m.
Carroll-Ford
Galt House Hotel
Louisville, KentuckyA NOTE CONCERNING THE PROGRAM MATERIALS
The materials included in this Kentucky Bar Association Continuing Legal
Education handbook are intended to provide current and accurate information about the
subject matter covered. No representation or warranty is made concerning the application
of the legal or other principles discussed by the instructors to any specific fact situation,
nor is any prediction made concerning how any particular judge or jury will interpret or
apply such principles. The proper interpretation or application of the principles discussed
is a matter for the considered judgement pf the induvial legal practitioner. The faculty and
staff of this Kentucky Bar Association CLE program disclaim liability therefore. Attorneys
using these materials, or information otherwise conveyed during the program in dealing
with a specific legal matter have a duty to research the original and current sources of
authority.
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Kentucky Bar AssociationTABLE OF CONTENTS The Presenters................................................................................................................. i Untreated Depression and the Risk of Suicide Among Lawyers and Veterans Who are Lawyers ............................................................ 1 At Risk Veterans: The Suicide Epidemic ....................................................................... 21
THE PRESENTERS
P. Yvette Hourigan
Kentucky Bar Association
Frankfort, Kentucky 40601
(502) 226-9373
yhourigan@kylap.org
YVETTE HOURIGAN is the director of the Kentucky Lawyer Assistance Program
(KYLAP). KYLAP provides assistance to all Kentucky law students, lawyers and judges
with mental health issues and impairments including depression, substance or alcohol
addictions, process addictions and chronic anxiety disorders. Ms. Hourigan is a graduate
of the University of Kentucky College of Law and practiced law in Lexington in all areas of
civil litigation including plaintiff’s personal injury work before being appointed as the
KYLAP director. She is credentialed as a Certified Employee Assistance Professional, an
Adult Peer Support Specialist, and is a QPR-trained Gatekeeper for suicide prevention.
Ms. Hourigan is a member of the ABA Commission on Lawyer Assistance Programs, Chair
of the ABA/COLAP Diversity & Inclusion Committee, and a member of the National Task
Force on Lawyer Well-Being. In 2014, she was awarded the Dave Nee Foundation’s
Uncommon Counselor Award which is given to a member of the legal profession who
exhibits “extraordinary compassion and concern for co-workers, family, friends, and
community.” Ms. Hourigan speaks locally and nationally on topics impacting lawyer well-
being, addiction and suicide prevention. She shares her personal experiences as lawyer,
employee assistance professional, and recovering person.
Dennis W. Shepherd
Kentucky Department of Veterans Affairs
111 B Louisville Road
Frankfort, Kentucky 40601
(859) 552-0983
dwshepherd@ky.gov
DENNIS SHEPHERD is General Counsel for the Kentucky Department of Veterans Affairs
in Frankfort. Mr. Shepherd earned his undergraduate degree from the University of
Kentucky, his J.D. from the University of Kentucky College of Law, and his LL.M. from
George Washington University.
iii
UNTREATED DEPRESSION AND THE RISK OF SUICIDE
AMONG LAWYERS AND VETERANS WHO ARE LAWYERS
Yvette Hourigan, KYLAP
I. INTRODUCTION
The purpose of this program is to educate lawyers about depression, the severity
of the problem here in Kentucky, and how untreated depression may lead to
suicide. We hope this information will encourage those who are suffering from
anxiety and/or depression, and who may be at risk for suicide, to seek help; as well
as to educate Kentucky Bar members how to identify warning signs among our
colleagues and our clients and be willing to explore ways we can offer assistance.
Depression rates in the Appalachian region of the United States have historically
been high. According to a 2016 study focusing on the Appalachian region of the
United States, things seem to be depressing in more ways than one for its
inhabitants. According to a July 2018 USA Today report, Kentucky is the sixth
most miserable place to live in the country. According to their research, we have
the second lowest job satisfaction rating (that is, 70 percent express job
dissatisfaction), we have the third worst health in the country (with the highest
percentage of smokers at 25 percent of adults), and we are the fourth poorest state
(the fourth highest poverty rate). In this study and in numerous others, Kentucky
is always in the top five most depressed states; is always in the top three in rates
of addiction and is now in the top states in overdose deaths. In 2018 there were
1,468 overdose deaths.
On average, people with depression go for nearly a decade before receiving
treatment. Id. It is likely that lawyers go much longer without seeking help than
the average person does, since lawyers seem to have a greater concern about the
stigma of treating mental health issues. In fact, a recent ABA/COLAP study
indicates that the stigma associated with getting mental health assistance is the
greatest barrier to treatment for the legal population.
The 2 most common barriers were the same for both groups: not
wanting others to find out they needed help (50.6 percent and 25.7
percent for the treatment and nontreatment groups, respectively),
and concerns regarding privacy or confidentiality (44.2 percent and
23.4 percent for the groups, respectively). Krill, Johnson, Albers, J
Addict Med 2016;10: 46–52.
As lawyers, we have a belief, perhaps it’s even subconscious, that because we
are paid to solve the problems of others, we must be able to solve our own
problems, including our mental health problems. This is, of course, false. There
is a saying in mental health that “a sick brain can’t fix a sick brain.” We frequently
hear lawyers saying, “I thought I could think my way out of it,” or “I thought it would
pass.” Unfortunately, most mental health problems, and particularly a major
depressive episode, do not spontaneously repair themselves.
1II. SITUATIONAL DEPRESSION V. CLINICAL DEPRESSION
There are two very general types of depression. Everyone feels sadness during
certain times, events, or under certain circumstances. This is referred to as
situational depression. But clinical depression is a far more serious mental health
condition that can have profound and even deadly impacts on a person’s life.
Situational depression is quite common. The medical diagnosis is adjustment
disorder with depressed mood. Situational depression is a short-term form of
depression that results after a traumatic event or significant life change (or a string
of life changes). Triggers can include:
• Divorce
• Empty nest (when the last child leaves home)
• Loss of a job
• Death of a close friend
• Serious accident
• Retirement
The depression that occurs is the struggle and difficulty in coming to terms with
the dramatic life changes. Some of the symptoms of a situational depression can
include:
• Listlessness
• Feelings of hopelessness and sadness
• Sleeping difficulties
• Frequent episodes of crying
• Unfocused anxiety and worry
• Loss of concentration
• Withdrawal from normal activities, families and/or friends
Situational depression usually occurs within 90 days of the triggering event. It’s a
natural response to a traumatic event. It will usually resolve:
• As time passes after the stressful situation or event
• As the situation improves
• When the person recovers from the life event
2As stated before, it’s only short-term. Mild cases of situational depression will often
resolve without active treatment. Lifestyle changes, including exercise, a well-
balanced diet, good sleep hygiene, interaction with family and friends, can all help
with easing a situational depression.
Compare that with clinical depression or Major Depressive Disorder (MDE) which
can develop when an individual does not recover from a depression. This is the
more severe and serious mental health condition that requires medical treatment.
Clinical depression is severe enough to interfere with a person’s daily functioning.
The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V)
classifies clinical depression or Major Depressive Disorder (MDE), as a mood
disorder. Depression can alter a person’s thought processes and bodily functions.
Disturbances in levels of brain chemicals – neurotransmitters – are thought to be
at the root of it. But other factors play a role, too, and we’re just learning of the
impact of the following situations:
• Genetic factors may influence an individual’s response to an experience or
event;
• Major life events can trigger negative emotions, such as anger,
disappointment, or frustration;
• Alcohol and drug dependence have direct links to depression.
The DSM-5 outlines the following criteria to make a diagnosis of depression. The
individual must be experiencing five or more symptoms during the same two-week
period and at least one of the symptoms should be either (1) depressed mood or
(2) loss of interest or pleasure.
• Depressed mood most of the day, nearly every day.
• Markedly diminished interest or pleasure in all, or almost all, activities most
of the day, nearly every day.
• Significant weight loss when not dieting or weight gain; or decrease or
increase in appetite nearly every day.
• A slowing down of thought and a reduction of physical movement
(observable by others, not merely subjective feelings of restlessness or
being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt nearly every
day.
• Diminished ability to think or concentrate, or indecisiveness, nearly every
day.
3• Recurrent thoughts of death, recurrent suicidal ideation without a specific
plan, or a suicide attempt or a specific plan for dying by suicide.
To receive a diagnosis of depression, these symptoms must cause the individual
clinically significant distress or impairment in social, occupational, or other
important areas of functioning. The symptoms must also not be a result of
substance abuse or another medical condition.
An MDE (clinical depression), will not resolve itself, and treatment can last for a
long time, and may require more long-term management and in-depth treatment
plan. A therapist or doctor may recommend counseling and medication. A primary
care doctor can prescribe medications or make referral to mental health
professionals if the individual requires this level of care. In the most severe cases,
the individual may need hospitalization or attend an outpatient treatment program
in the event they have tried to self-harm.
We often hear lawyers complaining about their work, or “hating the practice of law.”
This is not an insignificant complaint. In fact,
Using your strengths and enjoying what you do every day can
greatly contribute to a sense of purpose -- one of the most important
pillars of personal well-being. In Kentucky, just 70.6% of adults like
what they do every day, and 63.3% use their strengths to maximize
their potential every day -- the second smallest and smallest shares
of any state, respectively. The relatively weak sense of purpose
may partially explain the prevalence of depression in the state.
Some 23% of respondents in Kentucky have had a depression in
their lifetime, the fourth largest share of any state.
What is America's most miserable state? Answer may – or may
not – surprise you.
https://www.usatoday.com/story/money/economy/2018/07/24/ame
rica-happiest-and-most-miserable-states-well-being/36959203/
III. MANIFESTATION OF SEVERE DEPRESSION IN LAWYERS AND ETHICAL
CONCERNS
There are very few studies of lawyer impairment and its impact on ethical
breaches, and this is so for a couple of reasons. First, much of lawyer impairment
is hidden, and the client never knows there is an impairment or that there is an
ethical breach (i.e., the client generally has no idea whether the lawyer is filing
pleadings timely). Second, disciplinary counsels of most state boards typically
don’t keep records of the relationship of mental health impairment to ethical
violations, and so it is not reported in any usable statistical form. There are,
however, some general statistics. For example, a study of discipline cases in
Ontario, Canada reveled that nearly 50 percent of lawyers facing serious
disciplinary sanctions there have admitted to either alcohol, drug or psychiatric
impairment. Legal Profession Assistance Conference, Addiction and Psychiatric
Impairment of Lawyers and Judges; A Search for Meaningful Data. Discipline
Digest, LSUC, October 1992 - October 1995.
4The American Bar Association’s former Commission on Impaired Attorneys (now
the Commission on Lawyer Assistance Programs) has suggested that as many as
90 percent of all serious trust fund disciplinary matters involve severe mental
health issues and/or substance abuse, primarily alcoholism.
The areas in which Kentucky and other bar associations see the highest level of
complaints are not coincidentally the three areas in which the severely depressed
or impaired attorney will have the greatest struggle. Refer to the identifying traits,
supra. Specifically: communication, competency and diligence.
A. Pursuant to SCR 3.130(1.4) Communication:
(a) A lawyer should keep a client reasonably informed about the status of
a matter and promptly comply with reasonable request for information.
(b) A lawyer should explain a matter to the extent reasonably necessary to
permit the client to make informed decisions regarding the representation.
B. Pursuant to SCR 3.130(1.1) Competence:
A lawyer shall provide competent representation to a client. Competent
representation requires the legal knowledge, skill, thoroughness and
preparation reasonably necessary for the representation.
Commentary:
Thoroughness and Preparation
(5) Competent handling of a particular matter includes inquiry into and
analysis of the factual and legal elements of the problem, and use of
methods and procedures meeting the standards of competent
practitioners. It also includes adequate preparation. The required attention
and preparation are determined in part by what is at stake; major litigation
and complex transactions ordinarily require more elaborate treatment than
matters of lesser consequence.
Maintaining Competence
(6) To maintain the requisite knowledge and skill, a lawyer should engage
in continuing study and education. If a system of peer review has been
established, the lawyer should consider making use of it in appropriate
circumstances.
C. Pursuant to SCR 3.130 (1.3) Diligence:
A lawyer shall act with reasonable diligence and promptness in
representing a client.
Each of these requirements - communication, competency and diligence - become
harder and harder for the depressed attorney to complete or maintain as the
depressive illness progresses. Hence, hopelessness begins to set in. The more
5difficult the circumstance, the more likely that attorney’s thoughts may turn to
suicide and escape.
IV. SUICIDE WITHIN THE PRACTICE OF LAW
Risk factors for suicide include depression, anxiety, substance abuse, divorce and
stress. Lawyers experience ALL of these risk factors at a higher rate than the
general population. Lawyers are also more likely to be perfectionists and
competitive - personality traits which make a person considering suicide less likely
to seek help. Larry Berman, Executive Director, American Association of
Suicidology.
As stated by Robin Frazer Clark, Georgia Bar President, in her President’s Page
of the Georgia Bar Journal, December, 2012, “[F]ailure is not an option in a high-
stakes profession such as ours.”
The natural progression of depression, when untreated, is suicide. Lest there be
any doubt, if left untreated, depression can be fatal. In an 18-month period, at
least nine members of our Kentucky bar died by suicide. Sadly, these were deaths
that were almost completely preventable had the signs been clear or recognized.
Unfortunately, many times we, as lawyers, have gotten so good at hiding our true
feelings and repressing our actual emotions (skills which are not only useful, but
imperative if we are to be effective advocates for our clients), that it is nearly
impossible -- even for our loved ones -- to understand or recognize the symptoms.
No one is to blame. We only have an obligation to act when we know the signs of
which to be aware. That said, acknowledging that we, as lawyers, may be masters
of repressing our true feelings, means that we must be hyper-vigilant with our
colleagues. After we have been educated, we are responsible. There is a duty to
help your colleagues when you see the signs that may be preceding an attempted
suicide. It is better to be safe than sorry. It is better to have courage than regret.
Thoughts of suicide are not the distressed individual’s problem. They are the
distressed individual’s perceived solution to the real problem or problems.
Suicide has been called “a permanent solution to a temporary problem.” Our
obligation is to recognize when someone is anticipating or seriously
considering this “final solution” and guide them in the direction of real solutions
and help. When the mental health issues that may lead to suicide are
recognized early, experts agree that suicide is almost entirely preventable.
It is tempting when looking at the life of anyone who has committed
suicide to read into the decision to die a vastly complex web of
reasons; and, of course, such complexity is warranted. No one
illness or event causes suicide; and certainly no one knows all, or
perhaps even most, of the motivations behind the killing of the self.
But psychopathology is almost always there, and its deadliness is
fierce. Love, success and friendship are not always enough to
counter the pain and destructiveness of severe mental illness.
Kay Redfield Jamison, Night Falls Fast: Understanding Suicide.
6V. GENERAL POPULATION STATISTICS
Suicide is the 11th leading cause of death among all Americans. (Anderson &
Smith, 2003), the second leading cause of death among Americans ages 25-34,
and the third leading cause of death among Americans ages 10 to 14 and 15 to 24
(Centers for Disease Controls, 2005). Annual death certificates in the U.S. suggest
that over 30,000 persons die by suicide each year. (National Center for Health
Statistics, 2006).
Approximately 89 persons in the United States die by suicide every day (McIntosh,
2006). This equates to nearly four suicides each hour, or one suicide every 16
minutes (McIntosh, 2006).
In Kentucky, the general population facts about suicides are as follows:
• Kentucky loses more than twice as many citizens to suicide each year as
to homicide. (Closer to three times as many.)
• Someone dies by suicide every 12 hours in Kentucky.
• There is an average of 5.7 suicide attempts every day in Kentucky.
• Kentucky’s suicide death rate in 2018 was the 20th highest in the nation (up
from prior years).
• Suicide is the second leading cause of death for Kentuckians ages 15 to
34.
• Suicide is the fourth leading cause of death for adults ages 35 to 44.
• Our elderly have a higher suicide rate than the national average.
• Firearms caused 62 percent of suicide deaths in Kentucky.
• Two out of three Kentuckians (64 percent) know at least one person who
has attempted or died by suicide.
• One out of three (33.8 percent) consider themselves to be a suicide
survivor (someone who has lost a loved one or close friend to suicide).
• Experts believe most suicidal people don’t want to die, they just want to
end their pain. When suicidal behaviors are detected early, lives can be
saved.
www.kentuckysuicideprevention.org
In the United States, the suicide rate in the general population is 13.42 per 100,000
deaths. In Kentucky, the rate is 16.79 suicides per 100,000 deaths. That is,
Kentucky’s overall rate of suicide is 25 percent higher than the national
average.
7VI. LAWYER STATISTICS VERSUS GENERAL POPULATION
As compared to 13 deaths by suicide for each 100,000 deaths in the general population,
the national average rate for lawyers is 66 suicides per 100,000 deaths. Lawyers are
more than five times higher than general population, to die by suicide (National Institute
of Mental Health). And that number should be raised by 25 percent in Kentucky to reflect
our higher rate of suicide over the national average. That is far too great a loss.
In a 2015 ABA/HazeldenBettyFord national study, 11.5 percent of the attorneys
responding reported suicidal thoughts at some point during their career, 2.9 percent
reported self-injurious behaviors, and 0.7 percent reported at least 1 prior suicide attempt.
Male lawyers between the ages of 20 and 64 are more than twice as likely to die from
suicide as men of the same age in other occupations. National Institute for Safety and
Health Study.
Suicide was the 3rd leading cause of death among lawyers insured by the Canadian Bar
Insurance Association. (It’s the 10th leading cause of death in US in general). Canadian
Bar Association Study.
Unfortunately, these shockingly high suicide numbers set forth above may inaccurately
reflect the real numbers and real impact of US suicides. (Granello & Granello, 2007;
Granello & Juhnke, in press). This is because suicide data is based on causes of death
as reported on death certificates only. Given that many suicides are likely misreported --
not as suicides, but as automobile accidents, hunting accidents, swimming accidents, or
accidental alcohol or drug overdoses -- the true suicide number is most likely significantly
higher. (Juhnke, Granello & Lebron-Striker, Professional Counseling Digest, 2007).
“If they tell you that she died of sleeping pills, you must know that she died of a
wasting grief, of a slow bleeding at the soul.” Clifford Odets
Not insignificantly, the current suicide rates fail to address the number of suicide
attempts that were not completed. Since there is no standardized method of data
collection among doctors or hospitals related to suicide attempts, there is no hard data
to reflect these numbers. However, the American Association of Suicidology (2006)
has estimated that at least 25 suicide attempts occur for each completed suicide.
(Juhnke, Grenello & Lebron-Striker, supra). Based on this number, it is suggested that
approximately 811,000 persons in the US made unsuccessful suicide attempts in
2004. This equates to one suicide attempt every 39 seconds (McIntosh, 2006).
VII. RISK FACTORS FOR SUICIDE
A. Psychiatric Disorders
At least 90 percent of people who take their own lives have a diagnosable
and treatable psychiatric illness -- such as major depression, bipolar
disorder, or some other depressive illness, including:
1. Schizophrenia.
2. Alcohol or drug abuse, particularly when combined with depression.
83. Post-Traumatic Stress Disorder, or some other anxiety disorder.
4. Bulimia or anorexia nervosa.
5. Personality disorders especially borderline or antisocial (and
lawyers are at a higher risk for antisocial behavior than the general
population, too)
B. History of Attempted Suicide
Between 20 and 50 percent of people who kill themselves had previously
attempted suicide. Those who have made serious suicide attempts are at
a much higher risk for actually taking their own lives.
C. Genetic Predisposition
Family history of suicide, suicide attempts, depression or other psychiatric
illness.
D. Neurotransmitters
A clear relationship has been demonstrated between low concentrations of
the serotonin metabolite 5-hydroxyindoleactic acid (5-HIAA) in
cerebrospinal fluid and an increased incidence of attempted and completed
suicide in psychiatric patients.
E. Impulsivity
Impulsive individuals are more apt to act on suicidal impulses.
F. Demographics
1. Sex: Males are three to five times more likely to die by suicide than
females.
2. Age: Elderly Caucasian males have the highest suicide rates.
VIII. WARNING SIGNS OF A SUICIDE RISK
Suicide can be prevented. While some suicides occur without any outward
warning, most people who are suicidal do give advance warnings. You may be
able to reduce the likelihood of suicide by loved ones by learning to recognize the
signs of someone at risk, taking those signs seriously, and then knowing how to
respond to them.
A. General Warning Signs of Suicide Include:
1. Observable signs of serious depression:
a. Unrelenting low mood.
9b. Pessimism.
c. Hopelessness.
d. Desperation.
e. Signs of Anxiety (including panic, insomnia and agitation).
f. Withdrawal from usual activities or loved ones.
g. Sleep problems.
2. Increased alcohol and/or drug use.
3. Recent impulsiveness and taking unnecessary risks; reckless
behavior.
4. Threatening suicide or expressing a strong wish to die.
5. Making a plan.
a. Giving away prized possessions.
b. Sudden or impulsive purchase of a firearm.
c. Obtaining other means of killing oneself such as poisons or
medications.
6. Unexpected rage or anger or any other dramatic mood change.
B. Larry Berman, Executive Director, American Society of Suicidology, supra
The emotional crisis (or crises) that usually precede suicide is often
recognizable and treatable. Although most depressed people are not
suicidal, most suicidal people are depressed. Serious depression can be
manifested in obvious sadness, but often it is rather expressed as a loss of
pleasure or withdrawal from activities that had been enjoyable. One can
help prevent suicide through early recognition and treatment of depression
and other psychiatric illnesses.
IX. OTHER INDICATORS THAT SOMEONE MAYTAKE THEIR LIFE
Most suicidal individuals give some warning of their intentions. But there may be
less obvious signs. The most effective way to prevent a friend or loved one from
taking his or her life is to recognize the factors that put people at risk for suicide,
take warning signs seriously and know how to respond. Don’t be afraid to talk
about it. There is too much at stake to avoid these early warning signs.
Know the Facts:
10A. Psychiatric Disorders
More than 90 percent of people who die by suicide are suffering from one
or more psychiatric disorders, in particular:
• Major depression (especially when combined with alcohol and/or
drug abuse).
• Bipolar disorder.
• Alcohol abuse and dependence.
• Drug abuse and dependence.
• Schizophrenia.
• Post-Traumatic Stress Disorder (PTSD).
• Eating disorders.
• Personality disorders.
Depression and the other mental disorders that may lead to suicide
are -- in most cases -- both recognizable and treatable.
The core symptoms of major depression are a "down" or depressed mood
most of the day or a loss of interest or pleasure in activities that were
previously enjoyed for at least two weeks, as well as:
• Changes in sleeping patterns.
• Change in appetite or weight.
• Intense anxiety, agitation, restlessness or being slowed down.
• Fatigue or loss of energy.
• Decreased concentration, indecisiveness or poorer memory.
• Feelings of hopelessness, worthlessness, self-reproach or
excessive or inappropriate guilt.
• Recurrent thoughts of death or suicide.
B. Past Suicide Attempts
Between 25 and 50 percent of people who kill themselves had previously
attempted suicide. Those who have made suicide attempts are at higher
risk for actually taking their own lives.
111. Availability of means.
In the presence of depression and other risk factors, ready access
to guns and other weapons, medications or other methods of self-
harm increases suicide risk.
2. Recognize the imminent dangers. The signs that most directly warn
of suicide include:
a. Threatening to hurt or kill oneself.
b. Looking for ways to kill oneself (weapons, pills or other
means).
c. Talking or writing about death, dying or suicide.
d. Has made plans or preparations for a potentially serious
attempt.
3. Other warning signs include expressions or other indications of
certain intense feelings in addition to depression, in particular:
a. Insomnia.
b. Intense anxiety, usually exhibited as psychic pain or internal
tension, as well as panic attacks.
c. Feeling desperate or trapped -- like there's no way out.
d. Feeling hopeless.
e. Feeling there's no reason or purpose to live.
f. Rage or anger.
4. Certain behaviors can also serve as warning signs, particularly
when they are not characteristic of the person's normal behavior.
These include:
a. Acting reckless or engaging in risky activities.
b. Engaging in violent or self-destructive behavior.
c. Increasing alcohol or drug use.
d. Withdrawing from friends or family.
12X. WHAT CAN YOU DO?
A. Take it Seriously
1. Fifty to 75 percent of all suicides give some warning of their
intentions to a friend or family member.
2. Imminent signs must be taken seriously.
B. Be Willing to Listen
1. Start by telling the person you are concerned and give him/her
examples.
2. If he/she is depressed, don't be afraid to ask whether he/she is
considering suicide, or if he/she has a particular plan or method in
mind.
3. Ask if they have a therapist and are taking medication.
4. Do not attempt to argue someone out of suicide. Rather, let the
person know you care, that he/she is not alone, that suicidal
feelings are temporary, and that depression can be treated. Avoid
the temptation to say, "You have so much to live for," or "Your
suicide will hurt your family."
C. Seek Professional Help
1. Be actively involved in encouraging the person to see a physician
or mental health professional immediately.
2. Individuals contemplating suicide often don't believe they can be
helped, so you may have to do more.
3. Help the person find a knowledgeable mental health professional or
a reputable treatment facility and take them to the treatment.
XI. WHAT IS A SUICIDE CRISIS?
A “suicide crisis” is a time-limited occurrence signaling immediate danger of
suicide. This is as opposed to a “Suicide risk”, (discussed above), which is the
broader term that includes the above factors such as age and sex, psychiatric
diagnosis, past suicide attempts, and traits like impulsivity.
The signs of crisis (again, immediate danger) are:
A. Precipitating Event
A recent event that is particularly distressing, such as loss of loved one or
career failure. Sometimes the individual’s own behavior precipitates the
event: for example, a man's abusive behavior while drinking causes his
wife to leave him.
13B. Intense Affective State in Addition to Depression
Desperation (anguish plus urgency regarding need for relief), rage, psychic
pain or inner tension, anxiety, guilt, hopelessness, acute sense of
abandonment.
C. Changes in Behavior
1. Speech suggesting the individual is close to suicide. Such speech
may be indirect. Be alert to such statements as, "My family would
be better off without me." Sometimes those contemplating suicide
talk as if they are saying goodbye or going away.
2. Actions ranging from buying a gun to suddenly putting one's affairs
in order.
3. Deterioration in functioning at work or socially, increasing use of
alcohol, other self-destructive behavior, loss of control, rage
explosions.
XII. WHAT TO DO IN AN ACUTE CRISIS
• If a friend or loved one is threatening, talking about or making plans for
suicide, these are signs of an acute crisis.
• Do not leave the person alone.
• Remove all alcohol from the person or the home.
• Remove from the vicinity any firearms, drugs or sharp objects that could be
used for suicide.
• Take the person to an emergency room or walk-in clinic at a psychiatric
hospital.
• If a psychiatric facility is unavailable, go to your nearest hospital or clinic.
If the above options are unavailable, call 911 or the National Suicide Prevention
Lifeline at 1-800-273-TALK (8255) or 1-800-SUICIDE. OR Text 741741.
Veterans can text 741741 and press Option 1.
A. Follow-up on Treatment
1. Suicidal individuals are often hesitant to seek help and may need
your continuing support to pursue treatment after an initial contact.
2. If medication is prescribed, make sure your friend or loved one is
taking it exactly as prescribed. Be aware of possible side effects
and be sure to notify the physician if the person seems to be getting
worse. Usually, alternative medications can be prescribed.
143. Frequently, the first medication doesn’t work. It takes time and
persistence to find the right medication(s) and therapist for the
individual person. Encourage the individual to “keep trying.”
B. What to Do if You Notice Someone (of any age) Exhibiting Signs of Suicide
Risk:
1. Open a dialogue.
Asking questions will help you to determine if your client or
colleague is in immediate danger. Always take thoughts of, or plans
for, suicide.
The question you NEVER ask: “You’re not thinking about
committing suicide, are you?” This question tells the person
you want them to say “No.” It’s the wrong form.
Be direct. Talk openly and matter-of-factly about suicide. Ask, “Do
you ever feel so badly that you think about suicide?" or "Do you
have a plan to end your life?”
2. Be willing to listen. Allow expressions of feelings.
3. Be non-judgmental.
Don’t debate whether suicide is right or wrong, or whether feelings
are good or bad. Lecturing (for example, on the value of life or the
impact on family) or being shocked will put distance between you.
4. Be available. Show interest and support.
Offer hope that alternatives are available. Depression is among the
most treatable of mental disorders. Between 80 percent and 90
percent of people with depression eventually respond well to
treatment and almost all patients gain some relief from their
symptoms.https://www.psychiatry.org/patientsfamilies/depression/
what-is-depression
5. Take action. Do not leave the person alone, if you think they might
harm themselves, until the next steps are accomplished.
a. Let them know you are you are going to do what you can to
help them.
b. While they are with you, call the National Suicide Prevention
Lifeline at 1-800-273-TALK (8255) or 1-800-SUICIDE to be
connected to the nearest available crisis center for a referral
to local mental health resources.
c. You can also TEXT 741741 to “chat” with the National
Suicide Prevention Lifeline. (For veterans, hit option “1”).
15This is a good option if you are having suicidal thoughts or
are feeling desperate but are not ready to talk openly and
feel more comfortable texting.
6. If the person at risk is a colleague, take all the steps previously
mentioned, AND also refer the colleague to KYLAP at 1-502-226-
9373.
KYLAP is a CONFIDENTIAL service, and the phone is answered
24 hours a day. In emergencies, the after-hours service will make
sure there is an appointment with a healthcare provider within 24
hours. In non-emergencies, appointments are available within 48
hours. When financial problems exist, and certain criterion are met,
an individual can receive up to four free mental health visits.
Additional funds may be available through the KYLAP Foundation
through forgivable loans for mental health assistance, including
inpatient treatment, outpatient treatment, therapies and
medications (paid directly to providers). www.kylap.org/Foundation.
16APPENDIX A
I. STATE OF KENTUCKY – SUICIDE RESOURCES AND SUPPORT GROUPS
A. Kentucky suicide prevention group: www.kentuckysuicideprevention.org
Kentucky Suicide Prevention Group
1603 Vivian Lane
Louisville, KY 40205
TELEPHONE: (502) 931-3999
Jan Ulrich
State Suicide Prevention Coordinator
Kentucky Dept for Behavioral Health, Developmental and Intellectual
Disabilities
100 Fair Oaks Lane, 4E-D
Frankfort KY 40621
Email: jan.ulrich@ky.gov
TELEPHONE: (502) 564-4456 Ext: 4436
B. State Suicide Prevention Website http://dbhdid.ky.gov/dbh/sp.aspx
C. Suicide Prevention Resource Center https://www.sprc.org/states/kentucky
II. OTHER RESOURCES
A. Veterans Outreach Toolkit - Preventing Suicide.
https://www.va.gov/ve/docs/outreachToolkitPreventingVeteranSuicideIsE
veryonesBusiness.pdf
B. Start the Conversation: Veterans Dealing with Depression:
https://starttheconversation.veteranscrisisline.net/media/1043/vasp-
depression-508-11.pdf
C. Start the Conversation: Talking to a Veteran when you are Concerned:
https://starttheconversation.veteranscrisisline.net/media/1045/vasp_when
-you-are-concerned_final-508-11.pdf
D. Talking with a Veteran in Crisis:
https://www.va.gov/ve/docs/talkingWithVeteranInCrisisHandout.pdf
E. ACES Test for Resiliency: Take it anonymously online at,
https://www.npr.org/sections/health-shots/2015/03/02/387007941/take-
the-ace-quiz-and-learn-what-it-does-and-doesnt-mean
F. Nicholson McBride Resilience Questionnaire (NMRQ) Abbreviated:
https://www.nwpgmd.nhs.uk/sites/default/files/resiliencequestionnaire.pdf
1718
APPENDIX B
SUICIDE AMONG TEENS -- Frequently Asked Questions
There is also a growing number of teens and young adults who attempt suicide. To
address these issues, here are some frequently asked questions. Many of these
questions came from young teens struggling to understand the suicide attempts of friends
and trying to learn how they can help.
1. What percentage of college students who kill themselves are male? Why do
you think more/ less boys than girls kill themselves?
Seventy-five to 80 percent are boys although more girls attempt suicide. Boys are
more involved than girls in all forms of aggressive and violent behavior.
2. I've heard that suicides are more frequent around the holidays? Is this true,
and if so, how much do they increase at that time?
Suicides are not more frequent during the holidays. It appears that the rates are
the highest in April, and the summer months, June and July.
3. It is often said that a suicidal person goes through a period where he seeks
help from other people. Does this then mean that it could be ultimately the
fault of other people (because they don't appear concerned enough) that one
decides to kill him/herself?
Not a fair conclusion, although it could be a contributing factor in some cases
particularly with elderly, terminally ill people.
4. What is the biggest cause of suicide among college students?
Ninety-five percent are suffering from mental illness, usually depression. If
depressed, substance abuse, anxiety, impulsivity, rage, hopelessness and
desperation increase the risk.
5. Apart from talking to a suicidal person and encouraging him/her to go for
counseling, what else can we do to prevent this?
Going with someone to the counselor often helps. If the person won't listen to you,
you may need to talk to someone who might influence him or her. Saving a life is
more important than violating a confidence.
6. People often get uncomfortable when one discloses something as intimate
and frightening as suicidal thoughts. What do you think can be done to
reduce this stigma, either of suicidal people, or of depressive patients? Can
people actually "change" their minds and accept someone who is suicidal?
As people recognize that suicidal behavior is the result of a medical condition not
a sign of weakness or character defect it will change.
197. What is the most frequent method of suicide? Is the most frequent method
different for men and women?
Fifty-two percent of all people who kill themselves do so with a firearm, accounting
for almost 17,000 deaths each year in the U.S. Use of a firearm is the number one
method in those aged 35 and up.
20AT RISK VETERANS: THE SUICIDE EPIDEMIC
Dennis W. Shepherd
I. OVERVIEW: THE NATURE OF THE PROBLEM
“The report shows the total is 20.6 suicides every day. Of those, 16.8 were
veterans and 3.8 were active-duty servicemembers, guardsmen and reservists,
the report states. That amounts to 6,132 veterans and 1,387 servicemembers who
died by suicide in one year.” Stars and Stripes, 20 June 2018, referring to a recent
report by the U.S. Dept. of Veterans Affairs.
II. LIFE FACTORS, STRESSORS, PRESSURE POINTS MILITARY MEN AND
WOMEN ENDURE
A. Deployment Trauma
B. In the Crucible of Life and Death
C. Making the Ultimate Decision to Kill
D. Object of Physical, Psychological, or Sexual Abuse/Assault
E. Personality Disintegration
F. Aftermath of Combat: Mental, Physical, Psychological Deficit
III. THE DIRTY WORD SYNDROME: DON’T COMPLAIN; JUST PUT UP WITH IT
A. World War I
1. Charles Samuel Myers, English physician, described “shell shock.”
2. “A Contribution to the Study of Shell Shock” Lancet, 13 Feb. 1915.
3. Myers also referred to condition of “war neurosis.”
4. Fatigue, shell shock, battle fatigue, and combat neurosis.
B. World War II
1. Abram Kardiner, War Stress and Neurotic Illness, 1947.
2. Kardiner referred to condition of “physioneurosis.”
C. Vietnam
1. From Shell Shock and War Neurosis to Posttraumatic Stress
Disorder: A History of Psychotraumatology by Marc-Antoine Crocq,
MD.
212. 700,000 returning from Vietnam required psychological help.
3. In 1980, the Diagnostic and Statistical Manual of Mental Disorders
Third Edition (DSM-3) recognized Posttraumatic Disorder.
4. DSM-5 continues to recognize PTSD.
D. Wars in Iraq and Afghanistan
1. Invasion of Iraq: 2003.
2. Veterans exiting military 2003-2019: est. 4.3 million.
3. Post-9/11 Veterans: Up to 30 percent seek mental health
treatment or greater than 1,000,000. See “U.S. Military Veterans’
Difficult Transitions Back to Civilian Life and the VA’s Response,”
Anna Zogas, February 2017, Watson Institute, Brown University.
IV. THE DIRTY WORD SYNDROME: SUICIDE
A. People Commit Suicide; Other People Speculate on Motive
1. Kate Spade (fashion designer).
2. Anthony Bourdain (chef, traveler, TV personality).
B. Open Up; Stop Being Judgmental
C. “If people felt as comfortable talking about their PTSD, bipolar or anxiety
as they did talking about their eczema or tennis elbow, it would markedly
reduce the suffering of those with mental illness and the ability of those
around them to support them.” Margie Warrell, “The Rise and Rise of
Suicide: We Must Remove the Stigma of Mental Illness,” Forbes Magazine.
D. Case Study: Daniel Somers
1. “My mind is a wasteland, filled with visions of incredible horror,
unceasing depression, and crippling anxiety.”
2. Graphic suicidal thoughts captured in Daniel’s own words.
V. WHAT ARE WE DOING TO PREVENT SUICIDE INTERNATIONALLY?
A. Positive Trend Country by Country to Prevent
B. World Health Organization, “Global Mental Health Action Plan”
C. Suicide Prevention in an International Context (2017) by Ella Arensman
1. Small countries create suicide prevention programs.
222. Suriname, Bhutan, Guyana, Afghanistan.
D. Arensman’s Suicide Prevention Model
1. Statistics/database.
2. Restricting access to lethal means.
3. Responsible media reporting of suicides.
4. Training and education.
5. Treatment.
6. Reducing/eliminating the stigma of suicide discussion.
7. Postvention: continuing discussions with those affected.
8. Crisis intervention means.
VI. UNITED STATES AND NATIONAL SUICIDE PREVENTION
A. 1958: First Suicide Prevention Center Opens in Los Angeles
B. Suicide Prevention for Youth Act, 42 U.S.C. §290BB-36a
C. Suicide Prevention for Adults, 42 U.S.C. §290bb-43
D. Senate Bill 3460 (115th Congress): Native American Suicide Prevention
Act of 2018 (not passed)
VII. UNITED STATES AND STATE PROGRAMS FOR SUICIDE PREVENTION
A. “So far in 2018, at least 10 bills in eight states have been enacted around
suicide prevention in schools. These include Colorado, Idaho, Indiana,
Iowa, Kentucky, Rhode Island, Utah and New Mexico, which has requested
a study specifically on preventing suicide with firearms at
schools.” Education Dive newsletter, 20 September 2018.
B. Kentucky Laws on Suicide and Suicide Prevention
1. KRS 210.366 – Training program in suicide assessment, treatment,
and management.
2. Requires licensed professionals (social workers, psychologists,
alcohol/drug counselors, alcohol/drug peer support specialist, etc.)
completes such a program.
233. KRS 156.095: Kentucky Schools.
By August 1, 2010, the Kentucky Cabinet for Health and Family
Services shall post on its webpage suicide prevention awareness
information, to include recognizing the warning signs of a suicide
crisis. The webpage shall include information related to suicide
prevention training opportunities offered by the cabinet or an
agency recognized by the cabinet as a training provider.
4. KRS 216.302 Causing a suicide -- Assisting in a suicide.
(1) A person commits a Class C felony when the person knowingly
by force or duress causes another person to commit or to attempt
to commit suicide.
(2) A person commits a Class D felony when the person, with the
purpose of assisting another person to commit or to attempt to
commit suicide, knowingly and intentionally either:
(a) Provides the physical means by which another person commits
or attempts to commit suicide; or
(b) Participates in a physical act by which another person commits
or attempts to commit suicide. Effective: July 15, 1994
VIII. UNITED STATES AND VETERAN SUICIDE PREVENTION
A. Female Veteran Suicide Prevention Act (2016)
B. Clay Hunt Suicide Prevention Act for American Veterans (2015)
• Who was Clay Hunt?
o Marine injured in Iraq.
o Redeployed in 2008 to Afghanistan.
o Suffered depression after military service; suicide in 2009.
o Loan repayment for psychiatric medicine practitioners.
IX. RESOURCES TO HELP VETERANS AT RISK FOR SUICIDE
A. United States Department of Veterans Affairs
1. An at-risk veteran COMMUNICATES WITH SOMEONE.
a. Calls the Veterans Crisis Line at 1-800-273-2255.
b. Texts the Veterans Crisis Line at 838255.
24c. Chats online.
2. Communities must practice suicide prevention.
Integrate prevention lessons into the local community.
a. Health clubs, gyms.
b. City council.
c. Places of worship.
d. Veteran peer support groups (Veterans Treatment Court).
3. What can attorneys and paralegals do?
a. Promote community-based suicide prevention.
b. Participate in city councils, town halls, pro bono forums.
c. Learn what your community does for suicide prevention.
d. Work to get PSAs donated by local media.
e. Contact a U.S. Department of Veterans Affairs Suicide
Prevention Coordinator and invite to speak, train, assist.
i. Available at all VA Medical Centers.
ii. Lexington VA Medical Center.
iii. Louisville Robley Rex VA Medical Center.
iv. Cincinnati VA Medical Center.
v. Marion, Ill. VA Medical Center.
B. Kentucky Resources
1. County-by-county 24-hour crisis lines.
2. Veterans Crisis Line: 1-800-273-8255 (PRESS 1).
C. Kentucky Legislative Update: Green Alert
"Veteran at risk" means a veteran or an active-duty member of the Armed
Forces, the National Guard, or a military reserve component of the United
States who is known to have a physical or mental health condition, to
include post-traumatic stress disorder (PTSD), that is related to his or her
service.
25X. REFERENCE MATERIAL ON VETERAN AND NON-VETERAN SUICIDES
A. USDVA Fact Sheet: Suicide Among Women Veterans
B. “The Missing Context behind…22…a day”
C. Kentucky Veteran Suicide Data Sheet, 2016
D. Suicide Safety Assessment by National Institute of Mental Health
E. Clay Hunt Suicide Prevention for American Veterans Act
F. Female Veteran Suicide Prevention Act
G. “A Soldier’s Last Words” by Clay Somers
H. “The Parking Lot Suicides” by Emily Wax-Thibodeaux
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