Video: It’s Up to Everyone: Reducing Stigma and Suicide Among Students, Their Families and Communities with the Columbia Protocol

Speaker: Adam Lesser

Hi. My name is Adam Lesser. I'm the Deputy Director for Implementation and Training at the Columbia Lighthouse Project, and I'm going to be talking with you today about how to reduce stigma and screen for suicide risks so that we can go out there and protect our friends and loved ones from the tragedy of suicide. I'm going to start, however, with a recording from CNN that appeared right after the suicides of Anthony Bourdain and Kate Spade, with Chris Cuomo talking about screening and talking about the Columbia scales.

Speaker: Adam Lesser

All right, so as Zach was telling us, Anthony Bourdain, Kate Spade, surprising losses. But they did not die in a surprising way. Suicide is a dirty secret in our society. It is a plague that has taken more lives every year for decades. We don't talk about it because as Zach said there is a stigma and a shame attached. Even the phone number on the screen, all right, we put it up there. It's good. It's good to get the information out there. It's good to give people a chance. But there's an assumption and it's that people in that kind of pain will have the will to ask for help. But too often, they do not. The rest of us feel powerless to do anything, especially when the person in need never says anything. But maybe that's because we're not asking them the right questions. But you can. And in doing so, you might just help stop a suicide. Please do this for me and for yourself. Search online for Columbia Protocol for suicide prevention. Columbia Protocol for suicide prevention. I also tweeted out the link. Go to my page @ChrisCuomo. You'll see it. What is it? Six very simple questions that you can ask anyone that you're worrying about. One of them is would ever -- they ever wished they could go to sleep and not wake up? Have they started collecting pills? Have they gotten a gun or given away valuables? Basic ways to help pick up crucial warning signs. All right. You're going to be skeptical. I understand. The Marine Corps rolled out this protocol for everyone to use from legal assistance to members of clergy. What happened? Suicides among active duty Marines went down 22% in 2014. That's a big number. But here's the catch. Maybe it's not the magic of the questions. The catch is that the protocol works because people care enough to engage. That's another thing that is revealed by suicide, another dirty secret. 

We need to care. Caring counts. It can literally be medicine for someone in mental or emotional suffering. So, reach out. Don't wonder what's going on with someone. Ask them. So we know that suicide is a global public health crisis. It kills more Americans than car crashes, more people across the world than natural disasters, war and homicide combined, more soldiers than combat. It's the number one cause of death in teenage girls across the globe. Kills more firefighters than fire and more police officers than crime. And we know that roughly half of all Americans are impacted by suicide. We used to think that, when somebody died by suicide, just their immediate family and friends were impacted. But it turns out that a large number of people in the community also become impacted, and the studies show it's about 135 people become affected for everyone death. And those impacts linger, you know, across generations because of the silence that often follows after a suicide. As I said, it's the number one killer of adolescent girls across the globe, but it's also the second leading cause of death among all 10 to 24 year old’s in the US and the fourth leading cause of death among those between ages 35 and 54. ^M00:04:38 

Now, we know about how common suicidal thoughts and attempts are in our schools because of the Youth Risk Behavior Survey that the Centers for Disease Control does. And what we see year after year is that about 18% of your average high schooler will seriously consider it every year and about 13% of your average college undergrad, and about 8 to 10% will make attempts. Now, the highest risk group, unfortunately, are our transgender youth with about 68% considering suicide every year and about 40% making an attempt. So, if you have a typical classroom of like 50 kids, in that classroom, each year three of those kids will attempt suicide. Now, it's likely that it will be two girls and one boy because girls attempt suicide twice as often as boys do. But boys actually die by suicide four times as frequently as girls. And we're going to talk a little bit later on about why that might be the case. Now, there's a relation between suicide and school violence. So, when the Secret Service did its Safe School Study in 2002, it found that about 78% of school shooters had a documented history of suicide attempts or thoughts at some point prior to their attack. And a quarter of them said suicide was their motive, they just wanted to get revenge on some people or get some publicity, become famous, which is why they, you know, killed themselves via a school shooting.

And yet a third of them hadn't received any kind of mental health evaluation, and less than 1 out of 5 were ever diagnosed with a mental health issue. Now, unfortunately, because of suicide and other what we call deaths of certain, certain kinds of deaths of human suffering, we see that the average length of life among American, American men in particular has dropped over the last few years compared to every other nation in the world where it's constantly rising. A developed nation should not be having its average length of life decline. But because of deaths of despair, like suicide and substance abuse, overdosing, we've actually seen our average length of life decline. Now, suicide awareness needs to be part of every employee health and wellness program because, if you take an average large corporation have like 100,000 employees, every six days, one employee or a family member of theirs will die by suicide; and every day three employees or family members will make an attempt. So, it is part of the bottom line of any corporation. Healthy employees equal improved earnings. Depression is actually the number one cause of work-related absence. It actually costs our workplaces 75 -- $23 billion a year in lost productivity. And we know that half to all of the costs of treatment for depression could be offset by gains in work productivity if people were coming into work and they were feeling better. Now, we also -- it's critical that we take care of the caregiver. 

We know that suicide is the number one cause of death for medical residents. We've seen lots of doctors, nurses, firefighters, police officers, those who are out there protecting us and taking care of us die from suicide. And this recent survey of over 1200 healthcare workers that were caring for COVID-19 patients in China had almost three out of -- almost three out of every four reported symptoms of psychological distress, and about half reported symptoms of depression and/or anxiety. So, you need to ask and care your coworkers, for your coworkers and for your fellow firefighters. But it doesn't discriminate. You know, we need to screen everywhere. Whether it's within our hospitals, our jails and in lots of different professions. Now, while we've seen the rates of death in HIV AIDS, heart disease and leukemia decline over the past 15, 20 years, we've actually not seen that in suicide. And Dr. Lieberman, who is the former head of the APA and the current president of our hospital, those -- you know, suicides remain -- rates have remained unchanged because of stigma, because of a lack of a ready, easy-to-use method by which to detect it and then to take action and try to prevent it. Now, depression, as I said, is the number one cause of work-related absence, and that makes it the number one cause of global disability. At any one time, about 8% of the world has a significant mental illness. And a recent US survey showed that one out of every three Americans felt anxious or depressed. And during crisis, of course, we see that increased.

So, things like being a refugee or an asylum seeker, dealing with healthcare issues like SARS or COVID-19. And so, you know, we've actually seen rates of suicide traditionally track very closely along with rates of income inequality. So, when we see more people out of work, we see suicide rates increasing by about the same rate and pace. And that also has important information that we need during this current COVID crisis. In March of this year, the Substance Abuse and Mental Health Services Administration's Disaster Distress Helpline had an almost tenfold increase in call volume compared with the prior year. We are seeing that the Crisis Text Line is getting 6000 texts a week, which is double what they usually get. And recent data from there looking at first responders and grieving family members that have been texting them showed that 80% of them were feeling lonely and isolated, three-fourths of them were uncertain about the future. Two-thirds of them had distress over the loss of their routine. Half of them had financial distress. And among those who identified as essential workers, four out of every five reported that they were having coronavirus-related stress and anxiety. And for teens and youth, in particular, studies of adolescents this year found increases in depression, increases anxiety, increases in posttraumatic stress disorder. And in June the CDC reported higher rates of suicidal ideation in teens. And, of course, at this time when we're not seeing all of our kids in school every day, we have fewer opportunities to intervene and to find them. And this is compounded for groups that are already vulnerable.

So, we know low-income families have been hit hardest by COVID. And we have a huge portion of our New York City public schools with low-income families. They also are seeing their rates of anxiety and depression dramatically increase. But mental illness doesn't discriminate. It affects all ages, genders, races, religions, and income levels. And one out of every four people will experience a mental health issue this year. Now, while we know about lots of diseases, depression, and suicide is a disease that we know the least about. In fact, it gets the lowest amount of funding of all illnesses from the National Institutes of Health compared to, you know, say, HIV AIDS which has a positive net research dollars of almost 2 1/2 billion. Depression, on the other hand, comparatively comes in at minus $700 million. Now, of course, the high cost of not screening for suicide and not identifying high risk is tremendous, right? In 2010, the US lost $91 billion in wages and work productivity from people who are depressed. Worldwide, it results in about $300 billion a year in years of life disabled or lost due to suicide. And when you do screen, you save money, and you increase productivity. Centerstone, which you're going to hear a little bit about throughout this talk, is one of the largest providers of outpatient community behavioral healthcare in the US. And they reduced the recidivism rate of emergency department visits from 40% to 7%, after beginning a screening program with the Columbia tools. And so, we really believe and advocate that we need to ask these questions in the same way we monitor somebody's blood pressure or give them vision checks. 

We know that nearly half of people who die from suicide see their primary care doctor in the month before they die. And that two out of every three adolescent suicide attempters will show up in the emergency department for a nonpsychiatric issue. And so, we have vital opportunities where we could be screening and finding those who are suffering and providing them with the care that they need to prevent suicide. You know, imagine a school nurse or physical therapist asked me about mental health every time they gave a physical checkup. If we asked, we can find those who are suffering in silence. And that outpatient behavioral health program Centerstone in Tennessee alone reported over the first 20 months after starting a screening program that they reduce their suicide rate by 65%. And screening programs in schools are also successful. A program looking at screening in high schools found that they were able to identify 69% of the students in the school who had significant mental health issues compared to less than half who were able to be identified by the school counselors. And when both school counselors and screening was done, that's when they had the most effective identification of mental health issues. And a college screening project, interestingly, showed that screening with a tool like the Columbia actually brings more high-risk students into the Counseling Center for care when they need it. This college screened their students anonymously, so they didn't find out which students were at risk due to the screening. 

They sent everyone a link to do the Columbia. And what happened was during the school year, when students were struggling, they were more likely to come into the Center because they knew the Center existed, and they felt like they had permission to talk about these kinds of things because of that screening that happened. And they reported just one suicide in the four years after the screening program, compared to three suicides in the four years prior. Now, is suicide a choice, a sign of psychological weakness, akin to murder but of the self, akin to cancer, or all of the above? A lot of people say all of the above, but in fact, it's more likely akin to cancer, akin to any other chronic medical illness. We know that suicide is not a choice. It's the result of imbalances in brain chemistry. The biggest cause is this heritable, treatable medical illness called depression. And this misunderstanding that suicide is a choice can actually be lethal. You're maybe familiar with the Netflix drama 13 Reasons Why. And assuming that there are reasons why other than the fact that someone has a mental illness at the time really can be very damaging because there is no other reason why. The reason why in 90% of people who die from suicide is that they have a mental illness at the time that they die. And we know that programs like this also can provide some suicide contagion. Exposure to suicide or suicidal behaviors through the media or within one's family or peer group groups increase the suicidal behaviors of others, especially in young adults and adolescents. Now, we know that antidepressants are what saves lives and that not treating depression is what kills people.

When we see autopsies done after suicides, we see far more of them happen after there's no treatment or noncompliance with treatment. And this graph here at the bottom shows how we were bringing suicide rates down In the early 1980s, and 1990s, and then right around the time that we had these fears that antidepressants were causing suicidality, we saw folks stop taking their antidepressant medications. And look what happened. At the tail end in the early 2000s, we saw suicide rates increase again. And it turns out, a lot of people who are dying from the opioid crisis are actually dying by suicide. A large portion of opioid overdose deaths are suicides. And they don't always get identified as suicides by coroners and medical examiners because they don't always know about the motive. But in one out of every five suicide deaths, we do see opiates involved. And now, unfortunately, people who need treatment aren't getting it. 90% of people who die from suicide have an untreated mental health problem, and most often it's depression. But the under treatment of mental illness is pervasive, right? Half to three quarters of those who need care get no care or inadequate treatment. Over 80% of college students who die from suicide never got any kind of consistent treatment prior to their death.

And now, during the COVID-19 crisis with more economic uncertainty, many people can't afford or access their providers or, in some cases, their medications. Antidepressants are actually the number one prescription in the US. But we still worry that we are under treating folks, as opposed to worrying that we're over treating. Now why don't people get the lifesaving care that they need? A lot of it has to do with stigma and misunderstanding. Right? People feel this isn't a real illness. I'm weak if I ask for help. This is especially true in very macho professions like being a professional athlete or first responder or being in the military. And, incidentally, we see the same increased risk in women who are doing those same types of jobs. The stigma of talking to a psychologist of admitting that you have any kind of mental health issue in these professions is quite profound. And we actually do see fewer men seeking treatment because of the stigma. So, you know, while I told you earlier that there are four suicide deaths of men for every one by female, we actually see in women a lot more of them, trying to get some help and having antidepressants in their bodies or being involved in counseling. And that stigma can be life threatening. A good friend of ours, Kim Ruocco, lost her husband to suicide. 

He was a marine pilot. And when she called him, she felt that something was wrong, but she didn't get to him on time. And they went to their base commander and some friends and they said, don’t go to treatment. Don't go on medication, right, because you can't do that and fly. And until 2010, commercial pilots were banned from flying if they were on antidepressants, and so many of them lied about depression or ignored signs. And we actually saw one airline lose eight pilots who were already out on disability to suicide in a 15-month time span. Now, the Army is working towards destigmatizing depression and treatment by combining it with their medical care. So, it used to be that you would have to go to an off-base mental health center into a different building on base. And, you know, people knew why you were there. But now they've integrated mental health questions and treatment into their primary care, and they were able to reduce suicides and reduce overnight inpatient stays for mental health issues because people are getting found faster and are more willing to accept the help. So, asking is this first step to saving lives. If we can't find those who are suffering in silence, we can't help them. And the Columbia screener is the best tool for figuring out who those folks are.

So, it is just a minimum of two questions or three questions and a maximum of six questions. These are the questions here on these two cards. They start with, have you wished you were dead or wished you could go to sleep and not wake up? And then, have you actually had thoughts about killing yourself? If that second question is no, they have not had any thoughts about killing themselves, you skip 3, 4 and 5 and move on to asking question 6. But if question 2 is yes, they have had thoughts, you'll ask them, have you thought about how you might do this? Have you had any intention of acting on these thoughts or killing yourself as opposed to you have the thoughts, but you definitely won't act on them? And then, have you started to work out or worked out the details of how to kill yourself, and do you intend to carry out that plan? And then you ask question 6, have you ever done anything, started to do anything, or prepared to do anything to end your life in the last three months? Now, if they say yes to questions 4, 5 or 6 within the past three months, then they are at high risk. And the instructions on the card tell you to escort them to emergency personnel so that they can be further evaluated. Now, anybody can do this. 

Anybody can ask these questions. Coaches can ask their athletes. Peers can ask each other. We encourage university students to get ahold of this card and ask their peers. And so, the Columbia is actually reducing suicide, reducing the workload of those who are in the field of mental health and reducing the liability of not asking anything or asking the wrong questions. It was developed about 12 years ago in an IMH study, looking at adolescents. But it's been used in millions of organizations and has been administered tens or hundreds of millions of times by now. It's endorsed, recommended, adopted or mandated by many national and international agencies and is available in over 140 languages. You can download English and Spanish from our website. But if you need any other language, you can just get in touch with us and we can probably send it to you. All of the Columbia tools are free for you to access on our website or for us to send to you. Now, why are these questions different?

They're different because the science tells us that there are multiple behaviors that we need to worry about. You know, we used to just ask someone have they ever tried to kill themselves? And when that was the only suicide behavior question we asked, we were missing the person who had bought a gun or wrote a suicide note or put a noose around their neck and changed their mind, things that we call interrupted attempts and aborted attempts and preparatory behaviors. And those additional behaviors have just as much risk as someone who has made an attempt already and are responsible for more than 85% of the worrisome behaviors, we see yet are things that we didn't used to ask about. And we know now that we need to. Preparatory behaviors are very important because, you know, we think that by asking about preparatory behaviors in particular, maybe we'll find kids like Dylan Klebold, who was one of the Columbine shooters. He actually mentioned suicide more than five times in his journals, writing things like, I don't fit in here and thinking about suicide gives me hope. That's a preparatory behavior. And if we were able to identify that, we might have been able to get him into some care. Likewise, the Santa Fe shooter wrote in his journals that he wanted to kill himself. So, we finally know who to worry about. Screening along with these evidence-supported thresholds for imminent risk provide that group of high-risk individuals that need an absolute next step. And, again, those answers are yes to a 4, question 4 or question 5, which means they have intent to act or they had intent to act on their thoughts within the past 30 days or any of those behaviors within the past 90 days.

That puts someone at high risk. Only approximately 1% of people who get screened are at this high-risk level, but it's really helping us narrow down who need that level of care. And it used to be that a police officer or first responder would hear anything about suicide, and they would immediately take that person to the ER where they would sit with them for a couple hours. They wouldn't be back on the street doing their job. And the person being evaluated would end up being sent home. And we actually know that people who are evaluated in the emergency department and they don't need to be there, they don't get hospitalized, it actually shuts them down to care. They're actually less likely to stay involved in treatment when that happens. And so using a tool like the Columbia to actually figure out who's okay, to, you know, go home and not go to the ER actually helps to optimize the use of scarce resources and decrease these unnecessary emergency department holds. So, let me show you a demonstration of how a police officer might use the tool. I've been in situations like this before where it was really hard to tell if someone was actually in danger of suicide or not. Fortunately, I was recently introduced to CSSRS, and I could use a few quick questions to help me decide what level of care she needed. Hi. Are you Joan? 

Speaker: Joan

Uh-huh.

Speaker: Adam Lesser

I'm glad you called us. We're going to get you some help. Okay? 

Speaker: Joan

Okay.

Speaker: Adam Lesser

I'm going to ask you a few questions about your thoughts and behaviors over the past few weeks to help us better understand how to help you. Is that okay?

Speaker: Joan

Okay. Am I going to have to go to the hospital?

Speaker: Adam Lesser

Let's just get all the information about what's going on first, and then we can talk about that. All right? 

Speaker: Joan

Okay.

Speaker: Adam Lesser

Good. Have you wished you were dead or wished you could go to sleep and not wake up?

Speaker: Joan

Yeah. I wish I was dead right now.

Speaker: Adam Lesser

Have you actually had any thoughts about killing yourself?

Speaker: Joan

No, no. I would never do that.

Speaker: Adam Lesser

Okay. Have you ever done anything, started to do anything or prepared to do anything to end your life?

Speaker: Joan

I mean, once when I was a teenager, I wrote a note to my friend saying I wanted to die, but nothing recently.

Speaker: Adam Lesser

Okay. Thanks. So, as you saw, he asked questions 1 and 2. She said yes to question 1, no to question 2. So, he skipped 3, 4 and 5. And then he asked her about behaviors, and she said she had a behavior, but it was a long time ago. So, this is someone who's at moderate risk, and someone at moderate risk who's had a behavior a long time ago doesn't need to go to the emergency department. They can be asked if they have an outpatient therapist that they can call. Is there a friend or family member who can spend the day with them, so they don't have to be alone? What other things can they do? Here's a hotline number. If you start to feel worse, you can call the hotline. But, again, not clogging up our emergency departments with unnecessary evaluation. And so, wherever we see folks doing this, we're seeing about 1% having these high-risk answers. This is a demonstration study that was done at the VA. And they said to us, you know, we're not just going to have 1% to worry about because we're the VA. We have a high-risk population. But lo and behold, when they did it, they screened 3000 vets seeing a psychiatrist. And of those 3000 vets, only five required hospitalization. So that was less than a 10th of a percent, less than two tenths of a percent.

So, you're not going to be overwhelmed if you start asking these questions to everyone by the numbers of people who need treatment. What you will do is you will give folks permission to come back and talk to you when they are feeling bad and probably find a lot of people who have had thoughts about it who can get some care and some advice before it becomes too late. Parkland Hospital is the first hospital to ever do universal screening. They're in Dallas, Texas. And they reported back after screening 100,000 patients that they had 1.8% with positive answers. And so, they have a team of social workers that does the follow-up with them. And so, they're using it in the National Guard in Connecticut, for example, as part of their periodic health assessment. They've done over 38,000 screenings, and they have identified 17 soldiers during that -- during those screenings who needed assistance; and they've had no suicides in any of their screened soldiers. And I also told you that worrying about liability is an issue. 

People don't ask because they are afraid of what to do next. And the Columbia is great because it tells you exactly on it. What are the answers that require you to call 911, get a first responder, get a mental health professional to do an evaluation? And that provide you with liability protection. You know, a medical malpractice attorney was interviewed in an article about the Columbia in Crain's Magazine. And what they said was that, since this is the gold standard, this has scientific backing behind it, this actually provides you with the most protection you can get. Someone in a training said, you know, people don't get sued for bad outcomes. They get sued for negligence, for malpractice, for doing something wrong or harmful. Right? Asking these questions and taking the next steps recommended is not something wrong or harmful. It actually will provide you with protection. And this is that article in Crain's Magazine. So, everyone everywhere can ask these questions. We believe it should be policy and across the board. Vermont, for example, has a policy recommendation for schools where even school janitors have to be trained.

That's what they recommend for all their school districts. We recommend that everyone in a school have access to these questions because you never know who it's going to be that the person at risk feels comfortable with. Right? It may be their coach. And it may be someone who they work with in the cafeteria, when they're -- when they're on work study. And it may be one of their battle buddies. You just don't know. And so, it's important that we get these questions into the hands of as many people as we can. And people want to be saved. We work a lot with a man named Kevin Hines. If you've never heard of Kevin, you should Google him and hear him tell his story. He survived a suicide attempt jumping off the Golden Gate Bridge in California, which is lethal 95% of the time. And he tells his story. He was a 19-year-old adolescent who had a psychotic depression, and voices were telling him he had to die. But he made an agreement with his voices that day and said, if just one person asks me what's going on, I'm going to tell them everything. And so, he gets on the bus and goes to the bridge. Nobody says anything. He walks up and down the bridge a couple times, still nobody. Finally, a woman is approaching him. And he thinks to himself, I'm going to get some help now. She's going to ask what's wrong. But instead, when she gets to him, she says, will you take my picture. And so, he takes her picture three or four times, gives her back her camera, decides that it's hopeless, nobody cares, and he jumps. And what he says is that, instantly, as soon as his hands left that railing, he realized everything in his life he thought he couldn't fix was fixable except for what he had just done, and he has instant regret.

And what he says in his talks now is that we need a society where people aren't afraid to approach one another and ask these types of questions. And the Columbia questions can be a pioneering change. So, we think we should be putting this wherever people get access to lethal means. So, we train transit workers in the New York City and Los Angeles subways. We've had pharmacy colleges, trained pharmacy students. And we've even provided these questions to gun shop owners on posters that they can put up in their shop so that that person buying a gun, if they're thinking about suicide, they really don't want to die. Right? They want some help, but they don't know how to ask. They don't know where to get it. And so being reminded, having these questions on hand can actually make a difference, even in something as lethal as a firearm. So we used to use a very medical model when it came to suicide. We had a narrow approach where we screened those at high risk, who we thought were at high risk and provided mental health treatment and trained our mental health providers. But what we know now is that doesn't work when it comes to suicide because the people who are most at risk aren't in treatment right now. And so, we need to take this public health approach, a broad approach where we target a whole community, train all gatekeepers and put these questions across all health services.

And we actually learned this from the US Marines. The US Marines were the first branch of the military to ask us for training. But they didn't ask us to train their mental health clinicians. They asked us if we would come and train their clergy, their family advocacy workers, their substance abuse specialists and their lawyers because the number one precipitating event before a marine suicide was having a legal problem. So, they get arrested for a DUI, and they're ending their lives by suicide because of the impact that arrest can have on the rest of their career. And so now, in the Marines, every time a marine meets with a lawyer, the lawyer does the screening. And then the lawyer takes them to behavioral health if they screen as at risk. So the Air Force has taken this community wide, systems-wide approach to the best level where they have trained not only all their support workers but all of the primary care doctors and nurses, all of the security and safety staff, all their behavioral health staff and every single airman and their spouse gets one of these community cards that has the Columbia questions on the back. And they have reported the lowest level of suicides of all five or six now of our military branches. So, we know we need to find people where they live, work and thrive.

The Army has started to do that through their screening within all medical systems; The Air Force, as I said; and there are many places where there are universal screening policies in schools. South Carolina has policy recommendations for universal screening in schools. The Marysville -- Marysville Crisis Response Team does universal screening. And there is a policy recommendation book in Texas called the Texas Suicide Safer Schools Policy Guide from the Texas Department of State Health Services that also has this as a recommendation. And even internationally, every schoolteacher in Israel, for example, has a copy of the Columbia questions. So whether it's your state, whether your Department of Corrections, whether you're a military branch, whether you're a fire station or whether you're, you know, just one school, you can implement policy that includes universal screening and outreach and a rollout of these kinds of questions to reduce stigma and help you identify those at risk. Now, we can't understate the importance of having this common language for talking about suicide. The definitions that the Columbia uses have also been adopted by the Department of Defense and the Centers for Disease Control for all research. And so not only in the Centers for Disease Control Guidebook do they have our definitions from Columbia and a link to our website but they also have a list of the things we should stop saying, things like completed suicide and successful suicide, right? 

You complete a project and you're successful at your job. We want to take those negative words away from an event like suicide. We're also trying not to use the terminology committed suicide because loved ones tell us survivors that, when they hear that, it makes them think that their loved one committed a crime because that's the most common use of committed. And so, we recommend now just saying that someone died from suicide, or they ended their life by suicide and to not use any other kinds of descriptive terminology around it. And having a common language is an intervention in and of itself. Asking can literally be medicine because it shows that you care. A big study proved that the biggest impact in stopping kids from trying to take their own lives is peers helping them, peers coming alongside them and asking the questions. So, it's much more than just a screening intervention. This study in ten EU countries of about 11,000 students showed that the student-student component of the program was the most effective piece in preventing suicide. The CDC says this common language about suicide that you get with the Columbia develops connectedness which saves lives, and it can help fight the loneliness and hopelessness that causes suicide, right?

We see, especially in these times of COVID, where stay-at-home orders are in effect, that loneliness and isolation is even more of a problem. And using a tool like the Columbia to reach out to someone who you, you know, may be worried about is super important. You can even use it over the phone or by video conference. It's a tool that has shown just as much effectiveness when done either in asking the questions in person, over the phone having it be on a self-report piece of paper. And we know that there are devastating health effects when it comes to loneliness. They say that loneliness is actually equivalent health-wise to smoking 15 cigarettes a day. It's more lethal than heart disease and obesity because of suicide. And so, the Columbia is more than just a method to identify when someone is at risk. It's a framework for normalizing these tough conversations and reducing stigma around talking about suicide, and it promotes connectedness. It's just as important, however, to have flexible and innovative ways to deliver it as it is to have the right questions. You know, so someone from Amazon who we've talked with said, wouldn't it be great if we put these questions on the side of our boxes or on coffee cups. The University of Tennessee has them on badges that they give to every hospital employee. There is a mobile app with the Columbia questions. If you search on Columbia protocol on the Apple Store or the Google Play shop, you will find Columbia app where you just punch in the answers to the questions and it will tell you if some ones at high risk or not, and tell you what next step you should take.

So, at one point in history, learning to wash hands began saving lives. Now just asking and being there for each other gives us permission to connect and build a path of openness and resilience that can span generations and help us save lives. An official in the Israeli Department of Suicide Prevention says this is not only saving millions of lives, it's literally changing the way we live our lives by breaking down barriers that have been built over thousands of years. But we're just one nation, and every nation deserves this life-saving tool. And Ryan Petty, who lost his daughter to the school shooting at Parkland, Florida, says, the beauty of the Columbia protocol is that anyone can be involved. So as a community, we don't have to sit back and feel powerless. We can feel like we're part of the solution. It really does help in our own personal trauma and healing to be part of prevention going forward.

So, if you want to get in touch with us, it's very easy. You can send an email to Dr. Posner's email address, which is Kelly dot Posner at nyspi.columbia.edu. Or you can go to our website, which is cssrs.columbia.edu. And, there, there's a Contact Us page. So, you can fill in your information and get in touch with us that way. But you will also find lots of information including ways to download these community cards and the more formal evaluations that are part of the Columbia toolkit. Thank you very much for your time. Appreciate you being willing to listen. And I'm encouraged by how many of you are going to take the next step and go forward and do something to help prevent suicide in your community. Thank you.