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The Columbia Protocol For Suicide Prevention

outdoor banner advertising the National Suicide Prevention Lifeline with a telephone number and a URL.
photo by Nic Dayton

It has been more than a year since the shooting at Marjory Stoneman Douglas High School in Parkland, Florida, but the bullets that flew on that tragic Valentine’s Day may still be claiming lives and breaking hearts.

Two Parkland teenagers recently took their own lives within the same week. The first, a 19-year-old, was a senior at Marjory Stoneman Douglas at the time of the shooting. The other, a sophomore this year, likely knew many of the victims, since the shooting occurred in a freshman building. Suicide is complicated and seldom rests on one factor alone; from the outside, it is impossible to draw a direct line from the events of February 2018 to either of these deaths. But the older teen’s parents have stated publicly that she experienced survivor’s guilt in the shooting’s aftermath, and initial reports indicate that post-traumatic stress disorder may have contributed to both suicides.

The loss of these two young people would be heartbreaking at any time and in any place. But their deaths arrive as part of a larger conversation. Within days of the second Parkland suicide, news broke that a Connecticut man whose child was among the victims of the 2012 shooting at Sandy Hook Elementary School had also killed himself. In addition, as the South Florida Sun Sentinel reported, suicides and attempted suicides among teens generally in South Florida have risen over the past decade, and especially within the last year.

The American Foundation for Suicide Prevention reports that suicide is the 10th leading cause of death in America. About 47,000 Americans died by suicide in 2017, although the true number is probably higher because stigma can lead to underreporting or inaccurately labeling suicide deaths as accidental. One area where undercounting is virtually assured is the case of terminally ill individuals who do not reside in one of the five states where some form of assisted suicide is currently legal, but this situation is a rare outlier among all suicides.

Teen suicide is less common than suicide among middle-aged adults and senior citizens. But it is arguably the form of suicide most devastating to survivors, and its rise is alarming. The national teen suicide rate jumped by 70 percent between 2007 and 2017. Today, suicide is the second most common cause of death for Americans between the ages of 10 and 24.

Suicide is a complex problem with no single solution. One emerging tool is the Columbia Protocol, which medical practitioners increasingly recommend to family members, friends and others who are not mental health professionals but want to do everything possible to protect and support their loved ones. Sometimes called the Columbia-Suicide Severity Rating Scale, the Columbia Protocol is designed to help bystanders identify when someone is in crisis, since the signs are not always obvious.

The protocol involves a series of six questions someone can ask if they suspect a loved one may be in trouble. These range from identifying an abstract wish not to be alive anymore to asking whether the person has made any sort of concrete plan for how to end his or her life. The screening also distinguishes between having such thoughts or plans in general, and having had them within the past month. Affirmative answers to any of the questions indicate a need for treatment and support, but the protocol identifies certain responses as emergencies, indicating that the questioner should not leave the subject individual alone and should immediately secure professional help.

The Columbia Protocol was developed collaboratively by Columbia University, the University of Pennsylvania and the University of Pittsburgh. It initially focused on identifying risk among adolescents, though it is now used to screen patients of varying ages. The diagnostic tool has been endorsed, recommended or adopted by major medical organizations including the World Health Organization, the Centers for Disease Control and Prevention, and the National Institutes of Health. Some hospitals are beginning to apply the screening to patients as a matter of course, even when they come in with unrelated medical issues, in order to catch problems early.

A common misconception about suicide prevention is that mentioning suicide to someone struggling with depression or other mental health problems could put the idea into his or her head. This misconception may arise from the real phenomenon of “copycat” suicides that has been observed occasionally throughout history, and especially as the result of coverage of high-profile or celebrity suicides in the press. But the role of purely hypothetical discussion of suicide in such events is unclear at best, and the benefits of discussing the topic directly – especially in the context of checking in on a loved one – far outweigh any potential harm. If a person is a suicide risk, the topic has already been on his or her mind. Silence, even out of a misguided desire to avoid making a situation worse, can be deadly.

Some states are also considering the question of whether psychologists should have the power to prescribe medication to their patients. In general, such empowerment requires the psychologist to obtain additional education and training before issuing prescriptions. The evidence emerging from five states and several foreign jurisdictions where this is already allowed, under controlled circumstances, is that such powers can help and most likely will not hurt.

Many psychiatrists, who are medical doctors, have resisted the idea of allowing doctoral-level psychologists with additional training to prescribe medication. This resistance, which has been occasionally vigorous, may spring in part from professional self-interest. But that should not diminish the legitimate concerns opponents raise. Psychotropic medications, in particular, have the potential for significant side effects and serious interactions with other prescriptions. Further, some parents and advocates have already expressed concerns that psychotropic drugs are over-administered to large swaths of the population, including children diagnosed (rightly or wrongly) with attention deficit hyperactivity disorder. Some psychotropic drugs are also subject to abuse. I personally know psychologists who do not want to incorporate pharmacology into their therapies; they would prefer to refer patients to psychiatrists and to treat them in collaboration when appropriate.

Even if psychologists are allowed to prescribe more widely, the change will not be a panacea for suicide, or in general. And lack of it will not always spell disaster. New York, the only state that flatly rules out prescription powers for psychologists by statute, has one of the lowest suicide rates in the country.

Yet we still should put every tool in the toolkit at a treating professional’s disposal. America loses a sold-out baseball stadium’s worth of lives to suicide every year. In many parts of the country, mental health professionals of any sort are in short supply. For instance, in Idaho – the most recent state to allow psychologists to write prescriptions – patients routinely face wait times for psychiatrists of up to a year in rural areas, and two or three months in Boise. Before you can close a wound, you need to stop the bleeding. Medications can be a tourniquet even in instances when they are not a long-term cure.

The community in Parkland and South Florida has taken a variety of steps to support struggling teens, including increasing the number of mental health personnel employed by school districts, setting up a wellness center for Stoneman Douglas survivors and manning a local suicide prevention hotline. Just as suicide has no single cause, preventing it does not involve a single solution. From the very personal questions involved in the Columbia Protocol to the systemic question of who should prescribe medication for mental health, all of us have a role to play in stemming the epidemic of suicide among the young and not-so-young.

Larry M. Elkin is the founder and president of Palisades Hudson, and is based out of Palisades Hudson’s Fort Lauderdale, Florida headquarters. He wrote several of the chapters in the firm’s book, Looking Ahead: Life, Family, Wealth and Business After 55. His contributions include Chapter 1, “Looking Ahead When Youth Is Behind Us” and Chapter 4, “The Family Business."

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