Well, let's get started with several committee members who probably will join us shortly and just for a committee to know Laurie will not be with us today Today is Valentine's Day and her husband's flower shop requires all hands on Okay, so Welcome we have Some of us just had the opportunity to be part of a president of the press conference around suicide prevention efforts in state of Vermont And we are taking advantage here in the House Health Fair committee today to hear Additional to hear testimony around issues of suicide and suicide prevention in Vermont an issue that Is important in and of itself it also interacts with some of our statewide goals in terms of One cares we often count the current stations the large population health changes As well as initiatives and other parts of state I'm sure we'll be hearing more about So what I'd like to suggest is that we have about an hour Schedule at this point. I think we have five different witnesses at least according to this that I have I Think it might be useful to hear from each of our witnesses and then open it up to questions from the committee So that you know we get to hear from everyone, but I'm sure there are questions and comments from our committee members So with that Thank you so much for taking the time today and the initiative really to set this up And we need to have you identify yourself. I will do that I am Dr. Joellen Tarallo. I'm the executive director of the Center for Health and Learning 501 C3 That is a state partner to many health initiatives in Vermont addressing priority health issues We work with the agency of human service the agency of education We work with the agency of transportation and numerous departments in the state of Vermont to Bring capacity to projects that are well conceived and hopefully to identify Concrete outcome measures as we're doing with suicide prevention The Vermont Suicide Prevention Center is a public-private partnership in partnership with the agency of human services we get a small allocation and We do our work In partnership with many organization on a collective impact model As you may know, we know now pretty clearly that it's almost impossible to build out a community Prevention initiative without multiple partners and so virtually all the work we do is in partnership with other people the Vermont Suicide Prevention Center was created after Center for Health and Learning was identified as the lead designated agency for two federal grants in Vermont on behalf of the Department of Mental Health At that time we created the coalition and the Vermont Suicide Prevention Center is composed of more than 70 Organizations and individuals who support suicide prevention Everything that we do with the Vermont Suicide Prevention Center is advised by the statewide coalition And we we carry out deliverables under contract from the Department of Mental Health that are conceived by the center as well as the coalition We also build out projects that are funded by foundations and rely on donors to help us build out the project statewide So we about In 2015 the coalition was charged with developing a statewide guidance document for suicide prevention I'm sorry. I don't have slides today because I have some beautiful slides. It's my colleagues will attest But I will make sure I get some of those to you afterwards if that's okay representative Lipper So one of the things that we accomplished was bringing the coalition together to develop a guidance document called the Vermont Suicide Prevention Platform 2015 suicide prevention across the lifespan in that platform we identified a range of Objectives tied to a socio-ecological model, which we also understand that People exist in and of themselves, but they exist in family systems and those family systems exist in relationship to all sorts of community Systems as well as state government and policies. So when we built out a project We are aiming at the individual in the center, but we're really impacting the entire socio-ecological model on the family systems and the systems with which they engage in this case health care We are also the developers of the you matter suicide prevention program Which was conceived by the coalition the message behind you matter is You matter because you may need help and you matter because you may be in a position to help So if you're reading that you'll notice that I'm derivating quite quite a bit Extemporary meaninglessly, so please bear with me Right now and today we're focused on health care and the issue of creating a competent Well resourced approach to health care across a continuum of care, which includes health promotion prevention early intervention, that's the key intervention Targeted treatment suicide-saving pathways that include discussions about lethal means restriction when in person is in crisis And that has people tools all the way along the way with evidence-based practices for screening assessment treatment timely referral and Response because as it turns out timely referral and caring contact our Timely referral is not a low-cost intervention We all know the challenges of that in our our decentralized health system but creating partnerships and linkages that create timely referral is very important and Caring contact ongoing following somebody's suicidal crisis turns out to be the lowest cost Most important intervention there is aside from making sure that they don't have access to lethal means at the times of time crisis But people have to identify when they go to the primary care doctor They have to be able to identify in family medicine when they get to the emergency room and we have a partner doctor I cool to I bloom who will talk in a moment about the challenges from an emergency cyst department and medicine point of view We have to think about the system linkages But we have to have people in all those places who are trained and ready to respond About five years ago it became clear in the national discourse that a large number of people seek help from health care And then go on to die of suicide If that was happening with cardiovascular disease It would be evident and we would know that there were a certain set of procedures and evidence-based practices Screenings that had to happen medicine if it's indicated And a pathway to treatment that might include cardiac rehab in the physical therapies department of the local hospital This is what we're looking for with suicidality Treating suicidality as a condition in and of itself so that it can be identified Assessed treated and effectively reduced The foundational belief of zero suicide is that suicide deaths for individuals under care within health and behavioral health systems are preventable Zero suicide requires a system-wide approach to improve outcomes and close gaps and this morning We gathered health care leadership in a press conference to make an explicit Commitment to reduce deaths to suicide through the health care system and we have the all-payer outcome measures working in our favor in that regard This isn't rocket science one only need to look at the data to know that we have a problem And that we have it within ourselves and our systems to Impact that problem like we do in so many other areas No mental health providers cannot curb the tide on suicide alone They can adopt evidence-based practices and share the responsibility between primary care mental health services emergency department crisis response in patient units and Development of high-quality programming I have had to learn about advocacy and how you can Bring whatever leverage you have as a committee to bring more focus to the core values of zero suicide We thank Representative Donahue for mentoring us along this process and for a number of other legislators who have really taken up this issue over years The quichy bridge mitigation is a success story that took five years And we've we've implemented some evidence-based practices there It has not been easy and we're yet to see the full outcomes of bridge mitigation We're making good strides in building infrastructure in state government But the field has tremendous needs for workforce development and technical assistance Data and surveillance that must be supported by health care We stand by to support and help with capacity building planning Implementation and evaluation of such practices and ask you to consider what levers of influence Do you have as legislators in health care committee to bring to bear on a rising crisis for which we do not want? To be known in Vermont This is I did insert a Suicide prevention graphic which shows at the bottom of the pyramid universal strategies for suicide and then moving up more Targeted specific and indicated strategies as we go along We've identified the tools and the evidence-based practices in Vermont We have three pilot projects under small amount of funding from Department of Mental Health that we've been learning from over the past three years and They're just beginning. They were designated agencies and they're just beginning to engage health care as well So I'm happy to ask quite. Oh, no, we're going to turn it over to our next very good I do want to mention that these are some of the Vermont suicide prevention programs that department of mental health Department of Health Agency of Human Services Has initiated and Vermont Suicide Prevention Center has provided support for There are also resources for survivors of suicide loss on the www.vtspc.org website Which has a whole range of resources related to health care and zero suicide? Thank you Go back here and it looks like Dr. Lopez is next Hi, I'm Debra Lopez Goddison. Good morning, everyone I do have some paper copies. Does anyone want a paper copy of I have paper copies? Please pass around and I also have some a Reference paper that I thought would be useful for committee members This morning because I'm a grieving mother my son Alan Goddison died by suicide Just three years ago at the age of 25 Alan died as it has an inpatient in a psychiatric hospital He had left behind many who loved him including his younger sister my husband who's here today and myself We're one of the hundreds of Vermont families who suffer the devastating impacts of suicide But I'm not going to focus on that today Because I'm all because of this is the health care committee Yeah I don't think it can be de-emphasized, you know the impacts on our communities broadly But I have a different focus which is that I'm also Ironically a psychiatrist with over 30 years of patient care experience I've also served as a clinical teacher in a variety of settings including the UVM medical center where I'm a clinical faculty member And I care deeply about my profession and the patients were meant to serve so I'm here really wearing those two hats and So I'm going to talk briefly about my son's situation But I also want to say that he wasn't unique so I really think it's important to emphasize that I'll tell an individual's story, but his story I think just reveals Problems that other people face too So just briefly about Alan he was a jazz musician and especially sweet young man At the time of his death he was suffering from an episode of severe depression And that was related to a chronic pain problem that In his hands actually that made it hard for him to work and play music and Anyway, he became hopeless about his future. And so that's a sketch of what What the background was That led to him becoming suicidal But what I think is most pertinent about our story is that When he became suicidal he sought help Unlike many who die by suicide who don't access the health care system He sought help from many well-regarded health care professionals or a handful anyway and He disclosed his suicidal thinking to his treatment providers from the very beginning so No one needed to screen him He made it very obvious that he was looking for help and what he was struggling with I'm here to talk about that our son's death was the direct result of health care system failures And I'm going to mention a few of those And it's the main point I want to make What we learned after Alan died When we reviewed every word of his medical records Was that although his providers were well-intentioned They were either completely untrained And I mean completely I can give you examples or Severely out of date in their training related to the treatment of a suicidal patient I'm going to repeat this is the main point that I hope the committee will keep in mind At every level of care in which our son sought help for his suicidality Win our support From his primary care doctor to his private psychotherapist well-regarded person to his UBM Medical Center outpatient psychiatrist Should be well trained To his in the inpatient unit where he was at Central Vermont Medical Center To the out-of-state tertiary care hospital where he was referred so, you know the providers were either completely untrained or surprisingly out of date in their training and practices in Terms of how to evaluate and treat a suicidal patient I realize that what I'm saying may be hard for you to believe it certainly was hard for us to believe You might imagine that our son was especially difficult to evaluate or complicated to treat These assumptions would be incorrect. I Won't go into details, but the main point I'm trying to make here is that Really the practices where he sought care lacked protocols and Compatible competency in treating suicidal individuals and this is I Provided a published paper to you. That's actually a really good summary A set of practice improvements that's being recommended that Joelle and to Rallo mentions called the zero suicide initiative Which describes the problem we found also? The zero suicide approach has been shown to reduce suicide deaths in several health care systems nationally The problem in Vermont is that not one of our health systems has fully adopted the zero suicide approach or model And very few psychiatrists or therapists are trained in how to provide evidence-based treatments So I'm really emphasizing training problems as a major issue. I'm not going to go into How this would would this kind of situation would not be tolerated for another health condition I Could give an example, but I'll just move forward to say that much work is needed obviously and There's three main items that are also highlighted in this paper. I distributed first health care leaders should prioritize and put care for suicidal patients It's gotta come from leadership training protocols and practice guidelines are two issues that are often absent in practices and Poly-assurance professionals are needed desperately to make sure that providers adhere to protocols I Hope you just might ask to the committee is that I hope that you'll continue to educate yourselves about the deficits in health care system related to suicide care and How our systems can be improved Perhaps in the next year or so we will be able to make some more specific suggestions As to how you as legislative leaders Can help those of us who are working in the health care sector to partner on perhaps initiatives related to training or other program problems And then questions are for later. Thank you very much Good morning, thank you for having me My name is Ike Boll. I am an emergency medicine physician as well as a medical toxicologist and I practice at UVM Medical Center right now. I am one of the Not competent not trained physicians. You've just heard about and that is not an easy thing for a physician to say I was trained at one of the best medical schools in the country at Johns Hopkins I was trained at one of the best residencies in the country of the University of Massachusetts And I have received virtually no training in how to care for patients with suicidality or severe mental illness So I'm sitting in front of you today as an emergency medicine physician not as a patient advocate not as a psychiatrist But as somebody who sees the extent of suffering of mental illness in the emergency problem on a daily basis To help you appreciate what a patient with mental illness goes through when they present to the emergency department I want to run a little thought experiment with you. I want you to to imagine that After today you walk out of this building you slip on some eyes and you fall and break your leg You're taken to the hospital and I See you and we examine your leg together and it hurts take some x-rays and I confirm that yes, your leg is in fact broken And in fact, it's broken in a way that I think you need to be admitted to a hospital and you may require surgery from an orthopedic surgeon And then I tell you that the orthopedic surgeon will probably see you in maybe three days Maybe five And I leave the room and I leave you in a room with no windows no fresh air If you're lucky the TV works The nurse comes by to see if there's anything you need maybe turkey sandwich and Tells you the story of a patient who broke their leg kind of just like you and waited in the emergency department for an entire month to be seen by an orthopedic surgeon We leave you in that room with really no treatment. Don't give you pain medication We don't don't really reduce the fracture. We just leave you there for five days Till the orthopedic surgeon sees you You might be a little upset with your care because you did not receive it You were essentially in prison for five days with no treatment and It strikes us as absurd When we would do this to somebody with a broken leg or with heart attack or stroke And for some reason that right now is the standard of care for people who come to us to seek out for their mental illness And and over my career I've heard a bunch of explanations of why that is okay One of the explanations I hear is Well, these people they're not really dying like somebody with heart attack Their life is not an acute danger, but I would argue Yes, it is because their mental illness their mental illness their suicidality Has risen to the level where it overcomes their intrinsic instinct of self-preservation and They may not be acutely dying in front of us right now But after we've put them in a room with no treatment for five days or even a month The next time they feel like that They may not be willing to voice that they may not be coming back to us And I've also heard that well, they're just depressed. They're not really in pain. They don't they don't need pain They can any treatment acutely But I want you to remember and this is maybe my Valentine's Day pitch when you fall in love Feel butterflies in your stomach, right? You have physical symptoms from an emotional state And depression does the same thing suicidality does the same thing in fact it creates real somatic pain But we leave you untreated sitting in that pain in that room So the question is how do we fix this and it's it's it's both an upstream problem. It's a downstream There's not enough resources available to people with mental illness People can't access respite. They can't see their therapist in a reasonable amount of time. There's not enough therapists to go around Mental health is not well funded. It's not well reimbursed. There's insurance issues once you come to my emergency department and I make sure that You don't have a medical emergency, but then not much more Then there's a downstream problem because if you do need to be admitted If you do need psychiatric hospitalization, there's simply not enough beds to go around And if it's not safe to send you home because your depression around if you're not functional Your suicidal ideation is so severe that I think you're not safe by yourself You've no choice but to wait So there's the downstream problem and it sounds something where you could just throw some money at it Fix it, but I also realize that money is hard to come by So I want to do a little bit of a cost analysis of what we do right now the Center for medical for Medicare services in 2005 issued a report of How much it costs to hospitalize a mental health patient for one day? The dollar number comes down to about six hundred dollars Half of that is for overhead of the psychiatric hospital. The other half is for direct patient care Contrast those six hundred dollars per day to what an emergency medicine bed costs in the ED a bed costs about a hundred twenty dollars per hour to run and My example of three to five days is not an exaggeration In fact, it's the average And average means half of the people wait longer If you have a patient in a bed that costs a hundred twenty dollars per hour After five days that has cost the same amount of money as providing psychiatric hospitalization for three weeks So the question is are we spending our money? And it does have an impact on other people Everybody who comes to the emergency department is impacted We have a finite amount of rooms. We have a finite amount of resources Right now my emergency department dedicates approximately 25 percent of our resources to medications with mental illness And they deserve those resources. They're just not the resources that help them But as a result We have just last week Ren trauma in the hallway somebody who got hit by a car at internal bleeding. I treated in a hallway Two days ago, we had a cardiac arrest in the waiting room because they waited for so long that they went to cardiac arrest and This is the situation we're facing on the ground right now in the emergency department So I really appreciate the opportunity to tell you about this and Like all the other speakers will be available for questions Good morning, thank you chairman Lippert and members of the committee for having us this morning My name is Molly Dugan and I'm the director of the statewide sash program did provide Paper copies if that works Okay So I'm again, my name is Molly Dugan. I'm the director of the statewide stash program which stands for support and services at home Cathedral Square my employer is responsible for state-wide administration of this program Which is primarily funded by federal Medicare dollars by way of the all-payer model Sash has been in existence since 2011 and it is operated by the network of affordable housing organizations around the state I Would I would venture to say pretty confidently that what in each of your communities? There is a stash operated housing site. It's not in your community stones throw away And this includes all the public housing authorities in the state as well operate sash And what we do in the stash program is we embed a care coordinator Who we also offer a purchase of a community health worker and a wellness nurse RN in the affordable housing? Communities to provide person-centered direct support as well as care coordination to help our Client help primarily older adults and adults with disabilities to stay at home as their needs change We do this in full partnership with the existing community Organizations in the area that includes area agencies on aging the home health network As well as community mental health agencies, and we serve approximately 5,000 across the state I'm here today to underscore the severity of suicide among the primary We serve in the stash model and that is older adults and I want to explain Not so underscore the the issues around suicide and older adults and then I also want to explain how we're using This statewide stash platform that you all as a legislature have funded for many years now To improve the access to help for our participants So some of the facts around suicide older adults I did include for you guys just a really short power point on some of these facts I'm not going to go through this, but I did want to just highlight a few of them Because basically what we know is that the suicide rate among older adults generally across the country is high and In Vermont in particular the suicide death rates for older adults are in some cases alarmingly higher than the US rate and if you look on actually that first page the first bar chart you will see the rates of the older adult rates across Vermont, I mean Vermont versus the US Just a short And it's males in particular in the ages of between 70 and 74 that actually have the highest suicide death rate in our state and then the other I Consider alarming statistic around older adults in our state is I'm you'll see it on page 2 on the high chart and that is that older Adults have a much higher suicide completion rate than other ages And you know some of the reasons that are speculated for this have to do with the fact that older adults use firearms Usually and that's very effective unfortunately means as well as older adults tend to live alone. And so if they have tried Suicide they may not be found for a while to get the help that they need So those are just some of the some of the context around suicide and older adults I wanted to share so What are we doing within the sash? platform of the program across the state So using the sash program that's available as I said across the state. We are Doing our very best to provide timely support referral and prevention programs to the 5000 plus Participants that we serve so how exactly are we doing this? How are we doing this in your communities where you have sash? So we're available at our program is available at about 140 different housing sites across the state and this includes, you know six unit apartments up in the Northeast Kingdom to the hundred unit High-rises the only high-rises we really have in Vermont and Berry and Burlington so doesn't matter the size or scale of the housing for low-income older adults you can Pretty much bet the sash support structure there So sprinkled across the state and what we're doing is we're making sure that our Workforce our sash staff the coordinators the wellness nurses have training in the evidence-based Suicide prevention and mental health trainings that are out there and these include Programs and you've probably heard of some of these mental health first aid you matter suicide prevention Gatekeeper training as well as wellness recovery action planning So we're using our train our staff across the state no matter where they are to be trained in these really important programs Additionally our sash participants are assessed annually by our wellness nurses at least annually Whole host of things, but it also includes our assessments include validated screens for depression anxiety social isolation loneliness and importantly Suicide risk suicide risk in and of itself is a thing so you can't just Assess someone for depression and think you're going to catch suicide risk We learned that we made a change and we assess across the board for suicide risk now We also have built through the sash model across the state a strong strong and trusting Relationships with our participants that is the most important thing that we can do because that's how we get our participants Open up to our staff to talk about these really difficult and sensitive topics That is the first line of the job description for sash coordinators is that they build relationships with their participants We our staff provide regular check-ins daily weekly basis with high-risk participants they host support groups educational events to combat the stigma around mental health and suicide and Would they help our participants seek the mental health support they need I meant to do a little show and tell with you, but I forgot the yellow folder So imagine I'm holding a bright yellow folder and we provide to all of our sash programs across the state a Suicide prevention resource packet if I open the folder on the left-hand side is all the local Emergency numbers for our staff to be able to call if they're working with a participant that is showing Suicidal ideation it also has language to use and a script to ask those difficult questions So it's right at their fingertips on the right-hand side is information about national hotlines and a whole host of different Resources for them so we make sure these updated resource packet for our staff and that it's bright yellow So they can get to it really quickly in their offices And then we also have through our sash infrastructure across the state We have a really strong partnership with those folks that are here today in the Center for Health and Learning Dale the area agencies on aging and the designated community mental health agencies We're really working strongly in collaboration to to to provide that The support that really fills in the gaps for our participants And I want to lastly that I can't underscore Not the Prevention that we're able to do through the sash program our housing sites across the state a lot of them have Community space on the first floor or somewhere within their buildings And we're able to use that community space for these suicide prevention types of programs And I want to just in collaboration with Dale I wanted to make the point that the need for suicide prevention is also now highlighted in the new state plan on aging and that work is underway by Dale to train more and more of the community service providers across the state in this basic prevention So in closing, I just want to State that the sash program is committed to being part of the solution to preventing suicide death deaths in our state We want to continue to collaborate fully and closely with our existing partners and look for new ones to partner with To get to the ultimate and realistic goal of zero suicide in our state and I just want to make one final plug and that is that That is for the continued administrative funding for sash in the 2020 state budget Unfortunately in the governor's proposed budget for 2020. There's a Cut to our administrative Infrastructure funding that comes through Dale to the tune of 50 percent That kind of cut is going to be devastating To the work like this that we do to have a statewide system to deploy the workforce and to meet with your constituents where they live So I'd like to add to what she just said We've had sash up in in the Northeast Kingdom for a while and they they go above and beyond strictly suicide prevention And assist seniors to maintain their living ability in their own homes and that I want to thank you for that I have our copies people My name is Tom Duane on the faculty department of pediatrics and also in the Vermont Child Health Improvement Program at the University of Vermont in the larger College of Medicine I'm going to talk a little bit about some of the data and trends that some of some of them already been hinted at that It's often quite powerful. I think to to actually look at the data to be very instructive This is a graph I'm going to ask you to bear with me a little bit on this It shows trends and these are trends in suicide death rates So the top line the blue line is Vermont death rates and below that is US death rates We use rates because it accounts for the fact that Vermont has a small and more variable estimate We can compare apples to apples instead of apples to oranges So a couple of things I'd like you to notice about this graph. One is that the blue line is consistently higher than the green line So the Vermont's going all the way back to 2005 before 2005 Vermont's rates are substantially higher than the US rates Another thing I'd like you to know this is that if you look back to 2005 Vermont is about one and a half people worse in our rate than the US and you fast forward to 2017 and We're more than double than about worse than the US. So we are Accelerating we're actually getting worse faster than the US death rates. I'll make a bug at this point that We're our estimates are a little bit jagged you can see that and that's because we just don't have that big of a population We have a larger population I also want you to think a little bit about that We're talking about 110 plus or minus deaths a year, which is huge and which impacts thousands of families. This is dr. Lopez said Think about the attempts to so I'll show you data in a minute that says that especially among younger people There's probably 25 attempt survivors for every death. So think about that I think that the hospitalization is thinking about the people who wind up in the ED Many perhaps unnecessarily and preventably Molly mentioned some of the Differences that we see in death rates for older Vermonters and bigger people in the US I'd like you to look at the left part of this graph and this is the death rates for Broad age bands. Yeah, sorry Okay So these are broad-aged bands and the dark blue lines are for males and the green bars are for Females and what you see is that males are consistently three or four times higher in their death rates that females are and that's consistent with the US I Would point out that you know all these bars pretty much are higher on the left So we're not talking about Vermont's just worse among older people. It's across the board worse the last thing I would point out about this graph is that Females if females are making it to the mid 60s, they're actually doing fairly well We really see that males are are really driving this and then to really unpack that what's happening in the older population And Molly Molly mentioned this as well. She should be I will just point out that as she noted it is men in their 60s and early 70s that seem to be driving most of the disparity between Vermont's higher rates and the national rates One thing we've been looking at recently is trying to get finer grained and understanding where suicide deaths are happening also attempts But this graph focuses on deaths. This is the 14 Vermont counties broken out by their death rates over a three-year period Going back to We use a three-year period because there aren't that many deaths in some of the smaller counties So we love the years together But look at this variability. You see the Moille County is running four times higher in their death rates than Grand Isle County It's it's remarkable to me when we started looking at the county level data It was shocking to see what kind of disparities we're seeing now if we looked at a different three-year period We might get a different pattern, but we do see that, you know, on average There are huge disparities in where people are dying. I suspect if we looked at suicide attempts, we'd probably get a similar picture We just haven't done that yet I'd love to Attempts data is harder to get because you have to get it from e-gains, right? Inpatient hospitalizations I did want to make a point that's already been made while we made this point. The majority of Suicide deaths in Vermont are involving firearms Followed by suffocation poisoning in falls and other means When we look at younger people so so the firearms deaths are mostly being driven by older people Specifically older males who tend to be more likely to have firearms And and I think this point is worth making firearms injuries are much less reversible than intentional overdoses and suffocation On their instant and they're more they're more traumatic. So You could you could look at this graph and think about why? Why the lethality is so much higher for firearms? There's a lot of reasons why that would be a case And then among younger people we also see that among teenagers basically There seems to be a bit higher use of firearms and less so in the sort of middle-aged ranges I wanted to drill down on youth just a little bit very briefly CDC Estonates that there's 25 Suicide attempts among younger people for every death that you get from the suicide of younger people as well You know did this goes to four attempts currently got a lot of people and there's a bunch of reasons why that would be the case a Recent estimate that we came up with was that if you look at medically serious Suicide attempts, so this is an ideation or cutting or for Things that might not necessarily get you to the emergency room, but we are looking at a minimum of 375 annually just among young people and that's out of a total of over 15 Who would wind up having medically serious suicide attempts young people seem to be overrepresented Suicide attempts and I did want to make a Mention of some of the higher risk populations, so we we love the Vermont youth risk behavior survey It's a wonderful window into what young people are thinking what their behaviors are But we had really great participation in Vermont, which I'm very thankful for From the 2017 wire BS we learned that LGBTQ young people are about three times more likely to felt sad or hopeless Every day for at least two weeks. That's a marker. It's one of the diagnostic criteria for a major impressive episode That's pretty significant LGBTQ young people are four times more likely to have hurt themselves on purpose in the past 12 months That could be cutting piercing scratching and there are more than four times more likely to have made a suicide plan in the past year And four and a half times more likely to have actually made a suicide attempt So this is where we're talking getting up in 30 40 50 percent range of this population for for serious suicide Students who identify as being people of color are 50 percent more likely to be a suicide plan in the preceding 12 months and More than 50 percent increased likelihood to have actually made an attempt. This is in contrast with the national data where nationally Being a member of a racial ethnic minority is actually protected against suicide in Vermont. It appears not to be the case This is Vermont for my use risk behavior I just wanted to mention another wire BS data point We have these trends going from 2011 to 2017 the blue line is felt sad or hopeless between weeks green line Is purposefully else hurt self? The dark green is made a suicide plan in the past year and the red line is attempted suicide in the past year Vermont seems to have hit its high water mark on these bad measures in 2015 and there may be a slight change happening according to 2017 Except for that felt sad or hopeless seems like it's still trending in the wrong direction And the one line I would orient you towards on this graph is the top blue line that is Vermonters age 20 to 24 who actually died by suicide And again using bins of years through your bins of years. This trend has been increasing since about 2006 through 2017 We're consistently higher than the US rates, which are the green green bars and The US it's not so much that Vermont's trend is getting better. It's that the US is catching up to us Okay, so relative to the US we don't look as bad, but really we are pretty much just as bad And that's for ages 20 to 24 the dark green line of the squares below is Vermont ages 10 to 19 also higher I wanted just to make a few take away points about this this brief overview We know that US suicide death rates increased. There's been a lot of media in the past year about that I think there's been less focus in our state on the fact that Vermont suicide death rates have been increasing differentially faster Definitely feels to me like it's a public health crisis Most suicide deaths occur among middle-aged and older Vermonters, especially among males Firearms are the most frequently used means that the waters used to take their lives And lastly that specific groups of younger people including LGBTQ people and people of color Young people color should substantially higher rates of suicide. I think do we transition the questions now or? I'm happy to start answering And I just suggest that we have everyone who was speaking Hi, I'm Maura Cordes. I represent Lincoln, Monkton, Bristol and Starksboro and also a registered nurse have worked in inpatient psychiatry Currently working at UVM medical center where we are seeing the fruits of your work in screening for suicidality and I'm noticing an opportunity for growth as a healthcare professional among myself and my Colleague my nurse colleagues and again, I've had experience in inpatient psychiatry. I'm also survivor. I've had four immediate family members commit suicide So I take this very seriously in the inpatient admission process Recently we now started using a screening tool where we ask people what you know all sorts of questions like what's sort of Faith you are and you want to have someone come visit you we ask if you have advanced directives we ask clothing you brought And then now we're asking using a tool and I don't know actually be interested to know PQHQ is the the name of the tool this PHQ 9 and PHQ 2 Patient health questionnaire nine question version So that that has been very interesting Interesting I can see how it would be helpful what I'm noticing in my colleagues is the stigma around asking patients that We're hesitant to ask those questions, and I think it's a great opportunity for myself as a everything that I just described to help myself and to help my colleagues also Use it as a time to teach patients in their family around the issue and to be sure not to Rush those questions off because they might make us feel uncomfortable, or we think that it's going to make the patient of the family Feel more Uncomfortable, so I appreciate the work that you've done And the last thing is I also appreciate Before you got to the slide about the LGBTQ When you were looking at gender Statistics I was wishing that gender non-conforming was in that collection of data and so going forward it would be helpful to To have that I would encourage the state to collect it And we have it for YRBS the state's great for YRBS, but there may be other places Emory Not talking, this is Mari saying They don't really ask about And it was mentioned that doctors need more training, but they also Doctors don't seem to talk about death Even if you have a cancer diagnosis they're hesitant to say you've got two to three months left They usually say we have another treatment and they try to get hope We're used to just that training begins because that's not just it's a cultural shift. It's not just oh Let's go to this training We we just wrote a grant last year to start some training programs for residents who are the primary care Departments and suicide assessment of patients which gives them practice in asking those typical questions They're also there's a good amount of funding than just this is UVM medical center And it should be in other places, too, but I know UVM just started a palliative care Program which is making moving them all forward a little bit and training doctors on how to talk patients about death and dying and Applied questions and those sorts of things so training is an easy it takes and it takes leadership Someone has to decide that the training is necessary and then negotiate with training directors To say can you could you please put this into your? curriculum and Some training directors are not so open to but they're also have full curriculum. So it's it's not an easy situation, but it takes to committed people basically, I think Yes, I think it's a system Okay, yeah Yeah, it's a systems management issue You know zero suicide has three central facets a set of core values about shared responsibility And also a commitment to parity and physical and mental health But the second realm or facet is systems management and that's all about training Workforce development and we have very good tools a workforce development survey Sir for zero suicide that assesses all of the clinicians our health care practice Titianers knowledge and skills across a spectrum of services and then we can identify What the priorities are for training and then the third element is well? What are we going to train them in and that's evidence-based practices? So the core values the systems management and the evidence-based practices are really Quite laid out in the zero suicide framework My hope is that we would begin to see this kind of training in all health care training And I do want to mention because it concerns me that we sometimes ask clinicians to use these assessments Before they've had any time to deal with their own attitudes and stigmas and values And that's called gatekeeper training and if you notice on the sheet You've got the bottom of the pyramid includes universal for everybody training And that's for the public for community members for health care on Talking about these issues, and that's what we call new matter is a gatekeeper training and there are others as well And I feel strongly about that because we're giving Practitioners the Columbia Suicide severity rating scale or the collaborative assessment for the management of suicide And asking them to implement these with patients without even giving them an hour or an hour and a half To just confront societal adds attitudes and norms etc. Very helpful So I'm gonna suggest that we initially just for committee members or people who have the agenda plan to take a break about in a minute or two But given Where we are I think I would like to suggest that we continue with questions for another 10 minutes plus maybe 15 minutes Because I think that's a very rich opportunity Then we'll take a break a shorter break and then we'll hear from our other witnesses So I think and some of this will weave together as we hear from the other witnesses in late morning But that's that's agreeable with committee members and if you're available for us to continue that for those who are available Continue ask questions I've seen the the suicide death rates by counting statistics a few times I represent water bill in Cambridge, so two times in a while Which has the highest in the statistics I see I guess my question is for this would be First if there's any thought on why suicide rates would vary by county But then secondly and I'm assuming these numbers are per a hundred thousand individuals, which means we're talking two to three deaths per year in the oil county and The difference between two deaths there's three deaths being the difference between us being in the middle versus the top And so I guess I'm curious as to how much we can take away from that these numbers And it hasn't looked at over different year ranges because if it really is just the difference of Like it varies in some years different counties aren't taught I'm very Yes, your second question is great. That's about fluctuation. It's small You know, we're extrapolating based on small populations and to the extent that we're doing that we are definitely having more bouncing around So we try to use multiple years Estimates, and then we do also Revisit and look at different years. I can tell you the oil is consistently It's we haven't really seen that bouncing around And Well, this is a good point for me to point out This is what I should say that I'm representing my own views and not the views of University of Vermont So I should have said that earlier Demographics has a lot to do with it. So there are populations in the US that are inherently higher suicide death rates So rural rural areas are higher for death rates also higher for firearms ownership and social isolation and things like that Vermont has really high rates of binge drinking binge drinking is correlated with higher suicide death rates Vermont that I would suspect that your your county is one of the whitest counties and actually the demographic data is that More white population areas actually have higher suicide death rates than areas that have more racial ethnic minorities Rates of firearms ownership is a correlate ever mentioned that So there's a whole cluster of things it's it's probably important to note that it's You can't look at one person who died by suicide and extrapolate about all the different systems and ways that they were either helped or not helped but Everybody's unique, right? So it's hard to say What's what's impacting people in the wild differently than the rest of the state? I wish that we had a clearer story And all these things are correlated, but it's not like a causes be causes see Anyone could answer this question Firearms take a really bad rap all the time no matter what it's being talked about nowadays Do you or anyone I like all of your opinions as far as this goes, but do you think that if death by suicide The firearm is not available with the person that took their own life find an alternative way to do it So I can answer this from two different perspective ones from the emergency medicine point of view and one is from a medical oncologist point of view a Lot of people who attempt suicide do this in possibly They often require some degree of intoxication to overcome them in a hurdle and then Execute their plans whatever it is There are a couple of things that if you change your mind later You can't reverse it and those are fire injuries and jumping of heights if you admit fall you can't change your mind Once you pull the trigger you cannot change your mind If however you overdose for example, you can realize 10 minutes later. Oh my god. I did was incredibly stupid or desperate or Not well found out and go seek help With a firearm, you don't have an option After you have poisoned yourself most poisonings are sub-lethal Most people will define you without treatments and people who do need treatments most poisonings aren't treatable There's very few that we can't treat the gunshot wound Once you pull the triggers there The same goes for hanging most people that try to hang themselves They don't hang themselves, and they use the term carefully correctly Where they would have immediate death most people Actually suffocate at the strangulate and in that time sometimes they realize this is not working This is this is going to do and they get back on the feet or they struggle loud enough for someone to get help And cut them down in time once you hear a gunshot Wait, I think there's more to that. I'm sorry, and I'm not one of the speakers. Do you want to speak to this Deborah? I'm a family doctor There's a threshold effect and where there are when people get to a certain point of extreme where they're ready to pull the trigger It's because they cross the line But they don't but there's a lot of research to show they don't stay across the line And so the fact that what you asked would they kill themself anyway? And the answer is generally thought to be and correct me if I'm wrong. No, they would There's a lot of research showing this with veterans with a number of groups that really even just putting a barrier between you and like a lock between you and Access to the gun can make a difference And like you said, it's hand done pretty pretty permanent Yeah, or whatever firing I should say Thank you. Thank you for speaking up. Thank you Just what one thing I would add is I meant to when I was describing the yellow folders We give out to all of our staff across the state one thing I forgot to mention as we include gun locks on the right hand side as well and those are provided by the mental health agencies and we're what we have found is that our staff are able to have such Close relationships with their participants that they can have that conversation to say, you know We just talked about the suicidal ideation. I care about you. I'm worried about you We use this gun lock and put this on. I know you have a gun But you've told me that in the past can we do that and you know in some instances are able to do that But it's all about the relationship and having that gun lock Thanks about the practitioner if I may end my line because you're really on an important tack here The practitioner having the training to know that this is what's called collaborative safety planning That they need to have the conversations with the patient and the people in the environment to remove the lethal Yes, and it does take relationship and it takes asking the question knowing what you're asking and how to have that conversation I think I think my question is mostly directed to Sex check your name. Sorry to Joel and to Rallo Because it's about training, but So I'm Brian Tina, I represent Burlington and I'm actually a psychotherapist and I'm a substitute crisis clinician Thank you. Thanks, and And The question I had I'm just looking for this chart So, you know, I've had change they train it just for not that I'm a witness right now But just so people know they do train crisis clinicians at least at the Howard Center in calm And that's the counseling to access I might put you in the name a little bit counseling They train clinicians in how to talk with people how to be skillful about asking Access to weapons during any kind of assessment and how to like work with people and their families and support systems to like reduce Access to those what to lethal weapons Anyway, I have training in that and I have training as a psychotherapist in CBD at CBT and that was a 40 I have training in CBT and DBT Yeah, sure cognitive behavioral therapy and dialectical behavioral therapy and To suicide-specific treatments, right, but they're also like core foundations of psychotherapy and so You know every therapist is getting trained in CBT when they begin I think the question I have is sort of like how are we gonna? How are we helping people to? Build on that because I think this speaks to to um doctor I know you're I think you use the mom right now even though you're the doctor Yeah, but I think but you're still you know what you were saying about how You know people aren't kept up today I think everyone gets these some of these things in their training foundation, but how can we support providers in? Taking it to taking it to a new level based on what we've learned and so where I'm going with this is I'm curious Like I know we can do trauma-informed anything like we can do trauma-informed CBT or trauma-informed DBT and At least in my experience like Almost every person including myself who's dealt with do I've encountered who's dealt with suicide? It's connected to some kind of trauma or some kind of traumatic experience even if it's like societal trauma I'm wondering like where you know where trauma-informed treatment comes into into this and Maybe if you could just say more about that and also are there other therapies that you're looking at like EMDR? Or or ACT or which is attached. I'm not trained in that one. So for you me. It's like an attachment commitment therapy or Like EMDR means eye movement desensitization and reprocessing Or other trauma-informed therapies, so I'm going to answer in two words Suicide specific So CBT actually put out a whole augmentation Because the cognitive behavior therapy which is considered an effective therapy needs to be suicide specific So the practitioner who you're getting a referral for CBT treatment You need to know that this person has been identified for Suicidality that has to occur out of screening and then an assessment of how far they've gone with this Do they have a plan? Have they identified a means? How long have they thought of it? All of that has to inform how you use CBT and it needs to be suicide Dality specific or otherwise we miss it See more about what that training would look like for And also how can we help that like is there a way the state can fund it or provide it? So COM is a two-hour online free training the counseling access to lethal means two hours online We have clinicians in our state have Identified cams the collaborative assessment for the management of suicide as an assessment and a treatment and Department of Mental Health has been funding some cams training in three pilot designated agencies. We've trained about a hundred and 35 40 collision Clinicians, so it's just got to be made available Clinicians are motivated to do this work, you know this this is it's yeah It is hard hard to deal with a patient and not know the appropriate interface or tools to use so we need to Clarify the suicide specific nature of treatment and then we need to make the training Available and we would like to do that, but we need more dollars It's a little expensive sometimes depending on what you're using and that would go for the other treatments that you mentioned EMDR is a generally effective therapeutic tool for dealing with trauma. However If somebody isn't dealing with the cause of their suicidality, you know The treatment can go round and round just like talk-based therapy can, you know We have to really know how we're gearing for what purposes Does that help some of what you said was helpful like letting us know that I don't I mean it was all helpful But some of it was especially helpful like like what you said about how the state has to be pilot projects because that sounds like we're exploring that ways to to Disseminate these these practices and time is doing the evaluation on those workforce development initiatives Yes, it is too quick thoughts. What is that the the existing pilots really aimed at employees of the designated agencies and Isn't really touching the hundreds and hundreds of providers who were out in the community So that's one thought like a huge opportunity for expansion Another thought is that there's at least one or two states. I think Oregon is one of them that has mandated that continuing education for Psychological providers includes suicide prevention. So you can actually mandate that and it leads to a change mandatory change in providers behaviors Yeah, I think it's essentially been answered by the answers that you all just gave but it was whether The testimony that we heard about the lack of training and competency what is shared across the wider provider population in the state and whether There is possibly whether there's a legislative solution in mandating more training and You mentioned Oregon so that suggests maybe there is There are three states actually that that have passed a zero suicide Legislation We just got the links from those from our partners at American Foundation for suicide prevention And I haven't looked closely at them. I did forward them to you in about a week ago We could look at that I think we're trying right now to engage Healthcare because we've got the all-payer outcome measures and they have big motivation to do this along with the Swelling of concern of health care providers along the way So I think that has been our strategy and to work with the systems that deliver medical education to to raise awareness But get a commitment But it needs to be a formal commitment and there needs to be explicit leadership commitment The real issue is getting health care to fund the workforce development or I say that rather naively to figure out the funding Mechanisms behind because it does take some cost to organize Facilitate offer and also we know that training is not effective when it's a one-shot deal That you know training needs to be embedded in a series of hours that are contact But then followed up with consult coals and coaching and ongoing systems management My view is that we have work to do as as a coalition and as interested parties to actually figure out Where the legislative Peace can be helpful. I don't think we I don't think we've done the homework to really Figure out what's worked in other states? What are the right laws? What are the wrong laws? You know, I don't think we're there yet So I I'm hoping that this is an ongoing conversation. Maybe here or two. We'll have better Suggestions, but I don't think we have them right now and actually it's a national dialogue. Yeah Can I just say a couple things and then a couple of comments from my own experience of working with this as I think everyone knows I worked as a psychotherapist and worked in community mental health for 20 some years in Addison County and And and I've been part of the coalition at times in the past and this is a this is an issue I'm deeply passionate about in part because Again as most people know I've been committed to changing societal points of view around LGBTQ people particularly youth and it's incredibly painful after Probably 40 years of working to make change and having made some very significant changes in this state of Vermont to still be losing young people queer LGBTQ young people to suicide for me, it's it's it's it's just Personally and professionally very painful But I want to make two points one is that Having having Providing people with a list of questions isn't sufficient. I Can testify to the fact of people that I know Being in a primary care physician's office where there was a list of all the questions such a check to ask about and Knowing that the person was feeling suicidal And knowing that they skipped over all the questions that had anything to do with that so that by the time the person left The office they were not asked the question and they many people Gonna take the risk of being a witness here, but many people present Like they're functioning very well at the point where they're actually very high risk of suicide it is very easy to hide it is very easy to hide and Many of us know that because we've done it frankly and so You cannot just count on your personal observation and you think your clinical skills are the greatest You cannot with if you don't actually engage in asking questions in a way that you can get the answers You will miss what's really going on second point. I'd like to make Coming out of my work with LGBTQ youth queer youth as they many times prefer to be called these days I was working a young girl young woman Who had made had three psychiatric hospitalizations in Vermont in the state of Vermont for having made suicide attempts and In each of the psychiatric hospitalizations She was never asked or felt able to reveal anything about her conflict around sexual orientation and it was not until she was In a second outpatient setting did someone finally mention to her outright for mom Which was established in 1989 to help LGBTQ youth and to offer prevention services across the state And what she said to me was outright Vermont saved my life and What I was listening is I was hearing her story. I Was appalled I was absolutely appalled that someone could have been admitted three times in Vermont to psychiatric inpatient care and Never from her point of view never have someone asked or have her feel safe enough to raise that issue So we must and when we look at the data and the data is absolutely why are BS data? LGBTQ youth are some of the highest risk youth in Vermont as well as youth of color We must not just focus on issues of suicide We must focus on the issues that are the underlying causes of why do so many Why should an LGBTQ youth Feel that badly about themselves that they think the only solution is to end their life And we must confront that amongst ourselves These are the number kind of underlying issues that we that are harder for us to confront at times because because societal points of view Sometimes religious sometimes personal family Create the environment in which that youth is Feeling completely hopeless and they see no way out except to end their life And so sometimes our interventions are societal interventions as well in terms of saying we must not allow this to continue anymore It is actually a matter of a life and death so Maybe a final comment number thing You know bringing our attention to that Representative Lippert Is that today we're talking about health care, which is goal number seven of 11 in the Vermont suicide prevention platform Which is a public health model with sociological ecological objectives built for different populations across different systems and You know those other things are not being spoken about directly today But absolutely suicide is a complex societal issue and we need to address it in a very multi-pronged Public health approach Today is the health care discussion But other years and at other times and in other venues we have a larger discussion So I would like to end on that. Thank you Okay, let's take a break to a quarter after then we'll come back here Really again to those who were witnesses this morning. Thank you for your part in that It's hard to stop a lot of conversation that I know is important conversation going on but I I would like to turn our attention to hearing From Two other folks who are going to give us more of an update around some prevention efforts in the state and first turn to Tracy the ones from the Department of Health and And then to Allison That's fine Yourself for the record and then I'll leave a few to proceed and just suggest we hold questions So we've heard from both of you and then we'll engage in Depending on where these go. We might want to get your questions for some of our witnesses for this morning as well For the record Allison prompt I'm a senior quality advisor for the Department of Mental Health I Came on about a year ago and in my previous life was a mental health crisis clinician So I was the one in the Edie's assessing for suicidality During a very tight time at least so it's a passion of mine always has been and now I oversee the grant Center for Health and Learning And so that's one of the first things I wanted to talk about today I'm Tracy Dolan and I'm the Deputy Commissioner of the Department of Health So you've heard a lot today that this is a major issue So I think the goal for us today is to let you know what is going on right now In suicide prevention in the States and then identify What are the gaps and also where we see things headed? so The first thing to talk about is the Department of Mental Health supports the Vermont suicide prevention coalition So those are the folks that you met with I think just prior to us coming in So you know a lot about that and the group is really multifaceted. They're well established and We really support their work and part of this Things that we're using this group for to use data that we have to then inform what that group works on And so for instance, we wanted to highlight that our last quarterly Meeting there was a panel discussion for specific target populations. Those are populations that the data has Stated who needs that's at higher risk and needs attention. So we had panelists to speak to LGBTQ youth and adults new Americans Individuals with mental illness and survivors and older Vermonters And so this group is a major resource for the work going on And then in terms of the agency of human services We have a need to develop leadership on this issue and we are doing that at AHS Through this suicide prevention leadership group So myself and Tracy Dolan share this group and we have a few goals stated for this coming year One of them was today. I'm working towards Presenting the legislative report for Act 34 But also setting some in our agency leadership on implementing the zero suicide platform I'll talk a little bit more about what that is In a few minutes. We also provide oversight and direction for the data surveillance group Probably all know that giving standardized data really difficult People who do that in their line of work often get requests from all sorts of people all the time And so we're working really hard across agencies to create some standardized ways to get really clear data That we're all going to work on together and then one of the things that came up in our group as we were talking is Hey, how about our own staff? You know, we have a very large People who work at the agency of human services. What would they do if someone came up to them? One of their colleagues came up and said that they were feeling suicidal So starting with our art within our own house was a priority for this year Making sure we've got strong policy and people know what to do and how to seek help within a Hs And then the last piece is providing recommendations for future direction of policy and practice So taking what we know and figuring out where to go from there I'm just going to jump in the other goal also relay deck 34. I believe this time next year We are due to provide You with a plan moving forward for suicide prevention in the state and so this group this year will be developing those recommendations Also related to this group. We are pursuing a new grant. That's open now and we're looking on that From SAMHSA Not every state will get it. So it's competitive But if we get it, it's up to 750,000 a year. I think for five years Which is meant to be focused on use suicide prevention And so this group will also help inform that effort over the next four to six weeks So now we're moving on to Yeah, all right to the data. I just wanted to speak a little bit about the data sources that we use When we look at suicide deaths and I just want to acknowledge first. I wasn't in the room earlier, but You know a lot of us in the room have either lost someone through suicide or know someone Close to us. And so I understand that there's a human being behind every one of these numbers So we will be talking numbers and percentages and that can feel sometimes pretty cold when we look at trends But we recognize there's a human being behind each number We will be applying this year for another five-year grant to continue our national violent death reporting system We also have data through vital statistics the office of the chief medical examiner We also have data on suicide risk factors through the youth risk behavior survey The behavioral risk factor surveillance system and hospital discharge data So we do have some really good data sources both on the actual deaths and on the behaviors I'm just going to speak to a few of those so you can understand what they're about the national violent death reporting system We entered into a partnership with main on a cdc grant to examine factors associated with suicide using the nvdrs It collects data on violent deaths including suicides The three major data sources are death certificates our medical examiner reports and law enforcement reports And the information collected includes circumstances related to suicide deaths Like depression major life stresses relationship or financial problems So it does give us a more rich data than we get from our other sources Looking at trends over the past 10 years You can see here from 2008 through 2017 In 2016 the us suicide rate was 13.5 per 100,000 Vermont suicide is the eighth leading cause of death And in the US suicide is the 10th leading cause of death So you can see here that our rate in 2016 as an example the 17.3 so higher than the US average rate So that's just looking at it over over a period. We're going to bring it down a little bit I was whispering at the chair if we're saving questions for the end I didn't mean to I was trying to be discreet I think we will And some of this because we're going to pull it apart a little bit Yeah, you might get answered later and if it doesn't yeah, please note it for sure And if we can't get you a question unanswered right away, we'll come back And I think some of us that were presented with some data from earlier this morning and just Actually And where there's a mismatch we might have to get back to you Okay Males and females you can see that Males have a much higher rate of suicide in almost all age groups other than among young people Self-harm, however Works in the other direction females generally show more self-harm than males And self-harm decreases with age Self-harm may not mean something to folks or it can include cutting as an example We have other things that fall in the self-harm category burning There are I mean there's different trends in terms of teenagers, but I'm poking the neos things like that Yeah Yes Gonna cruise through these a little bit quickly, but hopefully you'll you'll grasp so suicide deaths in brahmon 2015 through 2016 some numbers here 98 percent of those deaths were white non-hispanic. That's a census category The average age was 49.5 42 of those who Died by suicide were never married 48 percent had a diagnosis of depression 32 percent had been receiving mental health treatment And 14 percent had events of recent release From an institution. I'll have to get back to you on what we need by institution there. I don't know if that would include corrections I think it's usually psychiatric hospitalization psychiatric hospitalization So risk factors and target populations you might read information about Who's most at risk in the united states? But that does vary from state to state and so when we first looked at The most at risk populations in the u.s. It didn't exactly line up. So we looked more closely at our data Our risk factors our depression diagnosis history of suicide attempt physical health problem The age range of 50 to 25 and then 60 and over and veteran status Our target populations in brahmont our teens and young adults older adults lgbtq new americans persons of color and veterans And we're going to break down for you a little bit some of those target groups and groups who've been identified as higher risk factors I can't help but just say when if you look at the target groups, and then you think about some of the fits into multiples of the target groups What that must be Yep, that's an incredibly important way Uh what we know about uh folks in brahmont who have died by depression or i'm sorry with depression who have died by suicide They are two times more likely to have previous attempts There are also six times more likely to have received mental health treatment Um, which I think is interesting. I think some of you may know Screening for depression has increased in brahmont. A ph q9 is a common screening tool used And so it's it's a good indication that people are getting two treatment if they have depression Whether or not they are then being screened for suicide ally or treated for that is another issue Um, and then one in four adolescents reported feeling sad or hopeless With our eucris behavior survey, which I think is just a staggering issue And if you look at that closely girls are up to 35 percent In our lgbtq q use are 50 8 percent or likely to have expressed feeling sad or hopeless So that's some statistics about our population with depression We broke things out into age groups And fourth the same group of youth who filled out the youth risk behavior survey 11 percent reported they made a suicide plan in the last year That number goes up again for girls and goes up again for lgbtq youth And then our older population have a lower rate of depression diagnosis They have a higher rate of disability But it's this group older men 65 and up who have the highest rate of suicide One of the things we're looking at is why that may be Do they actually not have a diagnosis of clinical depression? Maybe it's they're facing a health condition or financial stressors Or is it a help seeking behavior issue? But one thing to note is that older adults who took their lives were more likely to have used a firearm Which we know is a more lethal means could increase the rate of death And those were the history of suicide attempts So They are more likely to have expressed with some thoughts in the past We're likely to have a diagnosis of depression And then in vermont it is notable that there was over a thousand ed visits and hospitalizations for self harm And that's probably under reported We don't have a good way to code self harm at emergency departments. Sometimes it's just multiple complaints or lacerations You may not know that so that's just what we know of Um, and so we do know that um adolescence 15 to 24 are more likely To self harm we also know they're more likely to attempt multiple times Before there's any death by suicide Just good because it gives us more of a chance to intervene So one goes for a physical health problems those who died by suicide and who had a physical health problem are more likely to have been a veteran Older than 45 years of age four times more likely in this case Less likely to have reported problems with an intimate partner Among vermont adults 62 percent of at least one chronic disease Of those who have died by suicide and 25% live with a disability So like you mentioned, we have people obviously in multiple categories, which increases our risk Those more likely to have a disability 65 and older lower education lower income Is this relative to other people who died by suicide or relative to the population as a whole It's relative to our vermont Yes to other people who died by suicide So among veterans those who died by suicide and were a veteran were more likely to have been older than 60 Used a firearm and have physical health problems and males are more likely among veterans Ages 18 to 34 and that's 65 and older Veterans use of firearms to take their own lives females 100 percent versus 27 percent non-veterans males 80 percent versus 59 percent non-veterans So this is just telling us that veterans are much more likely to use a firearm And we do know that access to lethal means increases suicide risk across state groups So new americans persons of color and lgbtq These three groups have the least quantitative data about suicide available So we're asking new questions on BRFSS to gain insight And we hope to have better data available in 2019 So lgbtq adults are nearly twice as likely to be diagnosed with depressive disorder Adolescents are more likely to feel sad or hopeless Or to have made a suicide plan or attempt in the past year versus adolescents who are not lgbtq Adolescents of color are more likely to feel sad or hopeless or have made a suicide plan or attempt in the past year as well And among adults of color, we're not seeing a difference in diagnosis of depression But certainly lgbtq adolescents who can see us start differences We don't have specific information on who americans or refugees However, four important honors have similar suicide rate as you as part of the honors So what do we do about it? We want to highlight that Zero suicide is a framework that we are well versed in and it is working in other states And so we are working to adopt that framework throughout vermont And the pillars of that include leading So we've talked about a few of those initiatives. The coalition is an example of leading ahs suicide prevention group is another Training that includes not just having trained workforce within clinicians, but also training community members training Schools training primary care to have that further out ability to identify and refer And that includes um, they have for identification and assessing we're looking at Universal screening we screen in pockets. We screen Where it's obvious. We don't screen everywhere. Um, and so that's that's another piece and uh, fourth piece is engagement and um, I would argue we're really struggling there at vermont I'm giving that only 32 of those who died by suicide have been receiving mental health treatment We're not necessarily Getting people in the doors and getting them the help that they need at the time they need it To treat we have three pilots in vermont That are zero suicide pilots and they are trained in an evidence-based practice called hams, which I will highlight In a few minutes is collaborative assessment management and suicidality Those three pilots are in um, at the howard center in shinton county At the loyal and then also up at ncss for franklin and grandisle So Three pilots we could do better. Um, but we know that um treating and evidence-based practice is extremely important And then transitions So this is also a gap is always a problem in health care is getting people in between providers Maybe you got them what they needed, but then the follow-up care falls off the map And so working through those transitions is extremely important And the last pillar for zero suicide is improved and that's using Data using everything we know and making informed decisions based off that so examples of that are the ahs Suicide leadership group uses the data from our data surveillance group to inform practice We're also assessing all of our zero suicide Pilots to see how are they doing is it working and we're going to show you some of that data in a few minutes In terms of investments, um, there's the ndvrs grant that Tracy spoke of earlier that supports gathering this data The department of mental health invests 191 thousand dollars ish to the center for health and learning and with that they do A lot, um, they do basically All the things that we've mentioned earlier all of the training out in communities Zero suicide training the cams training and the work with the schools for prevention and so bdh also provides some upstream investments that go to center for health and learning And that's where you matter trainings and schools So that's really trying to broaden eight people training to help the people know how to identify those in need There was a project a few years ago at the nmc that looked at coding And coding people who come into the ed so that's data that's being analyzed now It's not an ongoing project. It was a one time And then blueprint they had a recent investment in 2018 $1,500 to get them started to work They worked with one pcp office and it does need an agency to try to work on referrals And so we see sash and blueprint and s spins as really good partners in this project because they They're bread and butter screening and referral and doing that very well So this is just giving you an idea of who those partners are and some of the things that have come out of that Um, and so in terms of means restriction the preachy preachy bridge mitigation project is a great example like I just heard a story of a State trooper who was passing by and someone was on the bridge Attempting to climb the fence and they were struggling to do that and they did have time to pull them down And that's just the perfect example of what time can buy you when someone's Experiencing a heightened challenge in their life a little bit about you matter. This is where we're doing our gatekeeper and upstream prevention So you matter has a series of trainings and schools and communities and it provides an asset based approach to suicide prevention So it's a nationally recognized best practice. It happens in our schools in vermont And there's this emphasis on creating prevention prepared community. So it's people feeling comfortable and confident asking Their friends how they're doing. Um, it's it's training trainers so that they can keep and sustain That knowledge and then it builds connections between schools and families and support services So whatever you matter training you're inundated with what are your resources? Who would you call? What would you do in this scenario to really try to bolster at a community level? What people's resources are and how they Act when a crisis occurs And that's jointly funded by the department of mental health and vh And just to show you the impact of you matter This is some pre and post data that we've gathered from that training And so for the training of trainers, we're really focusing on clinicians about how to treat But then what I find really interesting is this youth and young adults At the bottom of how they describe their ability to respond To their own peers when they're in a moment of crisis And I think this last piece where you see 64 percent of youth Understanding the difference between fixed and growth mindset And then at the end 98 percent do This I would just personally like to highlight because growth mindset is when you see a failure as a setback The one that you can get past It's one where it teaches you that if you develop skills and grow you will be able to overcome that Where some do really struggle with that ability and if they face a setback it can become permanent for them They consider it part of their makeup that I am a failure And therefore nothing will get better And it's that type of mindset that can really lead to lack of to more hopelessness Lack of optimism. You can't see your future beyond the trees And so when you have that type of fixed mindset, it's much more difficult for you to face challenges in your life And so more programs like this that can help build those skills are really important In terms of the investment dollars and what they're going to this is the makeup of Those events and so you'll see there's a great deal of the gatekeeper training and gatekeeper training is when I say You matter that's a gatekeeper training. That's going To the community level Mental health first aid is another community level effort. So I hope you've heard of mental health first aid it's been around a long time Mental health first aid trainer and I believe in it. Um, but it's for community members. Um, helping your neighbor That sort of thing and then we have our camps and comm trainings So cams training is the specific for clinicians to treat suicidality Com is counseling about um access to lethal means So that's really teaching anybody especially providers of any kind How would you talk to somebody about their access to lethal means in a non-judgemental way in a way that's just informative That's bringing the conversation to the forefront This is just some data that we've collected about how it's going with the zero suicide implementation and these cams trainings and cams again is the assessment and management of suicidality And we're seeing that people who are trained in cams are having a significantly increased Confidence in their ability to assess patients for suicidality and to treat patients who have expressed suicidality And so so far we feel that this has been a very successful pilot But again, it's only into the patients in Vermont. We wanted to highlight that we do have a crisis text line It's gotten a lot of hits over the past. We started it in November 2016. There's over 2000 Conversations where there were 1000 textures And so the main reasons we have for people texting into the text line our relationship issues Um followed by other stressors such as financial and legal But that's a high percentage 28.4 percent including the top of the suicide because this is a crisis line for a variety of crises And that really just shows you How suicide can be connected to such a variety of issues that people are facing Is this it's a Vermont line So the crisis text line is a national effort But our we are partnering with them for a Vermont specific text line So you text vt to this line and it identifies you as a promoter and we have all our data That's Vermont specific You get the national date from the national center We get the Vermont data. So where do you how do you know about this? How does anyone know the text? So we work on promoting that at every event we have So Okay Yeah, no, it's not necessarily widespread. That's something we've got to continue to work on. We don't have a Yeah, we don't have a dedicated budget for promotion of it. Although we have tried to mix it in. That's something to It's a really good comment. We don't have a good use this team, but it's really good for me to hear that Me if I'm having people in the room, you know the text number to call It's a text. I did, but I'm about to broadcast it Quick question here. I don't see the similar data or responses on do you also track the Vermont support line? We don't have the data on that now. I'd like to Yeah, okay. They produce it Yeah, great things right there. Yeah, it'd be good to Okay Thank you. So I know people are itching to ask questions. So let's Great, that's okay. I was because woody is a question and brian smith has a question brian Gina has a question So go for a couple of questions You focus on veterans Mainly those that are 60 years old of age But in in recent times now The focus is not just on older veterans. It's on the under veterans particularly combat veterans that Come back from a wartime environment and their numbers are increasing not just for males But also for fiends. I'm just pointing that out. Also. I don't see anything on first responders whether they're listed in in your statistics and then Finally, I don't think anyone has mentioned What does one do when they recognize that somebody is in In crisis. What what should I do to help? Yes, so I can speak to that in fact It's not on this slide, but we have a very handy list of resources that includes veterans specific because we do know that veterans often Are more likely to seek help when it's from people within their own culture. Um, and so The national lifeline has Vermont has a veteran specific line. So you press one and you're connected to that To that specialty So there's a national lifeline you can call there's a crisis text line that you can use and then there's a crisis center in each County that has 24 seven coverage But really what you can do if somebody comes up to you and expresses any sort of suicidal thoughts Is listen and stay with them until they can you connect them with somebody who's Can provide help Thank you And so we provide a little wallet cards whenever we do new matter trainings that has all of the resources and Just do you also work with are you part of the Vermont gun shop project? So in our previous grant that was one of the deliverables is not in this year's grant That was approached recently to restart that Yeah, I can just briefly it was working with gun shop owners to provide them more education and resources For those who might be coming into their shops Who are also in crisis to be able to provide that kind of support also to promote the The suicide call line for that population as well Is a partnership with the gun Federation Vermont and the sportsmen's association two major gun owning communities To move the discussion upstream and engage Give them the resources as Tracy said In their gun shops and including among themselves as Gun owners and friends sportsmen. Yes, how to that's what Woody's question reminded me of that How did you talk to a friend? Quite frankly it collapsed a bit last year with all of the you know, discussion about gun legislation And we would like very much to continue to do that work and Continue to focus on guns as a lethal means Yeah, the the one of the important pieces of it was really getting A connection to a population that we might not normally get a connection to through this work. So that was good Um, I think we learned about it from New Hampshire. Um, there wasn't an evidence base that necessarily supported it as a As an evidence-based practice, however that relationship is really important and a lot more can be done with that relationship And certainly it there is an evidence base that says when you give people the right kind of information at the right time That can be helpful. And so Brian Smith them right If someone gets treated Uh for potential suicide, you know, they go to the hospital And they've been treated there and they have medical records stating that it was a suicide attempt on their own life If they go down the road and try to buy a gun background checks Won't show That medical history will it They should shouldn't they One would think that could be very helpful. It would certainly be helpful Uh, that leads me to a different question. The first question I'm going to ask you about Sissy, do you believe that self harm Is a suicide attempt? No, it's definitely there is a distinction and it is usually to feel physical pain because it helps handle emotional pain And when you start to tell you forget about the rest of your words for the day, um, that it's a similar Thing but it is not Most of the time there are sometimes where somebody might have self-tarned with the hope that maybe but the majority of the time Youth and adults express that that is not the intention On just back to your first question I just do want to highlight the importance of course People's health records being private and so as much as as much as it would be helpful To be able to take that into account one also recognizes that people's health information is private So for vendors to be able to access people's health records could be of course It might also result in people not willing to seek help Because if they know that's gonna down the line maybe be on a list to prevent them From meeting a sportsman or on the other hand if they knew That they were going to have a background check and their medical history was there. They might not go in by gun Right, I guess it's too. So yeah, there's been a it is it is a big discussion. It's a good question because it I wouldn't want my medical history revealed life to anybody, but if it meant Being preventable preventing being able to buy a gun That might not be such a bad idea You follow me So just three three questions about some of the demographic stuff earlier on in the presentation um When you are looking at I'd have to go back to see the exact page when you're talking about High-risk populations. You mentioned, you know, lgbtq new americans individuals with mental illness older vermoners um I'm wondering if the state of vermont looks at abinacchi children Or abinacchi adults. Do you is that is that a question like when when you're doing surveys? Like do you give people a chance to identify? We have had some specific Um Partnerships with the abinacchi community Joan probably speak very well to that. There's one going on. Sure. One of our uh agencies northwest counseling support has long been concerned about this They work up in the franklin county. So, um Dr. Tom Delaney who presented earlier took a look at the data with us and we identified a disproportionate number of abinacchi Results, although you would notice on that state county wide data that grand aisle was at the bottom of the list But it represented a disproportionate amount of suicide deaths in the abinacchi population UVM medical center community investment funds have funded a three-year project With the fqhc federally qualified health center in burlington Northwest counseling support service in the abinacchi family advisory council of missis boy county Um and the center for health and learning to build out a project and it's brought us to our needs in terms of Really understanding that our perception of health care systems May or may not Meet the needs of the abinacchi and that if they do it's going to it's got to be informed by We're taking a community-based participatory research approach so that We don't do any interaction without Everything being vetted through the abinacchi community and we've trained Abinacis to as community members to go out and collect qualitative interview Information to try and learn more about health seeking Thank you in terms of state surveillance systems It gets challenging because the numbers are small so that they don't reveal themselves in the way that they might if We were to significantly over sample in a particular Population so the numbers are small so they don't reveal themselves as a standalone Who've been the same way that a more targeted project I had two more demographic questions. Um, one of them these should be simpler. I think one I'm just looking for the slide, but it said somewhere that they were that Suicide was the eighth leading cause of death. I don't know what page that was How many causes of death Are listed like eight out of how many eight out of ten eight out of a hundred eight out of a thousand like You don't have to answer it right now, but that's I wonder that because whenever I see numbers I always I'm starting to think more of the context of the numbers. Um, and you know So eight out of one, I think you know the reason we listed as eight years just to compare it To the tenth leading cause in the u.s. So to just hide that in vermont We have a problem that we need more serious than that the u.s Based on our numbers. Okay, and it's a little more of a relative rather than the number this All right, and then the other question. I'm trying to be quick. So other people have time. Um Suicide deaths in vermont 2015 to 2016. I think it's Two down or something there. Yeah, so Uh, this you know this section on marriage or whatever you want to call it. Um 42 relationships dad is like 42 percent So 42 percent were never married 25 percent married 26 7 percent winner I'm curious how that compares to like how many people have never been married How many people have been married because seeing that by itself? I'm like, well, you can draw all kinds of conclusions Like you know, yeah Yeah, it'd be interesting to see the like, why does that compare like to that's all? Yeah, thank you. Yeah I think I think maybe you were gonna ask about the age adjusted information that was on an earlier slide So we know that vermont has a as the second oldest population in the country No, no it was the graph that showed It showed age you mentioned age adjusted figures on it. It was a line graph. Yeah, there you go. Yeah, so I guess I'm I'm just wondering that since we know that we have an older population Overall When you adjust for that every saying that consistently vermont has a higher suicide rate were that so we still would make that statement, okay Back to the marriage just real quickly. We do know that being married or being in a couple generally is more protective for every health outcome So that would be that would be That would be that Maybe my mom's right So I just want to comment this is coming out of my own experience as well. Um, the working without the community Is that is that we identify we identify the those who I did well If you are in fact wrestling with your identity And it's not safe to identify You will not play that statistic about what's happening in for non non publicly identifying lgbtq people and so I would just suggest that there is a whole another cohort of Vermonters who are in that highest risk category or a very high risk category And who are not reflected as being lgbtq in the other day because in fact the very issue For many people that's keeping them from being safely identified in family or workplace or wherever Uh is part of the dynamic and so we we have to It's just another it's just another Layer layer. It's just another layer. Yeah Well, this is we're going to stop here Just one more question. Yeah, please. Um, your physical health problem that you had to slide Those who died by suicide and had physical health issue I was just wondering about medically assisted suicide. Um, do you take that into into consideration at all? I know it's a different category obviously, but It's just the thought that I was thinking about when I saw your sign In vermon our numbers are very Low there. I don't know how what our numbers were for last year, but I don't know that it would impact this these numbers in any sense Josie But you know, we've discussed this a lot of the coalition level and really the coalition which is composed of low Organizations and perspectives feels very strongly that you know, that's an end of life Conscious decisions our target target population are people who are feeling, you know, the risk factors Lonely isolated chronic pain responded whatever it is So we've really been able to separate it out and it's not included in the data at the medical exam Thank you. Thank you very much. And thank you. And again, thank you to those who were here for the whole morning And they really probably wanted to thank you all And just to say that I think we need to stop and think what is it what role can we play? It may or not may not be things to do right now I'll just mention as a representative donnie who did interestingly everyone has testified how important sash is and we have A budget proposal that would slash the money by half so Which we didn't know about because it's not our committee in theory, but obviously there's overlap in our committee But so there are places where we would clearly Think about interacting and we will look forward to other initiatives in the future. Thank you. Thank you