Saving Lives
in New York:
Suicide Prevention
and Public Health
Volume 2
Approaches and Special Populations
New York State
George E. Pataki
Governor
Office of Mental Health
Sharon E. Carpinello, RN, PhD,
Commissioner
November 2005
T
HIS IS THE SECOND OF THREE VOLUMES which together comprise
Saving Lives in New York: Suicide Prevention and Public Health, a comprehensive, data-driven report on suicide, its risks and prevention,
released in May 2005 by the New York State Office of Mental Health
(OMH). Prepared by researchers at OMH, Columbia University/New York
State Psychiatric Institute, the University of Rochester and the New York
State Suicide Prevention Council, the report outlines a prevention strategy
with two primary components: diagnose and effectively treat those who
have a psychiatric condition that puts them at high risk to end their own
life; and use community resources, family and friends to engage individuals who harbor risk factors for suicide well before they become a danger to
themselves.
Volume One of the report includes an Executive Summary of all three volumes, a public health strategy for suicide prevention across New York
State, and a plan for suicide prevention and public health in New York City.
Volume One also includes recommendations and action steps that are
designed to: improve access to mental health care and services; enhance
identification of those at risk; restrict access to means of self-harm; and
expand the knowledge base through research.
Volume Two includes authored chapters that examine specific approaches
to suicide prevention, and also review specific needs of identified populations. When viewed together, the chapters of Volume Two illustrate that
the risk factors contributing to suicide are unevenly distributed across the
population, and that protective factors need to be enhanced to maintain a
favorable balance for anyone at risk of suicide. The result is an integrated
prevention strategy because most suicides involve complex causes, and no
single intervention can serve as a panacea for all those at risk. The recommendations and action steps outlined in Volume One are extrapolated
from the information contained in the chapters of Volume Two.
Volume Three of the report is a data book of statewide and county-specific
information about suicide that is gathered and maintained by the New
York State Department of Health.
On the cover:
Lifekeeper Memory Quilts created by Samaritans help us remember the New Yorkers that have been tragically lost to
suicide. Their faces and names also inspire others to save future lives through sharing, courage, and commitment to the
prevention of suicide. Since 1998, nine quilts have been filled to capacity.
Saving Lives in New York:
Suicide Prevention and Public Health
Volume 2
Approaches
and Populations
New York State
George E. Pataki
Governor
Office of Mental Health
Sharon E. Carpinello, RN, PhD,
Commissioner
November 2005
Contents
Approaches
Neurobiological Aspects of Suicide ......................................................................................1
A Message to the Physicians of New York State
Regarding Their Role in Suicide Prevention ............................................................................5
Resilience ................................................................................................................................7
Media ....................................................................................................................................13
Voluntary Mental Health Screening as a Means to Prevent Suicide ....................................19
National Suicide Prevention Lifeline ....................................................................................25
Means Restriction ..................................................................................................................29
Special Populations
Adolescents ..........................................................................................................................37
College Students ..................................................................................................................65
Families ..................................................................................................................................77
Suicide Survivors....................................................................................................................81
New Mothers ........................................................................................................................89
New York Men in the Middle Years ......................................................................................91
Cultural, Ethnic and Racial Groups......................................................................................101
Recipients of Mental Health Services..................................................................................105
Dually Diagnosed (Substance Abuse and Mental Illness) ..................................................109
Elders ..................................................................................................................................113
Saving Lives in New York Volume 2: Approaches and Special Populations
Neurobiological Aspects of Suicide
J. John Mann, M.D., Chief of Neuroscience,
New York State Psychiatric Institute & Professor of Psychiatry
and Radiology Columbia University
Suicide is a complication of psychiatric disorders, with over 90% of suicide victims or
suicide attempters having a diagnosable
psychiatric illness 1-7. However, diagnosis
alone is not sufficient to explain suicidal
behavior. Clinical studies have found a
range of other factors including aggressive/impulsive traits, hopeless ness or pessimistic traits, substance abuse and alcoholism 5; 8-16, a history of physical or sexual
abuse during childhood 17, a history of
head injury or neurological disorder 18-22,
and cigarette smoking 23 all contribute to
increased risk for suicidal behavior 24-27.
A stress-diathesis model attributes suicidal
behavior to the coincidence of stressors,
such as onset of a depressive episode, with
a diathesis, or predisposition, for suicidal
behavior. Pessimism, aggression/impulsivity, and suicidal intent have been identified
as three elements of the diathesis for suicidal behavior 25. These diathesis factors are
due to both genetic and environmental
causes, and neurobiological studies have
identified brain-related abnormalities associated with impulsivity and aggression.
Serotonin, an important brain neurotransmitter, has been the most fruitful object of
study to date. Suicide attempters have been
found to have lower serotonin functioning,
with those who complete suicide having
the lowest levels. Importantly, this dysfunction has been linked to particular regions of
Neurobiological Aspects of Suicide
the brain. Studies 28; 29 have identified
abnormalities of the serotonin system in
suicide victims, in a part of the prefrontal
cortex area of the brain located above the
eyes and called the ventromedial prefrontal
cortex 30;31. Moreover, this alteration in the
brain has been found to be related to suicide independently of a history of a major
depressive episode 32 indicating that it is
involved in the predisposition to suicide in
many psychiatric disorders.
The ventromedial prefrontal cortex is
involved in the executive function of
behavioral and cognitive inhibition 33.
Injuries to this brain area can result in disinhibition 34. Such disinhibition can be
manifested by a disregard for social strictures or requirements in terms of politeness, job performance, impulsive aggression or suicide depending on the circumstances or emotional state. Low serotonergic input into this part of the brain may
contribute to impaired inhibition, and thus
create a greater propensity to act on suicidal or aggressive feelings. In brain imaging
studies we, and others, have linked activity
in this area and serotonin release 35 to
severity of suicidal acts and impulsivity 36.
This area of the brain is part of a universal
restraint mechanism and less behavioral
restraint can lead to aggressive or suicidal
behavior depending on the affective state
of the individual.
1
Saving Lives in New York Volume 2: Approaches and Special Populations
While serotonergic function and both
aggressive and suicidal behavior are under
substantial genetic control37 it is also subject to environmental influences. Demonstrating the interaction of genetics and
environment, peer-reared monkeys, in
comparison with maternally raised monkeys, develop lower serotonergic activity
that persists into adulthood and is reflected
in greater impulsivity and aggression. Thus,
effects of rearing are superimposed on
genetic effects. Given that a history of child
abuse is associated with a greater risk for
suicidal behavior in adult life, and extrapolating from these monkey studies, one can
hypothesize that adverse rearing such as
child abuse, resets serotonergic function at
a lower level, an effect that persists into
adulthood, contributing to the increased
risk for suicidal behavior.
Other neurobiological systems are also
implicated in the diathesis for suicidal
behavior, though their role is less clear than
the sertonergic system. Abnormal function
of the dopamine neurotransmitter system
has been associated with major depression
and while the influence of dopamine on suicidal behavior is unclear 38-39, it may be
related to impulsivity and decision making.
Studies have also found evidence of noradrenergic neurotransmitter system dysfunction in suicide victims 40;41. The noradrenergic system mediates acute stress responses
to circumstances such as a psychiatric illness or severe suicidal ideation and overactivity of that system has been associated
with both severe anxiety or agitation and
higher suicide risk 42. The hypothalamicpituitary-adrenal (HPA) axis is another
major stress response system. Major
depression is often associated with hyperactivity of the HPA axis 43, and suicide victims exhibit HPA axis abnormalities 44;45.
Studies of both the HPA axis and noradrenergic activity indicate biological responses
to stress that may reflect the risk for suicide.
Genetic and Familial Influences
There is an important genetic contribution
to the propensity for suicidal behavior as
shown by several lines of researchers. Individuals who commit suicide or make suicide
attempts have a higher rate of familial sui-
2
cide acts46. Both twin 47;48 and adoption 49
studies have noted a heritability of suicidal
behavior independent of psychiatric disorders 50. As yet, the specific genes that contribute to suicide risk are unknown. However since serotonin activity is related to suicidal behavior, and under partial genetic control, investigators have examined the relationship between genetic variation in serotonin-related genes and both suicidal
behavior and impulsive aggression. To date
candidate gene association findings are
inconsistent and unlikely to bear fruit without directly sequencing candidate genes.
Non-genetic familial factors that may contribute to diathesis for suicidal behavior
include the impact of parenting . Adults
reporting childhood abuse experiences
have a higher rate of suicidal behavior and
greater impulsivity in adulthood, consistent
with findings in peer-reared monkeys. We
have observed familial transmission of
impulsivity where greater parental impulsivity and/or greater provocation from an
impulsive child may increase the probability of physical or sexual abuse 51. Overly
sensitive stress response systems in the
brain and body are reported in abused populations and may be the neurobiological
consequences of abuse and neglect, as
demonstrated in animal studies of maternal separation 52. Thus adverse rearing
might contribute to the neurobiological
anomalies associated with components,
such as impulsivity and aggression, in the
diathesis for suicidal behavior in adulthood.
Treatment and prevention
If suicidal behavior occurs as the outcome
of stress-diathesis, management of suicidal
patients necessitates addressing both
aspects; diagnosis and treatment of psychiatric disorders which act as stressors, and
treatment to reduce the diathesis, or
propensity, to attempt suicide. As we have
seen, diathesis, or predisposition, has an
element of biological determination.
Diathesis includes more hopelessness or
pessimism perhaps related to the
noradregergic system, and more lifetime
impulsivity partly related to impaired serotonergic input into ventromedial prefrontal
cortex region of the brain. Because it is
Neurobiological Aspects of Suicide
Saving Lives in New York Volume 2: Approaches and Special Populations
related to these biological systems, the
diathesis or propensity for suicidal behavior
is a potential therapeutic target, and a
reduction of the diathesis for suicidal
behavior has been observed in the clinical
effects of lithium, clozapine and psychotherapy called dialectical behavior therapy, which have been shown to reduce suicidal behavior 53-57. Both lithium and clozapine act on the serotonergic system and
raising serotonergic activity may reduce
risk of serious suicidal behavior by decreasing aggressive behavior and impulsivity 58.
There are many promising areas for future
neurobiological research into reducing the
diathesis for suicidal behavior. These
include genetic and neurochemical studies,
efforts to identify a genetic haplotype indicating risk for suicidal behavior, development of brain imaging and neuropsychological tests of decision making to measure
risk of attempting suicide when depressed,
and the development of treatments to ameliorate the risk of suicidal acts while waiting for antidepressants and antipsychotic
medications to work. Another promising
direction is use of animal models of impulsive and aggressive behaviors in the identification of candidate genes, investigation of
genetic and rearing effects, and testing
pharmacological treatments to ameliorate
aggressive/impulsive behavior that extrapolation may reduce probability of suicidal
behavior.
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Neurobiological Aspects of Suicide
Saving Lives in New York Volume 2: Approaches and Special Populations
A Message
to the Physicians of New York State
Regarding Their Role
in Suicide Prevention
from
Dr. William E. Tucker
Interim Chief Medical Officer (Emeritus),
New York State Office of Mental Health
A little-known fact is that more people die
by suicide than from homicide in the United
States – and New York – each year. Though
not all suicides are preventable, most who
die from suicide have made previous
attempts, and a substantial number have
consulted physicians in the weeks leading
up to the event; thus, many may be preventable, if appropriate attention is devoted
to identifying and intervening with those at
immediate risk. (Note: Since the under-lying
biological and psychosocial causes of suicidal behavior are addressed in the OMH suicide prevention plan, this document will
focus only on the role of physicians in early
identification and referral).
A commonly held misconception, even
among many physicians, is that it is somehow embarrassing to a patient to be asked
about suicidal thoughts or plans – or worse,
insulting; the patient will respond, "What do
you think I am, crazy?" An extension of this
misconception, also mistaken, is that
patients will therefore deny or conceal their
suicidal thoughts. In fact, the overwhelming
majority of patients experience considerable
relief at being asked: there is finally an
opportunity to express their terrifying concerns to the person they consider responsible and and most capable of providing for
their overall health. Therefore, they are
forth-coming in response to being asked.
Within this framework, three questions
immediately arise: Who are the most
appropriate professionals to pose the question? What is an effective way to pose it?
What is the appropriate next step, if the
answer is positive?
Generalist and specialist physicians of all
types, in their role as public health agents,
make up the "front line" on this. The routine initial or follow-up visit is the appropriate setting for a physician to inquire about
suicide. There need be no more index of
suspicion than for any other general health
issue, such as changes in diet, activity,
sleep, discomfort, or somatic concern.
Broaching the subject can be as general
and unexceptional as that to any other
organ system. Individual styles vary, but the
question may take the form of, for example, "Since your last visit, would you say
that, for the most part, you have been
happy with your life?" The follow-up question is simply, "Are you saying then, that
you have or have not had any thoughts of
suicide?" A negative response is sufficient
to end the line of inquiry. If the response is
positive, it is imperative to ask: "And have
you made any plans to do something to
carry them out?"
Positive responses to inquiries about suicidal thoughts or plans should trigger a referral to a psychiatrist, just as positive indications should be reffered to other systemic
pathology outside the realm of the physicians's usual practice. It should also be
A Message to the Physicians of New York State
5
Saving Lives in New York Volume 2: Approaches and Special Populations
acknowledged that the front-line physician
is no more responsible for effecting the
patient's acceptance of such a referral than
that of any other referral to a specialist.
Given that there are approximately 150,000
suicide attempts by teenagers in New York
State each year (though only 70 completed
suicides), the pediatricians would face a
significant work load increase in accordance with such a practice of inquiry; other
primary-care physicians might not be similarly affected.
6
There is no question but that inquiring
about suicidal thoughts in the course of
routine visits represents a significant departure from current practice. Therefore, some
resources must be dedicated to making it
possible. The most direct is the provision of
at least annual lectures to residents and to
departmental physicians.
In the context of the national awareness of
suicide, inaugurated three years ago in the
Surgeon General's Report on Mental Health
and likely to be given particular emphasis
by the current President in his upcoming
public health initiatives, it is not unlikely
that pharmaceutical companies would be
willing to underwrite such an effort. The
goal, after all, is to reduce the rate of suicide in this state and to set a model for the
rest of the nation.
A Message to the Physicians of New York State
Saving Lives in New York Volume 2: Approaches and Special Populations
Resilience
Gary L. Spielmann, M.A., M.S.
Director of Suicide Prevention
New York State Office of Mental Health
Resilience and self-help are a cornerstone
of the public health strategy to reduce the
Number of incidents of suicide in New
York. Resilience is the human capacity to
deal with, overcome, learn from or even be
transformed by adversity (Grotberg: 1999).
In the words of a leading neuroscientist:
“People don’t come preassembled, but are
glued together by life.” (LeDoux: 1996).
“Like the immune system, the emotional
system evolves continuously, taking experiences and situations and attaching emotional value to them in subtle gradations of
risk and reward. Moderate stress enhances
learning. Risk is an integral part of life and
learning.” (Gonzales: 2003)
I. Findings.
Human Nature and Nurture.
Human nature is a powerful source of an
individual’s ability to cope with challenges
and threats. Parents provide their children
with genes as well as a home environment,
but infants’ minds come equipped with certain perceptual and behavioral biases.
(Restak: 1988) Discoveries in the sciences
of mind, brain, genes and evolution challenge the notion that human nature is irrelevant to how we think, feel and behave.
Human nature is central to all three, as is
human nurture. (Pinker: 2002)
Resilience can be developed through practice, but the extent and depth of its devel-
Resilience
opment will depend on individual, genetic
and environmental forces Resilience is promoted by external support – access to care,
aids to autonomy – as well as internally,
through pride, self-respect and the ability to
empathize. Role models are important in
the development of resilience at all ages,
from early childhood onward.
According to the American Psychological
Association (2003), resilience is ordinary,
not extraordinary. People commonly
demonstrate resilience and bounce back
from adversity. The response of many New
Yorkers to the September 2001 terrorist
attack and individual efforts to rebuild their
lives is more typical than atypical. Many
people react to traumatic events with a
flood of strong emotions and a sense of
uncertainty and anxiety. Yet in the face of
adversity, most people adapt well over time
to even life-altering situations. What
enables them to do so? It involves
resilience. Being “resilient” does not mean
that a person doesn’t experience difficulty
or distress. Emotional pain and sadness are
common in people who have suffered
major adversity or trauma in their lives. In
fact, the road to resilience is likely to
involve considerable emotional distress.
Resilience involves behaviors, thoughts and
actions that can be learned and developed
in anyone. For this reason, promoting
resilience is an essential element in New
York’s suicide prevention strategy.
(APA/DHC: 2003)
7
Saving Lives in New York Volume 2: Approaches and Special Populations
B. Factors Promoting Resilience
Multiple factors contribute to an individual’s resilience. Many studies have shown
that a prime factor is having caring and
supportive primary relationships within and
outside the family. Relationships that create
love and trust, provide role models, and
offer encouragement, reassurance and
hope help to bolster a person’s resilience.
Resilience is also enhanced by the capacity
to make realistic plans and take steps to
carry them out and having a positive view
of one’s own journey.
People react differently to various traumatic
and stressful life events. They also use different approaches and strategies. Cultural
differences also produce variations and
preferences in how individuals communicate and deal with adversity. Growing cultural diversity provides the public with
additional approaches to building
resilience. (APA/DHC: 2003)
C. Origins of Resilience
According to Grotberg (2002), resilience
comes from three sources: external supports that promote resilience; inner
strengths that develop over time and sustain those who are dealing with adversities;
and interpersonal, problem-solving skills
that deal with the actual adversity. Specifically, these are:
I Have
(External Supports)
1. One or more persons within my family
I can trust and who love me without
reservation.
2. One or more persons outside my family
I can trust without reservation.
I Am
(Inner strengths)
1. A person most people like
2. Generally calm and good-natured
3. An achiever who plans for the future
4. A person who respects myself
and others
5. Empathic and caring of others
6. Responsible for my own behavior and
accepting of the consequences
7. A confident, optimistic, hopeful person,
with faith
I Can
(Interpersonal and problem-solving skills)
1. Generate new ideas or new ways to do
things
2. Stay with a task until it is finished
3. See the humor in life and use it to
reduce tensions
4. Express thoughts and feelings in communication with others
5. Solve problems in various settings –
academic, job-related, personal and
social
6. Manage my behavior – feelings,
impulses, acting-out
7. Reach out for help when I need it.
(Grotberg: 2002)
D. Approaches to Teaching Resilience
3. Limits to my behavior
4. People who encourage me to be independent.
5. Good role models
6. Access to health, education, and the
social and security services I need
7. A stable family and community
8
1. Penn Resiliency Project (Positive Psychology for Youth Project)
This Project seeks to prevent depression by
giving children the tools to deal with challenges faced in high school and life. It uses
psychology, to optimize human potential.
Research shows that children who are
resilient – who bounce back from problems because they are good at seeing them
from multiple perspectives – and who
Resilience
Saving Lives in New York Volume 2: Approaches and Special Populations
accurately understand their role in the situation fare better after trauma.
The curriculum flows from an Adversity
Belief s and Consequencees model (ABC
model). Step A: Identify “push-button
adversities,” challenges in the important
areas of an adolescent’s life: school, friendships and family. Step B: Capture what it is
you say to yourself in the heat of the
moment. This is an internal radio station,
often a litany of negative thoughts about
the adversity. “I’m not good enough to get
the grade.” Step C: Examine how inaccurate beliefs shape the quality of your feelings and behavior – the consequences. Did
you get the low grade because you were
too busy to study during the semester? Will
your negative reaction keep you from pursuing a genuine interest? What are the
facts surrounding the adversity? Does your
reaction reflect them?
The key to the exercise is connecting Steps
B and C and separating fact from interpretation. “It’s your beliefs that drive
you...They will determine how you
respond.” If the Project can help children
“evaluate themselves more realistically and
less harshly, that’s important. It can loosen
them from the grip of pressures they face.”
As one of the students put it: “People have
the idea that being happy means skipping
through the flowers...But happy is being
happy with who you are.” (Simon: 2004)
2. Natural Therapy
Another prominent model promoting
resilience involves Natural Therapy. Based
on the premise that most of life’s difficulties
require telling or hearing the truth, this
approach teaches that living in a lie
eclipses the joy of the world and lowers a
person’s self-esteem. Concealing lies drain
people’s energy so they don’t have enough
strength to do their best. Lies complicate.
The truth simplifies. The truth has the
power to heal, to protect, to guide. Living
in the truth is living free and at one’s best.
Moreover, the greatest pleasures come
only when you are aware of yourself and
know your strengths and limitations. Our
capacity to enjoy pleasure is limited by our
self-acceptance. More than anything else, it
Resilience
is our openness with ourselves that allows
us to enjoy life fully. “Peace of mind comes
with self-acceptance. It is not conferred by
achievement, it is the gift you give to yourself.” (Viscott: 1996)
3. Enhancing Natural Support Networks
Local communities of neighborhoods have
individuals, organizations and institutions
where people go to seek advice, information and support. These are the resources
that influence and enhance community life
by providing numerous support mechanisms. Some of the informal community
sources of support that regularly dispense
advice and support – such as barbers, hairdressers and taxi drivers – are not usually
recognized for providing this service, but
they constitute part of a natural support
network for people around them. Besides
providing information, they serve as listening posts that are in themselves a valuable
form of natural support.
These networks are valuable for both individuals and groups affected by a common
threat, such as a terrorist attack or natural
disaster. While these lay persons typically
lack formal training as counselors or
providers, they do come in contact with
large numbers of the public. As such, they
can be a valuable adjunct to a community’s
crisis-response. Properly trained,they could
help local communities heal themselves.
Such a proposal was made to sustain and
broaden the community response to the
World Trade Center terrorist attack and create what is termed an island of resilience in
a sea of uncertainty. In the future, they
could be trained and deployed to help individuals become more resilient and able to
fend off future disasters and attacks. (Allen:
2003)
4. Extreme Resilience
What makes a difference in determining
whether someone succumbs to a threat or
survives? Who lives and who dies? A
recent analysis of “deep survival” examined
the attitudes and behaviors exhibited by
individuals caught in life and death situations in a range of adverse environments.
(Gonzales: 2003) The study revealed 12 lessons for prevailing against extreme odds.
9
Saving Lives in New York Volume 2: Approaches and Special Populations
Such conditions can produce what could
be termed “extreme resilience,” the ability
to think and behave successfully in the
clutch of mortal danger.
1. Perceive, believe (look, see, believe).
Extreme survivors rapidly grasp the
reality of their situation and acknowledge that everything – good or bad –
emanates from within. Their life is ultimately in their grasp. They move quickly through denial, anger, bargaining,
depression and acceptance very quickly.
2. Stay calm (use humor, use fear to focus).
Survivors use fear, turn it into anger,
and it motivates them. They understand at a deep level about being cool
and are ever on guard against the
mutiny of too much emotion. They
keep their sense of humor and keep
calm.
8. See the beauty (remember: it’s a vision
quest). The appreciation of beauty can
relieve stress and create strong motivations, as well as help to take in new
information more effectively.
9. Believe that you will succeed (develop a
deep conviction that you will live.) Survivors consolidate their personalities
and fix their determination; they
admonish themselves to make no more
mistakes, to be very careful and to do
their very best. They become convinced
that they will prevail if they do these
things.
10. Surrender (let go of your fear of dying).
Survivors manage pain well. They
practice resignation without giving up.
It is survival by surrender.
3. Think/analyze/plan. Survivors quickly
organize, set up routines, and institute
discipline. They push away thoughts
that their situation is hopeless. They act
with the expectation of success.
11. Do whatever is necessary (be determined:
have the will and the skill). Survivors
have meta-knowledge: they know their
abilities and do not over or under-estimate them.
4. Take correct, decisive action. Survivors
are able to transform thought into
action: take risks to save themselves
and others and break down large jobs
into small, manageable tasks.
12. Never give up (let nothing break your
support). Survivors have a clear reason
for going on. They are not discouraged
by setbacks. They come to embrace the
world in which they find themselves
and see opportunity in adversity. (Gonzales: 2003, 270-274)
5. Celebrate your successes (take joy in
completing tasks). Survivors take great
joy from even the smallest successes.
Important to sustain motivation, this
attitude also prevents the descent into
hopelessness.
6. Count your successes (take joy in completing tasks). This is how survivors
become rescuers instead of victims.
There is always someone else they are
helping more than themselves, even if
that someone is not present.
7. Play (wing, play mind games, recite poetry, count anything). Using deeper powers of intellect can help to stimulate,
calm, and entertain the mind. It can
10
also lead to a novel solution to the
problem at hand.
II. Action Steps
To build resilience, the following steps are
recommended by the American Psychological Association:
1. Make Connections. Good relationships
with other family members, friends, or
others are important. Accepting help
and support from those who care about
you and will listen to you strengthens
resilience. Some people find that being
active in civic groups, faith-based
organizations, or other local groups
provides social support and can help
with reclaiming hope. Assisting others
Resilience
Saving Lives in New York Volume 2: Approaches and Special Populations
in their time of need also can benefit
the helper.
2. Avoid Seeing Crises as Insurmountable
Problems. While you can’t change the
fact that highly stressful events do happen, you can change how you interpret
and respond to these events. Look
beyond the present for how future circumstances may be a little better.
3. Accept that Change is a Part of Living.
Certain goals may no longer be attainable as a result of adverse situations.
Accepting circumstances that cannot
be changed can help you focus on circumstances that you can alter. As one
sage observer noted, “freedom is the
recognition of necessity.”
4. Move Toward Your Goals. Develop some
realistic goals and do something regularly that enables you to move towards
your goals, even if it seems like a small
accomplishment. Instead of focusing
on tasks that seems unachievable, ask
yourself, “What’s one thing I know I
can accomplish today that helps me
move in the direction I want to go?”
One step does not make a big difference, but one step taken regularly can.
5. Take Decisive Action. Act on adverse situations as much as you can. Take decisive action, rather than detaching completely from problems and stresses and
wishing they would just go away.
Chances are they won’t, but decisive
action may do just that.
6. Look for Opportunities for Self-Discovery.
People often learn something about
themselves and may find that they have
grown in some respect as a result of
their struggle with loss. Many people
who have experienced tragedies and
hardship have reported better relationships, greater sense of personal
strength, even while feeling vulnerable,
an increased sense of self-worth, a
more developed spirituality, and heightened appreciation for life.
Resilience
7. Nurture a Positive View of Yourself.
Developing confidence in your ability to
solve problems and trusting your
instincts helps build resilience.
8. Keep Things in Perspective. Even when
facing very painful events, try to consider the stressful situation in a broader
context and keep a long-term perspective. Avoid blowing the event out of
proportion.
9. Maintain a Hopeful Outlook. An optimistic outlook enables you to expect
that good things will happen in your life.
Try visualizing what you want, rather
than worrying about what you fear.
10. Take Care of Yourself. Pay attention to
your own needs and feelings. Engage
in activities that you enjoy and find
relaxing. Exercise regularly. Taking care
of yourself helps to keep your mind and
body primed to deal with situations that
require resilience.
11. Learn From Experience. Focusing on
past experiences and sources of personal strength can help you learn about
what strategies for building resilience
might work for you.
12. Stay Flexible. Resilience involves maintaining flexibility and balance in your
life as you deal with stressful circumstances and traumatic events.
13. Complete Your Journey. Developing
resilience is similar to taking a raft trip
down a river. “Perseverance and trust
in your ability to work your way around
boulders and other obstacles are
important. You can gain courage and
insight by successfully navigating your
way through white water... You can
climb out to rest alongside the river.
But to get to the end of your journey,
you need to get back in the raft and
continue.” (APA/DHC: 2003)
11
Saving Lives in New York Volume 2: Approaches and Special Populations
References
Allen, John, Enhancing Outreach Efforts through Indigenous
Natural Support Networks, (Albany: Project Liberty (OMH),
2003)
American Psychological Association & Discovery Health Channel,
(APA/DHC) The Road to Resilience (Washington, DC: 2003)
American Psychological Association, www.helping.apa.org or 1800-964-2000
Discovery Health Channel, Aftermath: The Road to Resilience
(Coping with Tragedy, Learning to Live Again) , Broadcast on
August 29, 2003 with an encore presentation on September
11, 2003.
Erikson, Erik, Childhood and Society (New York: WW Norton,
1985)
Gonzales, Laurence, Deep Survival: Who Lives, Who Dies, and
Why (New York: W.W. Norton, 2003)
Grotberg, Edith Henderson, Ph.D., How To Deal with Anything,
(New York: MJF Books, Fine Communications, 1999)
_________________________, A Guide to Promoting
Resilience in Children:
Strengthening the Human Spirit (The Hague: Bernard Van Leer
Foundation, 1995) (May be downloaded from www.
resilnet.uiuc.edu)
__________________________ "International Resilience
Research Project,”
379-399 . In A.L. Comunian & U. Gielen (eds.) International
Perspectives on Human Development (Vienna: Pabst
Science Publishers, 2000)
LeDoux, Joseph, The Emotional Brain: The Mysterious
Underpinnings of Emotional Life. (New York: Simon &
Schuster, 1996)
___________, The Synaptic Self: How Our Brains Become Who
We Are (New York: Viking, 2002)
Pinker, Steven, The Blank Slate: The Modern Denial of Human
Nature (New York: Viking, 2002)
Restak, Richard, The Mind (New York: Bantam Books, 1988)
Simon, Cecilia Capuzzi, "Adolescents, Sunny Side Up," in
Education Life, The New York Times, Section 4A, August 1,
2004.
Viscott, David, M.D., Emotional Resilience: Simple Truths for
Dealing with the Unfinished Business of Your Past (New
York: Random House, 1996)
12
Resilience
Saving Lives in New York Volume 2: Approaches and Special Populations
Media
Dempsey Rice, M.A.
Daughter One Productions, Inc.
Brooklyn, New York
I. Findings
Today’s media play a major role in influencing peoples’ images and ideas about
mental illness and suicide. Negative stereotypes are too often the only image the public receives about these subjects and, in
effect, become the only sources of their
knowledge about them. Many New Yorkers
continue to associate mental illness with
people who are dangerous and pose a
threat to public safety and welfare. The
stigma that accompanies mental illness is a
major barrier for people who are struggling
to manage their illness through medication
and therapy.
Despite advances in treatment that enable
people to live and work successfully in the
community, mental illness continues to be
regarded as a social disease rather than a
neurobiological disorder. This lag in the
public mind does a profound disservice to
thousands of New York citizens who suffer
from a mental illness. Feelings of internalized shame and low self-esteem continue
to plague these individuals, compounding
the effects of the illness.
It contributes to the reality that only 1 person in 5 will seek professional help for an
emotional disorder and choose instead to
suffer silently, but not painlessly. The media
must take responsibility for the misinformation and stereotyping projected daily
about people with mental illness, including
Media
those who lose their lives to suicide. Fortunately, the potency of the media means
they must be part of the solution as well.
Research shows that media alone do not
cause suicide – healthy people, even
teenagers – don’t normally “up and kill
themselves” due to what they see or read.
But media are unhelpful when they present
an inaccurate, overly dramatized image of
mental illness and its treatment, thereby
discouraging help-seeking. Moreover,
media can also play a real role in preventing suicide – compassionate reporting and
accurate representation can both educate
and reduce stigma, leading to treatment
and eventually, healthy people.
A. The Annenberg Report (2001)
1. Four years ago, the Annenberg Public
Policy Center at the University of Pennsylvania, in collaboration with the
American Association of Suicidology
and the American Foundation for Suicide Prevention, issued a report, Reporting on Suicide: Recommendations for the
Media.
Highlights of the Report are these:
•
The media can play a powerful role in
educating the public about suicide prevention. Stories about suicide can
inform readers, viewers, and listeners
about the likely causes of suicide, its
warning signs, trends in suicide rates,
and recent treatment advances. They
13
Saving Lives in New York Volume 2: Approaches and Special Populations
can also highlight opportunities to prevent suicide. Media stories about individual deaths by suicide may be newsworthy and need to be covered, but
they also have the potential to do harm.
Implementation of recommendations for
media coverage of suicides has been
shown to decrease suicide rates. Unfortunately, many media practices can have
negative effects on the public:
1. Certain ways of describing suicide in
the news contribute to what is called
“suicide contagion” or “copycat suicides.” This is especially potent within
the adolescent population. (See Chapter on Adolescents for more information)
2. Research suggests that inadvertently
romanticizing suicide or idealizing
those who take their own lives by portraying suicide as a heroic or romantic
act may encourage others to identify
with the victim.
3. Exposure to suicide method through
media reports can encourage vulnerable individuals to imitate it. Clinicians
warn the danger is even greater if there
is a detailed description of the method.
Research indicates that pictures or
other detailed information of the site of
a suicide also encourages imitation.
4. Presenting suicide as the inexplicable
act of an otherwise healthy or highachieving person may encourage identification with the victim, and engender
a “copycat behavior.”
5. The media should know that 90% of
suicide victims have a significant psychiatric illness at their time of death.
These are often undiagnosed, untreated, or both. Mood disorders and substance abuse are the two most common diagnoses.
6. When both mood disorders and substance abuse are present, the risk for
suicide is much greater, especially for
adolescents and young adults.
14
7. Research has shown that when open
aggression, anxiety or agitation is present in individuals who are depressed,
the risk for suicide increases significantly.
8. The cause of an individual suicide is
typically more complicated than a
recent painful event, such as a breakup of a relationship or the loss of a job.
Social conditions alone do not explain
a suicide.
9. People who appear to become suicidal
in response to such events, or in
response to a physical illness, generally
have significant mental problems,
though they may be well-hidden.
II. Action Steps for Working
with the Media
1. If you don’t know what good and bad
examples of how the media reports on
suicide are, educate yourself. Read the
Annenberg Report and go to the American Foundation for Suicide Prevention’s
web site for current examples
(www.afsp.org).
2. Once you understand the issues and
have some examples to back yourself
up, tell others. Helping the media
understand the issue and educating
them about how they might do a better
job is a concrete way that you can
bring about change.
3. Reach out to the news and health editors at your local newspapers – big or
small – and at your local broadcast
newsrooms. Often a suicide in a specific neighborhood or borough is reported
in the neighborhood paper and not the
major paper. If you live in a college
town, get in touch with the editor of the
student newspaper or student-run
radio and television station: young
adults need this information as well.
4. Get phone, fax and e-mail contact
information for these individuals, but
open your communication with something written: a letter, fax or e-mail that
explains who you are and why you
Media
Saving Lives in New York Volume 2: Approaches and Special Populations
care about suicide prevention (and its
coverage). If you can help your reader
understand why you are writing and
that you are truly invested in suicide
prevention, they will take you more
seriously. Include a copy of Reporting
on Suicide with your letter.
5. Offer to meet with editors, reporters
and copy editors at your local media
outlets. Each of these groups plays a
key role in how the media represents
suicide: the editor by assigning the
story to a reporter, a reporter by telling
that story and a copy editor by writing
the headline and photo captions for
that story.
6. Maintain ongoing communication and
dialogue with your local news agencies. Let them know you are available
to consult as an “expert” or that you
can help them get the information they
need when reporting on a suicide. Keep
them abreast of mental health and suicide related legislative news at the state
and federal levels.
7. In addition to working with your local
media outlets, get in touch with professors at the local university or community college. Offer to speak to journalism classes or at schools of communications. We need to educate today’s
students before they begin working as
professional journalists.
mental health in the press and fictional
media. If it’s very good, nominate it for
an award.
10. Use the media to educate your local
community by asking local health editors to assign stories about depression
and mental illness at any time of the
year, but specifically when a suicide
occurs in your community. Stories
about warning signs for suicide, stories
that profile local organizations or individuals who work in suicide prevention, and stories about mental health
and suicide related legislation can all
be effective uses of media to de-stigmatize mental health, educate the public and, ultimately, combat suicide. If
information about warning signs and
prevention is presented along side a
story about a local suicide your community will learn something from the
tragedy.
11. If a local mental health organization is
having a rally or educational event,
invite the media. This is a great opportunity to educate them and to provide
them with “content” for a story.
12. If a television program or (fictional) film
misrepresents suicide or mental illness,
media watchers can do several things:
8. If you find examples of “bad” reporting
in your local news outlets, let them
know in a calm, intelligent, educational
manner. Refer them to the Annenberg
Report. Help them to understand where
they went wrong and how they could
have done better without alienating
them. Provide examples of how they
could have done better and make yourself available for ongoing communication about the issue.
• Write a letter to the production company that created the program and
the distribution outlet. Most films are
produced and distributed by studios
but some are produced by one company and then distributed by a studio
or distribution company. All of this
information is found in the opening
credits of the film...take notes. To
comment on a television program,
look for the production company’s
credit at the end of the show and
write to the broadcast outlet (the television channel).
9. If you find examples of “good” reporting....praise them. Many mental health
associations, including the National
Mental Health Association, offer media
awards for positive representations of
• Write a letter to the editor of your
local newspaper about the program
or film, ask a local columnist to do
an opinion piece, or find out if your
local news station will let you read a
Media
15
Saving Lives in New York Volume 2: Approaches and Special Populations
commentary on air. Many television
stations do program commentary by
local residents.
• Hold an awareness event and invite
local media to cover the event.
13. Deliver the message yourself. Give presentations to local houses of worship,
community centers and libraries. Collaborate with institutions in the community, and ask them to help spread
the word about suicide and mental illness...Talk helps to spread information
and de-stigmatize the issues. If you live
in a college or university town, volunteer to coordinate a public awareness
campaign on campus. If your community has a web site, ask for a link to the
local suicide prevention council. Better
yet, ask the webmaster to include information about suicide and mental illness.
III. Guidelines for Media Coverage
of Suicides *
1. In covering a story about suicide, find
out if the victim ever received treatment for depression or any other mental illness. Did the victim have a substance abuse problem? Conveying the
message that effective treatments for
most of these conditions are available –
but underutilized – may encourage
those with such problems to seek help.
one’s death by suicide inexplicable or
they may deny that there were warning
signs. Accounts based on these initial
reactions are often unreliable.
5. Thorough investigations generally reveal
underlying problems unrecognized even
by close friends and family members.
Most victims do, however, give warning
signs of their risk for suicide.
6. Some informants are likely to suggest
that a particular individual – a family
member, school employee, health service provider – played a role in the victim’s death by suicide. Thorough investigation almost always finds multiple
causes for suicide and fails to corroborate a simple attribution of responsibility.
7. A concern exists about dramatizing the
impact of suicide through descriptions
and pictures of grieving relatives,
teachers or classmates. This may
encourage potential victims to see suicide as a way of getting attention or as
a means of retaliation against others.
8. Using adolescents on TV or in print
media to tell the stories of their suicide
attempts may be harmful to the adolescents themselves or may encourage
other vulnerable young people to seek
attention this way.
IV. The Significance of Language.
2. Acknowledging the deceased person’s
problems and struggles as well as the
positive aspects of his/her life or character contributes to a more balanced
picture.
Notes:
*
3. During the period immediately following a suicide death, grieving family
members or friends may have difficulty
understanding what happened.
Responses may be extreme, problems
may be minimized, and motives may
be complicated.
From the American
Foundation for Suicide 4.
Prevention and the
Annenberg School of
Communications and
Public Policy (2001)
16
1. A cautionary note on language: referring to a “rise” in suicide rates is usually
more accurate than calling such a rise
an “epidemic,” which implies a more
dramatic and sudden increase than
what we generally find in suicide rates.
Similarly, research has shown that the
use of the word “suicide” in headlines
and reference to the cause of death as
“self-inflicted” increases the likelihood
of contagion.
Studies of suicide based on in-depth
interviews with those close to the victim
indicate that, in their first, shocked reaction friends and family may find a loved
Media
Saving Lives in New York Volume 2: Approaches and Special Populations
2. Unless the death took place in public,
the cause of death should be reported
in the body of the story, not in the
headline.
VI. Stories To Consider Covering.
3. In deaths that will be covered nationally, such as celebrities, or those apt to be
covered locally, such as persons living
in small towns, consider phrasing
headlines such as “Marilyn Monroe
dead at 36” or “John Smith dead at 48.”
How they died could be reported in the
body of the article.
3. Individual stories of how treatment was
life-saving
1. Trends in suicide rates
2. Recent treatment advances
4. Stories of people who overcame
despair without attempting suicide
5. Myths about suicide
6. Warning signs of suicide
4. In the body of the story, it is preferable
to describe the deceased as “having
died by suicide” rather than as “a suicide,” or having “committed suicide.”
The latter two expressions reduce the
person to the mode of death, or connote criminal or sinful behavior.
5. Contrasting “suicide deaths” with “nonfatal attempts” is preferable to using
terms such as “successful,” “unsuccessful” or “failed.”
V. Special Situations.
1. Celebrity deaths by suicide (e.g. Marilyn
Monroe, Kurt Cobain) are more likely
than non-celebrity deaths to produce
imitations. While suicides by celebrities
will receive prominent coverage, it is
important not to let the glamour of the
individual obscure any mental health
problems or use of drugs.
7. Actions that individuals can take to
prevent suicide by others
References
For reporting on Suicide – Recommendations for the Media:
American Foundation for Suicide Prevention www.afsp.org
or 1-888-333-AFSP
The Annenberg Public Policy Center of the University of
Pennsylvania www.appcpenn.org or (215) 898-7041
American Association of Suicidology www.suicidology.org or
(202) 237-2280
Articles and Papers: Goldsmith, SK; Pellmar, TC; Kleinman AM;
Bunney, WE; Reducing Suicide: A National Imperative
(Washington: The National Academies Press, 2002)
www.nap.edu
Gould, M.; Jamieson, P.; Romer, D., Media Contagion and Suicide
Among the Young American Behavioral Scientist, Vol.46,
No.9, May 2003, 1269-1284
Mann, J.John, MD, A Current Perspective of Suicide and
Attempted Suicide, Annals of Internal Medicine, 2002; 136:
302-311
Web Site: The Advertising Council provides advice to not-for-profits that want to work with the media on their web site.
www.adcouncil.org
Book: Jason Salzman, Making the News: A Guide for Nonprofits
and Activists. (Westview Press, May 1998)
2. Homicide – suicide coverage should be
aware that the tragedy of the homicide
can mask the suicidal intent of the act.
Feelings of depression and hopelessness present before the homicide and
suicide are often the impetus for both.
3. Suicide pacts are mutual arrangements
between two people who kill themselves at the same time, and are rare.
They are not simply the act of loving
individuals who do not wish to be separated (e.g. Romeo and Juliet). Research
shows that most pacts involve an individual who is coercive and another who
is extremely dependent.
Media
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Saving Lives in New York Volume 2: Approaches and Special Populations
Voluntary Mental Health Screening
as a Means to Prevent Suicide
Laurie Flynn and Roisin O’Mara
The Carmel Hill Center
Division of Child and Adolescent Psychiatry,
Columbia University
The problems of mental illness and suicide
have reached crisis proportions in the United States and throughout the world. Mental
illness is now the leading cause of disability
worldwide, accounting for nearly 25% of all
disability across major industrialized countries. Suicide claims more than 30,000 lives
in the United States every year.
Findings
More Americans suffer from depression
than coronary heart disease (7 million),
cancer (6 million) and AIDS (200,000) combined. About 15 percent of the population
will suffer from clinical depression at some
time during their lifetime. Depression is a
very serious disease and is one of the leading causes of suicide. Thirty percent of all
clinically depressed patients attempt suicide, and half of them ultimately succeed.
However, depression is one of the most
treatable of psychiatric illnesses. Some estimates suggest that between 80 and 90 percent of people with depression respond
positively to treatment, and almost all
patients gain some relief from their symptoms. But first, depression has to be recognized (AFSP). Other mental health disorders such as schizophrenia, anxiety and
alcohol and substance abuse also carry an
increased risk for suicide.
Psychological autopsy studies have reliably
shown that 90% of people who die by suicide have a diagnosable mental illness at
the time of their death. (Shaffer, D.: 1996)as
In any other area of medicine, if we knew
what caused 90% of mortality associated
with a particular illness, we would certainly
implement widespread screening for the
associated risk factors. Since the risk factors
for suicide are both identifiable and treatable, screening for untreated mental health
disorders should be an important component of any suicide prevention program
(Shaffer: 1994). Advances in the area of
efforts to prevent suicide should promote
voluntary mental health screening for all
ages in order to find those most at risk for
suicide and link them to further evaluation
and services.
The President’s New Freedom Commission
for Mental Health (2003) called special
attention to the need for mental health
screening in schools and primary health
care. Accordingly, these two areas will be of
special focus in this chapter as they relate to
mental health screening across the lifespan.
Voluntary mental health screening is important at any age, starting with adolescence
and continuing through old age. Undetected
mental illness and suicide is a tragedy that
we all need to work towards preventing in
every stage of life.
Mental Health Screening
for Adolescents
It is estimated that one in ten youth suffer
from a mental health problem serious
enough to cause impairment, yet only one
in five of these receive any treatment. Sui-
Voluntary Mental Health Screening as a Means to Prevent Suicide
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Saving Lives in New York Volume 2: Approaches and Special Populations
cide is the third leading cause of death
among young people aged 13-19 years,
and more teens die from suicide than all
natural causes combined. Each year an
additional 600,000 youth require medical
services as a result of suicide attempts
(CDC: 2002). Mental health screening represents a way to find these youth early and
link them to treatment long before suicide
seems like their only solution.
The President’s New Freedom Commission
on Mental Health (2003) sent a strong message to schools and parents about the
importance of mental health in academic
achievement, stating: “The mission of public
schools is to educate all students. However,
children with serious emotional disturbances have the highest rate of school failure. While schools are primarily concerned
with education, mental health is essential to
learning as well as to social and emotional
development. Because of this important
interplay between emotional health and
school success, schools must be partners in
the mental health care of our children.”
The President’s Commission named the
Columbia University TeenScreen Program as
a model screening and early intervention
program. The Columbia University TeenScreen Program works by creating partnerships with schools and communities across
the nation to implement their evidencebased mental health screening program.
The Columbia TeenScreen Program provides
consultation, training, screening tools, software and technical assistance free of charge
to schools and communities who want to
implement mental health screening.
The Columbia University TeenScreen Program uses a two-stage process to identify
at-risk youth. First, all youth who have
parental consent, and who themselves
assent to participation, complete a brief
mental health check-up. Ther are several
screening instruments available through the
TeenScreen program, both computerized
and paper/pencil, which screen for mental
health problems and suicide risk. Teens
who “screen negative” are debriefed and
dismissed from the screening, and youth
who “screen positive” are advanced to the
20
second stage where they are interviewed by
a mental health professional to determine if
an outside referral for further evaluation
would be beneficial. If this is recommended,
the youth and his/her family are then provided assistance with the referral process.
Follow up contact with the family continues
through the first clinical appointment.
Signs of Suicide (SOS) is another national
school-based suicide prevention program
that incorporates two prominent suicide
prevention strategies into a single program,
combining a curriculum that aims to raise
awareness of suicide and its related issues
with a briefing screening for depression
and other risk factors. The educational
component is expected to reduce suicidality by increasing students understanding of
and promoting more adaptive attitudes
toward depression and suicidal behavior.
The self-screening component enables students to recognize depression and suicidal
thoughts and behaviors in themselves and
prompts them to seek assistance.
The program’s main educational materials
are a video (featuring dramatizations
depicting the signs of suicidality and
depression, recommended ways to react to
someone who is depressed and suicidal, as
well as interviews with real people whose
lives have been touched by suicide) and a
discussion guide. There are additional
materials included for training of school
personnel, including videos and step-bystep instructions for implementation. The
screening tool is optional but recommended and is included in the training packet.
The screening tool used by SOS is the
seven-item Brief Screen for Adolescent
Depression (BSAD). The BSAD includes a
scoring system that allows the student to
score his or her own questionnaire and to
determine personally whether to seek help
based on the results. The SOS Program has
been shown in a randomized, controlled
study to significantly reduce the suicide
attempt rate among those who participated
in their program in the three months following the intervention by 40%. (Aseltine &
DeMartino, 2004)
Voluntary Mental Health Screening as a Means to Prevent Suicide
Saving Lives in New York Volume 2: Approaches and Special Populations
A recently published article about the safety of asking about suicide ideation and
attempt has shown that there is no evidence of iatrogenic effects of suicide
screening. Neither distress nor suicidality
increased among the general student group
or among the high school students – in fact
the findings suggested that asking about
suicidal ideation or behavior may have
been beneficial for students with depression symptoms or previous suicide
attempts (Gould, M. et al.: 2005)
Mental Health Screening
for College Students
Suicide is the second leading cause of
death among college-age students. Among
college students, 7.5 of every 100,000 take
their own lives and the National College
Health Risk Behavior Study (1995) found
that 11.4% of students seriously consider
attempting suicide. To tackle this problem,
the Jed Foundation and the American
Foundation for Suicide Prevention (AFSP)
have been actively working to develop and
implement effective suicide prevention
screening programs for college students.
To leverage the anonymity of the Internet
and its popularity among young adults, the
Jed Foundation has created Ulifeline.org.
Ulifeling is an anonymous, web-based
resource that provides students with a nonthreatening and supportive link to their college mental health or counseling center.
Ulifeline was created to give students more
knowledge about mental health and the
signs and symptoms of emotional problems. The website includes a library of
mental health information and an interactive screening tool to help students uncover whether they, or a friend, are at risk.
Currently, more than 160 universities are
participating in the Ulifeline network,
including Columbia, Harvard, MIT, Northwestern and the University of Arizona.
The American Foundation for Suicide Prevention is implementing a college screening project designed to identify and refer
for treatment students at risk for suicide. To
date, the project has targeted students in
five successive semesters at Emory University in Atlanta, and is currently being pilot-
tested at The University of North Carolina
at Chapel Hill (UNC/CH). The college
screening project uses a screening instrument known as the Depression Screening
Questionnaire. Students responding to the
online questionnaire identify themselves by
a self-assigned User ID.
Based on their responses to specific questions, a computer program places each student in one of three tiers, according to the
level of their psychological problems, and
sends an email with this information to a
counselor affiliated with the university’s
mental health services. The counselor then
accesses and reviews each questionnaire
and provides an assessment. An individually tailored counselor’s assessment is then
sent back to the student’s User ID on the
secure website. In this assessment, the
counselor will recommend students whose
questionnaire responses suggest psychological difficulties to come in for a face-toface evaluation by a counselor. The questionnaires of students identified as experiencing the most significant problems are
assessed within 24 hours of receipt. Students then access their personalized
assessment and are given the option of
communicating anonymously with a counselor online.
Voluntary Mental Health Screening
for Adults
Screening for Mental Health, Inc. is a nonprofit organization developed to coordinate
nationwide mental health screening programs and to ensure cooperation, professionalism, and accountability in mental
health screenings.
National Depression Screening Day, held
every October during Mental Illness Awareness Week, is designed to call attention to
the illnesses of depression, bipolar disorder, PTSD, and anxiety on a national level,
to educate the public about their symptoms
and effective treatments, to offer individuals the opportunity to be screened for the
disorders, and to connect those in need of
treatment to the mental health system. Follow-up studies of the National Depression
Screening Day are demonstrating that the
program is effective in motivating those
Voluntary Mental Health Screening as a Means to Prevent Suicide
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Saving Lives in New York Volume 2: Approaches and Special Populations
who screen positive for the illness to seek
treatment. Recent data indicates that as
many as 65% of those who score positive
and are referred for a full evaluation follow
through on the recommendation.
Voluntary Mental Health Screening
for Older Adults
Suicide disproportionately impacts the elderly, with the highest suicide rates of any age
group occurring among persons aged 65
years and older. According to the American
Association of Geriatric Psychiatry, depression affects 15 percent of adults older than
65 in the United States. Depression is not
just a condition that occurs when people get
older, but rather, it is a medical illness that is
treatable. There are over 40 million Americans over the age of 65, and more than 6
million are affected by depression.
Risk factors for suicide among the elderly
include the presence of a mental illness
(especially depression and alcohol abuse);
the presence of a physical illness; social isolation (especially being widowed in males);
and the availability of firearms in the home
(AFSP).
It is estimated that 20% of elderly over 65
years who die by suicide visited a physician
within 24 hours of the act; 41% visited within a week of their suicide; and 75% have
been seen by a physician within one month
of their suicide (National Strategy for Suicide Prevention: 2001).
Regular mental health screening of this
population in primary care would allow
physicians the opportunity to quickly and
reliably screen for depression among this
age group and offer treatment. One current
mental health screening program for the
elderly is run in association with National
Depression Screening Day. “Older Adult
Outreach” is a part of National Depression
Screening Day and brings the depression
and anxiety screening to places where elderly people can participate, including retirement communities, assisted living facilities,
social clubs and nursing homes.
22
Action Steps
1. Endorse the report of the President’s
New Freedom Commission for Mental
Health (2003) call for screening in
schools and primary health care and
linkages to appropriate treatment.
2. Support the efforts of the Columbia
University TeenScreen Program in New
York schools, SOS, the Jed Foundation
and the American Foundation for Suicide Prevention with college students,
Screening for Mental Health, Inc. in
their National Depression Day efforts
for adults, and Older Adult Outreach in
their work with the elderly.
3. Validated, self-administered screening
tools for depression should be routinely
used in primary care offices with elderly patients.
4. Screen chemical dependency patients
for depression or mood changes, and
violence toward an intimate partner or
spouse.
5. Screening programs are an important
strategy in a campus suicide prevention
program. Voluntary screening for specific conditions associated with suicide,
especially depression and substance
abuse, can identify students at risk and
facilitate referral to appropriate treatment services. The Internet provides an
excellent mechanism for reaching college students because of high access
and usage. Voluntary screening programs that allow for anonymity until he
or she is ready to self-identify, and that
provide a personalized response from a
trained clinician, appear to be the most
successful.
6. Support research on mental health
screening to improve the capacity to
identify mental illness in its early
stages, and to promote adoption of
mental health checkups.
Voluntary Mental Health Screening as a Means to Prevent Suicide
Saving Lives in New York Volume 2: Approaches and Special Populations
References
American Association of Geriatric Psychiatry www.aagpgpa.org
American Foundation for Suicide Prevention (AFSP) www.afsp.org
Aseltine, Jr., R.H. & DeMartino, R. (2004). An outcome evaluation
of the SOS Suicide Prevention Program. American Journal
of Public Health; 94 (3); 446-451
Gould, M., Marrocco, F., Kleinman, M., Thomas, J.G., Mostkoff,
K., Cote, J. And Davies, M. (2005) Evaluating Iatrogenic Risk
of Youth Suicide Screening Programs. A Randomized
Controlled Trial. Journal of the American Medical
Association, 293 (13) 1635-1643.
Lucas, C. (2001). The Disc Predictive Scales: Efficiently Screening
for Diagnosis. Journal of American Academy of Child and
Adolescent Psychiatry; 40(4): 443-449
The Jed Foundation www.jedfoundation.org
President’s New Freedom Commission on Mental Health,
Achieving the Promise: Transforming Mental Health Care in
America. Final Report. DHHS Pub. No.SMA-03-3832.
Rockville, MD: 2003
Shaffer, D., Scott, M., Wilcox, H., Maslow, C., Hicks, R., Lucas,
C.P., Garfinkel, R., and Greenwald, S. (2004). The Columbia
Suicide Screen: Validity and Reliability of a Screen for Youth
Suicide and Depression. Journal of the American Academy
of Child and Adolescent Psychiatry; 43;1, 71-79
Shaffer, D., Gould, M., Fisher, P., Trautman, P., Moreau, D.,
Kleinman, M., and Flory, M. (1996) Psychiatric diagnosis in
child and adolescent suicide. Archives of General
Psychiatry; 53; 339-348.
Satcher, D. (2001). The National Strategy for Suicide Prevention.
(2001: Washington, DC)
Screening for Mental Health, Inc.
www.mentalhealthscreening. org
Youth Risk Surveillance: National College Health Risk Behavior
Survey, United States, 1995.
http://www.cdc.gov/mmwr/preview/mmwrhtml/
00049859.htm
Voluntary Mental Health Screening as a Means to Prevent Suicide
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Saving Lives in New York Volume 2: Approaches and Special Populations
National Suicide Prevention Lifeline
Mental Health Association of New York City
National Association of State Mental Health Program Directors (NASMHPD)
Columbia University in the City of New York
Rutgers University Center for Mental Health Services
Center for Mental Health Services
(Substance Abuse and Mental Health Services Administration)
On January 1, 2005, the National Suicide
Prevention Lifeline came into existence. It
is a national, 24-hour, 7-day a week, tollfree suicide prevention service available to
all those in suicidal crisis who are seeking
help. Individuals seeking help can dial 1800-273-TALK (8255). Callers to the Lifeline
will receive suicide prevention counseling
from staff at the closest available certified
crisis center in the network. It is administered through the Mental Health Association of New York City, an organization with
experience in crisis, information, and referral help management. More than 109 crisis
centers in 42 states currently participate in
the National Suicide Prevention Lifeline
•
In New York State, the list of participating
crisis centers includes:
“For many people, crisis hotlines serve as
an entry point into the mental health system,” said Dr. Robert Glover, Executive
Director of NASMHPD. “By expanding the
National Suicide Prevention Lifeline into
underserved regions and by linking crisis
centers to a national database of mental
health resources, we can get people the
help they need and reduce suicide in this
country.”
•
Long Island Crisis Center (Bellmore)
•
Crisis Services (Buffalo)
•
Covenant House Nineline (New York
City)
•
HELPLINE/Jewish Board of Family and
Children’s Services (NYC)
•
LifeNet (New York City)
•
Dutchess County Department of Mental
Hygiene/HELPLINE
National Suicide Prevention Lifeline
Life Line: A Program of DePaul
(Rochester)
Approximately 30,000 lives are lost to suicide each year in the United States. About
1,300 lives (or 1 in 25 deaths by suicide
nationally) are lost in New York annually.
“The purpose and promise of this national
suicide hotline is to be there for people in
their time of need,” said Lifeline Director,
Dr. John Draper “Working with our federal,
state and local partners, we will be able to
build on our strength and expand this
national hotline to reach suffering individuals in ways that each of us could not do
alone.”
25
Saving Lives in New York Volume 2: Approaches and Special Populations
Suicide Hotlines And Public Access
Alan Ross, Executive Director
The Samaritans of New York
The recognition that suicide poses a major
health threat that demands a proven
means of prevention came to the public’s
attention almost simultaneously in the
United States and England a little over 50
years ago. While in California psychologist
Edward Schneidman was pouring over
hundreds of “suicide notes” at a county
coroner’s office, Schneidman came to the
conclusion that suicides could and should
be prevented. Soon thereafter, the first recognized crisis hotline in the United States
was set up as the Los Angeles Suicide Prevention Center. The same initiative led to
the establishment of the field of “suicidology,” and the American Association of Suicidology (AAS)
In London, an Anglican minister, Chad
Varah, who was trained in psychotherapy,
was making some remarkable discoveries
of his own. He had set up a walk-in site for
those in his parish who were experiencing
some form of emotional or spiritual crisis.
He discovered that many of the people who
came to see him would sit in the waiting
room, have a cup of tea with one of the
“church ladies” (community volunteers
who oversaw much of the church’s daily
operations), and, after talking to them and
pouring out their hearts about their troubles, trials and tribulations, would experience a sense of catharsis, and leave his
office feeling no further need to see the
“professional” counselor/minister. And so
the non-religious Samaritans volunteer
hotline movement was born. Today, there
are 350 such centers in 32 countries
Findings
Today, suicide prevention hotlines tend to
fall into one of four categories: 1. All-volunteer lay “humanistic” emotional support 2.
Combination volunteer/lay emotional support and clinical service 3. Completely clinical “professional help” service 4. Information and referral service
A Characteristics And Functions
At their best, 24-hour suicide prevention
hotlines respond to a wide range of
26
inquiries from New Yorkers from all walks
of life, ranging from simply having a bad
day, to feeling overwhelmed by some
“reversal” in their life including a major
trauma, personal loss, chronic physical and
mental illnesses. These hotlines provide:
1. Free of charge an immediately available, caring, professionally trained volunteer or staff member who will talk
about what callers are feeling and,
most importantly, listen to what they
are going through 24 hours a day
2. An ongoing “bridging service,” i.e., a
place callers can turn 24 hours a day,
while they are seeking other forms of
professional care or personal support,
and as a transition service as they are
moving from one form of treatment to
another
3. An immediately accessible individual
who will talk to callers and assist them
in “calming down,” stabilizing their situation (whether the result of anxiety,
panic attack, waiting for their medication to take effect, or a care giver to
arrive) without requiring them to seek
out more formal and/or dramatic professional attention
4. Emotional support, information and,
when appropriate, professional referrals, including immediate emergency
medical attention, as the extent of a
caller’s problems, suicidal behavior,
and degree of risk is assessed and
determined
B Community Benefits
1. A majority of callers to suicide prevention hotlines come from the chronically
sick, elderly, homebound, disabled and
isolated. Many are MICA clients (See
Chapter on Co-Occurring Disorders), or
those who suffer from alcohol and/or
substance misuse. Others are those
who suffer from alcohol and/or substance misuse. Others are dealing with
issues tied to violence, child and sexual
abuse. Frequently, callers are suffering
from grief following a recent loss, traumatic event or personal tragedy. Hot-
National Suicide Prevention Lifeline
Saving Lives in New York Volume 2: Approaches and Special Populations
lines are often an outlet for those in the
lesbian, gay, bisexual and trans-gendered communities (LGBT), as well as
“at risk” youth and those with AIDS
2. On a community level, suicide prevention hotlines and crisis centers provide
mental and public health consumers
with a safety net: a place they can turn
to when they are afraid to go someplace else, or feel they have no place
else, whether it is 2 o’clock in the
morning, after attending a counseling
session, while seeking professional
help or after exhausting those clinical
or professional services that have specified limits. That net extends as well to
lay and professional mental health
service providers, in that 24-hour hotlines offer an additional level of support
and care that is available as a “back
up” to other care and services they are
providing to consumers
3. At a practical level, suicide prevention
hotlines and crisis centers save millions of dollars by providing callers with
an immediate, personal response that
acts as a pressure release valve, often
diffusing individuals’ crisis events and
stabilizing their situation, thereby, preventing the potentially unnecessary –
and costly – dispatching of ambulances,
use of hospital emergency rooms, utilization of hospital medical staff ,etc.
Finally, hotline services reduce the
demand for and drain on other social
service, mental health, emergency
response and medical staff, facilities
and agencies
Role In The National Strategy
for Suicide Prevention
Three objectives of the National Strategy for
Suicide Prevention (NSSP) bear directly on
the significant role played by suicide prevention hotlines and crisis centers in addressing
this serious public health problem
1. Develop broad-based support for suicide prevention
2. Develop and implement communitybased suicide prevention programs
National Suicide Prevention Lifeline
3. Increase access to and community linkages with mental health and substance
abuse services
Suicide hotlines and crisis centers’ role in
furthering the National Strategy is supported
by the finding in the President’s New Freedom Commission on Mental Health report
that a key goal is to “increase and improve a
diverse mental health workforce across the
country through public-private partnerships
based on multi- disciplinary training models.”
This goal builds on the research and findings
of the Institute of Medicine report which calls
for “collaborative and cooperative efforts” to
implement effective suicide prevention initiatives and the evaluation of the US Air Force
highly successful program which found that
a key component of its effectiveness was in
“creating competent communities,” utilizing
leadership, professionals, peers and caring
members of the community in addressing
the needs of those at risk and providing them
with a myriad of services
The two national organizations that have
received federal appropriations for certifying,
evaluating and “linking” suicide prevention
hotlines: the AAS and the Kristin Brooks
Hope Center have estimated that there are
600 suicide-related crisis hotlines throughout the country, but the exact number and
quality of such services offered in any one
state remains a matter of speculation
This is due in part to the absence of a designating authority overseeing hotlines (suicide prevention included), the ease with
which any individual or organization can
set up a hotline and the lack of coordination and networking of hotlines
II. Action Steps
1. Ensure availability of “suicide hotlines”
and “warm lines” statewide. Such services are heavily used by certain risk groups,
from female adolescents and middleaged men to elders. Ensure statewide
access to them is a matter of equity.
2. Enhance the quality of suicide prevention hotlines and warm lines statewide
by establishing minimal operating standards and formal risk-assessment pro-
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Saving Lives in New York Volume 2: Approaches and Special Populations
tocols, providing comprehensive qualitative training for lay and professional
hotline crisis counselors, and stabilizing their funding
3. Enhance the coverage and benefits of
suicide prevention hotlines and warm
lines in serving the public by improving
their linkages to clinical mental health,
public health, police and rescue agencies and promoting awareness of their
availability in the community.
28
National Suicide Prevention Lifeline
Saving Lives in New York Volume 2: Approaches and Special Populations
Means Restriction
Gary L. Spielmann, M.A., M.S.
Director of Suicide Prevention
New York State Office of Mental Health
Limiting access to lethal means of selfharm is an effective strategy to prevent
self-destructive behavior, including suicide.
Some suicidal acts are impulsive, resulting
from a combination of psychological pain
or despair coupled with easy availability of
the means to inflict self-injury: firearms,
carbon monoxide, medications, sharp
objects, tall structures. By limiting the individual’s accessibility to the means of selfharm, a suicidal act may be prevented. The
goal is to separate in time and space the
individual experiencing an acute suicidal
crisis from easy access to lethal means of
self-injury and personal harm. The hope is
by making it harder for those intent on selfharm to act on that impulse, one can buy
time for the crisis to pass and for healing
and recovery to occur.
A study by Dr. Richard Seiden of 515 people who were prevented from jumping
from the Golden Gate Bridge to a near-certain death found that 26 years later, 94% of
the would-be suicides were either still
alive or had died of natural causes. The
study, Where Are They Now? (1978) “confirmed previous observations that suicidal
behavior is crisis-oriented and acute in
nature. It concluded that if a suicidal person can be helped through his/her crises,
one at a time, chances are extremely good
that he/she won’t die by suicide later.”
(Friend: 2003)
Means Restriction
The value of means restriction also pertains to adolescent behavior. “When vulnerable kids crack, the weapons that are at
hand make the consequences of that vulnerability more serious.” (JJ Mann in Goode:
1999) According to the Centers for Disease
Control and Prevention (CDC), the rate of
firearm death in the United States of children ages 0 to 14 is nearly 12 times higher
than in the 25 other industrialized nations
combined. More than 800 Americans,
young and old, die each year from guns
shot by children under the age of 19.
In New York, firearms were used in 33% of
all suicides in 2002, and in approximately
28% of those between 15-24 years of age.
(CDC: 2005) A 2004 study examined the
association between youth-focused firearm
laws and suicides among youth in 18
states. The study’s author concluded that
as many as 300 lives have been saved as a
result of laws that require guns to be safely
stored away from children. Laws that
raised the required age of gun buyers and
owners, however, did not significantly
reduce suicide rates. (Webster et al.: 2004)
Firearms are the most common method of
completed suicides nationwide (54%), followed by suffocation (20%), poisoning
(17.5%), falls (2.3%), cut/pierce (1.8%), and
drowning (1.2%) (CDC: 2005). This is true for
men, women and adolescents who complete suicide. In New York, firearms are also
the predominant means of suicide, but by a
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Saving Lives in New York Volume 2: Approaches and Special Populations
much slimmer margin. Suicide by firearms
seems to be associated with their availability
in the home and with victim intoxication.
Many homes contain guns and nearly half
(43%) of all homicides and suicides occur in
a home. Most victims are shot: 67% of the
homicides and 54% of the suicides in 2002
(CDC: WISQARS, 2005). In some studies,
handguns pose the greatest risk.
Several studies have shown that the mere
presence of a firearm in a home significantly increases the risk of completed suicide.
This holds true for the population as a
whole and for every age group.(Miller,
Hemenway and Azrael: 2004) A recent
national study (2003) found that having a
gun at home is a risk factor for adults to be
fatally shot (gun homicide) and to die by
one’s own hand (gun suicide). The adjusted
odds ratio for suicide by gun increased by a
factor of 16 compared to homes with no
guns. (Wiebe: 2003) Another study concluded that the purchase of a handgun
from a licensed dealer was associated with
becoming a suicide victim (Miller, Hemenway and Azrael: 2004).
Most children older than age 7 have the
strength to pull the trigger of a firearm,
especially a handgun, so that restricting
access to a loaded weapon would also
decrease the chances of an accidental
shooting leading to death or injury. Finally,
“methods used in fatal suicide attempts differed from those commonly used in
attempts overall.” (Miller, Hemenway and
Azrael: 2004) When it comes to surviving a
suicide attempt, the choice of means
employed is critical. Most victims who use
a firearm do not survive. Other means are
more forgiving. Regardless of the means
employed, two routes to means restriction
are: education and technology.
Educational Initiatives
Educating the public is an important strategy for shaping behavior. The impact of
stricter gun control laws on suicide rates
has been evaluated in a small number of
studies. A gun control law in Ontario was
followed by a decrease in firearm suicides.
A District of Columbia handgun control law
was followed by a decrease both in homi-
30
cides (-25%) and suicides (-23%). New York
City has one of the most stringent handgun
control laws of any jurisdiction in the country. It also has one of the lowest suicide
rates as well.
To further reduce the rate of suicide by
firearm, the American Academy of Pediatrics
recommends that parents and others who
possess firearms should be educated to:
•
keep the gun unloaded and locked up;
•
lock and store bullets in a separate
location;
•
make sure children don’t have access
to keys;
•
ask police for advice on safe storage
and gun locks;
•
remove all firearms from the homes of
adolescents and others judged by a
physician to be at suicidal risk.
Those who don’t own a gun should be
educated to:
•
talk with children about the risks of gun
injury outside the home;
•
tell children to stay clear of guns when
they are in the homes of friends;
•
ask parents of children’s friends if they
keep a gun at home;
•
if they do, urge them to empty it out
and lock it up.
Parents and/or guardians of children and
adolescents experiencing substance abuse
or emotional disturbance problems should
be informed that these individuals may use
lethal firearms or another means of selfinjury if these means are not safely
secured. To reduce the threat of ingesting
poison, parents should be made aware of
safe methods for storing and dispensing
common pediatric medications, as well as
household toxics. Physicians should be
encouraged to prescribe medications that
are efficacious but not lethal for those that
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Saving Lives in New York Volume 2: Approaches and Special Populations
are lethal, e.g. desipramine and other tricyclic antidepressants, when treating an atrisk suicidal patient.
Safety Technologies
“Every two weeks, on average, someone
jumps off the Golden Gate Bridge” into the
55-degree water of San Francisco Bay some
two hundred and twenty feet below. “ It is
the world’s leading suicide location.” Since
the 1950’s, the idea of building a barrier to
prevent would-be jumpers from completing
their suicide has been hotly debated. Dr.
Lanny Berman, the executive director of the
American Association of Suicidology, says,
“Suicidal people have transformational fantasies and are prone to magical thinking,
like children and psychotics...Jumpers are
drawn to the Golden Gate because they
believe it’s a gateway to another place.
They think that life will slow down in those
final seconds, and then they’ll hit the water
cleanly, like a high diver.” (Friend: 2003).
They rarely do. Most die by multiple bluntforce trauma. Others drown in the three
hundred and fifty feet of water beneath the
bridge. Only 2 in 100 jumpers survive.
“Survivors often regret their decision in
midair, if not before. Ken Baldwin and
Kevin Hines both say they hurdled over the
railing, afraid that if they stood on the
chord they might lose their courage. Baldwin was twenty-eight and severely
depressed on the August day of 1985 when
he told his wife not to expect him home
until later. “I wanted to disappear,” he said.
“So the Golden Gate was the spot. I’d heard
that the water just sweeps you under.” On
the bridge, Baldwin counted to ten and
stayed frozen. He counted to ten again,
then vaulted over. “I still see my hands
coming off the railing,” he said. As he
crossed the chord in flight, Baldwin recalls,
“I instantly realized that everything in my
life that I’d thought was unfixable was
totally fixable – except for having just
jumped.” (Friend: 2003)
Through the years, efforts to thwart wouldbe jumpers have been made, but no physical barrier exists today to do so. Objections
have been raised to installing a barrier
above the four-foot high railing on the
Means Restriction
grounds of aesthetics, obstructed views,
and cost. Even though they are decidedly
low-tech, barriers have worked on other
high structures. “The Empire State Building,
the Duomo, St. Peter’s Basilica, and Sydney
Harbor Bridge were all suicide magnets
before barriers were erected on them. At all
of these places, after the barriers were in
place the number of jumpers declined to a
handful, or to zero.” (Friend: 2003)
The current system for preventing suicide
on the Golden Gate is what officials call the
“non-physical barrier.” This includes
“numerous security cameras, thirteen telephones, which potential suicides or
alarmed passers-by can use to reach the
bridge’s control tower. The most important
element is randomly scheduled patrols by
the California Highway Patrolmen and
Golden Gate Bridge personnel in squad
cars and on foot, bicycle, and motorcycle.”
(Friend: 2003) Despite these countermeasures, the jumpers continue to plunge at
the rate of one suicide every two weeks.
More recently, The Board of Directors of
the Bridge has voted to explore installing a
barrier and is seeking $2 million for studies
and preliminary designs of a barrier. (Blum:
March 20, 2005)
While New York does not have the Golden
Gate, it does have at least two bridges like
it: the George Washington and Verrazano
Narrows. Neither attract would-be suicides
the way that the Golden Gate does. In fact,
the suicide rate in New York City, where
both bridges are located, is below the
statewide average. Within the New York
City rate, however, is an interesting contrast: suicides by jumping were highest in
Manhattan, site of the tallest buildings in
the world, and lowest in Staten Island,
largely devoid of buildings over 7 stories
high. (Marzuk et al.: 1992) In another study
in New York, 81 percent of all suicides
jumped from their own residences (Fischer
et al.: 1993)
Following five student suicides, New York
University has turned to physical barriers to
deny access to jumping-off sites on campus. More than 179 balconies will now
have restricted access. NYU’s safety con-
31
Saving Lives in New York Volume 2: Approaches and Special Populations
sultant called the move “a rational step.”
“What you have is a systems approach that
makes it less easy for someone to take
impulsive action. It is no different from putting up fences to prevent suicide on the
Golden Gate Bridge.” (Arenson: March 30,
2005) The move to restricted access is not
without controversy: the student newspaper at NYU described the installation of
barriers as “a face-saving way for NYU to
ensure that students don’t end their lives
on NYU’s campus, rather than a way to
reach out to suicidal students and offer
them help and guidance.” (Arenson: March
30, 2005) Meanwhile, the University has
also expanded counseling services, promoted mental health literacy, and
increased access to information on depression and related disorders for its students.
Another example of technology successfully reducing suicide deaths is the conversion
in England in 1963 from deadly coke gas to
a less lethal natural gas for home use.
There was little substitution to more available means such as hanging or drowning
and within a few years, the overall suicide
rate was reduced by one-third. (Seiden:
1978) To make a major impact on our own
suicide rate, safety technologies that make
discharge of firearms less likely should be
made more widely available. A law signed
by Governor Pataki in 2000 has helped to
achieve this goal. It requires firearms retailers to include a child safety locking device
with all purchases; post notices regarding
safe storage of guns in their place of business; and include gun safety information
with the purchase of any gun. Failure to
comply with this law is punishable as a
class A misdemeanor.
This law also places a ban on assault
weapons; raises the minimum age to
obtain a permit to purchase a handgun to
21 years old; implements a DNA for Handguns program; establishes a gun trafficking
interdiction; and directs a study to be conducted on “smart gun” technology. In signing this law, Governor Pataki said: “While
New York State leads the nation with a 39
percent drop in violent crime since 1994,
we still have too much gun violence in our
communities. Each year more New Yorkers
32
are killed by guns than die in car crashes –
and that must change. This new law will
help.” (Pataki: 2000) Recent statistics on the
use of firearms in suicides show this
change is occurring.
A recent study, published in the Journal of
the American Medical Association on February 9, 2005 found that locked guns appear
to offer the most protection against accidental death and injury or during a suicide
attempt. Any one of the four storage methods, including keeping guns and ammunition in different locations, cuts the risk of
death and injury by between 55 and 73 percent. (Grossman et al: February 9, 2005)
The study found that when guns are stored
unloaded, locked and separate from ammunition, this practice offers the most protection against accidental or suicidal use.
“Doctors who treated suicidal teens should
use the study to reinforce the effectiveness
of keeping guns securely locked and inaccessible,” said Jerry Reed, executive director
of the Suicide Prevention Action Network.
“It just seems appropriate we would look at
this just like we would storing poison under
the sink.” Finally, we should recognize the
limits of means restriction. In New Jersey,
there has been a rash of ‘suicides by locomotive’, where people deliberately place
themselves in front of moving commuter
trains traveling at high speeds. Because rail
lines are so extensive, fences are not a real
deterrent to someone who is determined to
gain access to the railroad tracks. Death on
the tracks – at a rate of about 25 a year –
has become a regular occurrence. The New
Jersey Transit Authority has responded by
providing a regular counseling program for
train crews who respond to these grisly suicidal incidents. (Smothers: 2003)
As noted, a possible outcome of restricting
one specific means of self-harm is the substitution of another means in its place. This has
apparently been the case for American adolescents, ages 10-14, between 1992-2001
(CDC: 2004). Over this period, rates of suicide
using firearms and poisoning decreased,
whereas suicides by suffocation increased.
By 2001, suffocation (asphyxia/hanging) had
surpassed firearms to become the most common method of suicide death for this age
Means Restriction
Saving Lives in New York Volume 2: Approaches and Special Populations
group. The reasons for this change in suicide
methods are not fully understood. However,
tougher handgun laws, the private nature of
suffocation, its widespread availability, and
its high lethality suggest that populationbased prevention efforts must address the
underlying reasons for suicidality to avoid
the potential for method substitution. (CDC:
2004) In 2002, suicide was the 3rd leading
cause of death for persons age 15-19 in New
York. (CDC: 2005)
Given the many means of ending one’s life,
restricting access by confining those at suicidal risk to institutional settings has been
considered. In most cases, this is a difficult
proposition to justify. While many people
who die by suicide possess multiple risk
factors, many more will not die by suicide.
Confinement in a safe and secure facility
for the vast majority of these at-risk individuals would be counterproductive. “ The
great number of false positives would
result in commitment of large numbers of
patients not in need of such treatment (and
control). This inability to predict the outcome would probably be the result of any
attempt to predict a rare occurrence.”
(Kaufman and Doty: 2002)
“Governor Pataki Signs Legislation to Combat Gun Violence,”
Executive Chamber, Albany, NY: August 9, 2000
Grossman, David, MD et al.: (Safely Storing Firearms Saves
Young Lives,) JAMA, February 9, 2005
Group for the Advancement of Psychiatry, Committee on
Preventive Psychiatry, Violent Behavior in Children and
Youth: Preventive Intervention from a Psychiatric
Perspective, J. American Academy of Child & Adolescent
Psychiatry, 38:3, March 1999, 235-241
Kaufman, AS and Doty, CS, Esqs. Prosecution and Defense of
Suicide Claims, New York Law Journal, 228: 117, pp.4-5,
July 26, 2002
Marzuk PM, Leon AC, Tardiff K, Morgan EB, Stajic M, Mann JJ.
1992. The effect of access to lethal methods of injury on suicide rates. Archives of General Psychiatry, 49 (6); 451-458.
Miller, M; Hemenway, D; Azrael, D, Firearms and Suicide in the
Northeast, Trauma, September 2004, 57, 626-632
National Center for Injury Prevention and Control, CDC, NCHS
Vital Statistics System, 2003
Pataki, George E. Governor, New York State 2004-05 Executive
Budget Overview, (Albany: The Executive Chamber, January
20, 2004)
Seiden, RH, “Where Are They Now ? A Follow-Up Study of
Suicide Attempters From the Golden Gate Bridge,” Suicide
and Life-Threatening Behavior, 8 (4), Winter 1978
Smothers, Ronald, Death Shares Commuter Tracks: New Jersey
Suicides Illustrate Morbid Lure of the Rails, The New York
Times, October 15, 2003
U.S. Dept. of Health and Human Services, Multiple Causes of
Death for ICD-9 1998 Data: Washington, DC, 1999
Webster, DW, Vernick,JS, Zeoli, AM, Manganello, JA,
Association Between Youth-Focused Firearms Laws and
Youth Suicides, JAMA, (2004), 292: 594-601
Wiebe, DJ, Ph.D. Homicide and Suicide Risks Associated with
Firearms in the Home: A National Case-Control Study,
Annals of Emergency Medicine, 41:6, 771-782, June 2003
References
American Academy of Child & Adolescent Psychiatry, Children
and Firearms. Facts for Families, Washington, DC, 1997
American Academy of Child & Adolescent Psychiatry, Children’s
Threats: When Are They Serious? Facts for Families,
Washington, DC, 1997
American Academy of Child & Adolescent Psychiatry,
Understanding Violent Behavior in Children & Adolescents.
Facts for Families, Washington, DC: 1996
Arneson, Karen W., After Suicides, NYU Will Limit Access to
Balconies, The New York Times, March 30, 2005
Blum, Andrew, Suicide Watch, The New York Times, March 20,
2005
Centers for Disease Control and Prevention, Methods of Suicide
Among Persons Aged 10-19 Years, United States, 19922001, Mortality and Morbidity Weekly Review (MMWR),
June 11, 2004/53 (22); 471-474
Centers for Disease Control and Prevention. Web-based Injury
Statistics Query and Reporting Systems (WISQARS).
National Center for Injury Prevention and Control, 2005.
Davidow, Julie, Safely Storing Firearms Saves Young Lives,
Researchers Find, Seattle Post-Intelligencer, February 9,
2005. Retrieved February 17, 2005
Fischer EP, Comstock GW, Monk MA, Sencer DJ. 1993.
Characteristics of completed suicides: Implications of differences among methods. Suicide and Life-Threatening
Behavior, 23 (2); 91-100.
Friend, Tad, Jumpers: The Fatal Grandeur of the Golden Gate
Bridge, The New Yorker, October 13, 2003
Goode, Erica, Deeper Truths Sought in Violence By Youths, The
New York Times, May 4, 1999 (Source of Dr. J. John Mann
quotation)
Means Restriction
33
Saving Lives in New York Volume 2: Approaches and Special Populations
10 Leading Causes of Violence-Related Injury Deaths, 2001, All Races, Both Sexes
Age Groups
<1
1-4
5-9
10-14
15-24
25-34
35-44
45-54
55-64
1
Homicide
Homicide Homicide Homicide Homicide
Homicide
Homicide
Suicide
Homicide
Other Spec.,
Transportati Transportati Transportati Transportati
Suffocation
Firearm Suffocation Firearm
classifiable
on Related on Related onRelated onRelated
5
4
8
253
8
551
614
365
146
2
Homicide
Homicide
Homicide Homicide
Homicide
Homicide
Other Spec.,
Transportati
Unspecified Unspecified
Firearm
Firearm
NECN
onRelated
4
4
4
189
2
78
3
4
Rank
5
Homicide
Drowning
2
Homicide
Fire/burn
3
Homicide
Drowning
1
Suicide
Firearm 69
Suicide
Firearm
69
Suicide
Firearm
88
Suicide
Firearm
79
Suicide
Firearm
65
All Ages
Suicide
Firearm
82
Homicide
Transportati
onRelated
1,774
Suicide
Homicide
Suffocation Firearm
46
583
Suicide
Suicide
Suicide
Poisoning Suffocation Poisoning
49
36
38
Suicide
Firearm
453
Homicide Homicide Homicide Homicide
Suicide
Suicide
Suicide
Suicide
Suicide
Suicide
Other Spec., Other Spec., Other Spec., Other Spec.,
Suicide Fall
Suffocation Suffocation Suffocation Suffocation Poisoning
Suffocation
NECN
NECN
classifiable classifiable
25
59
61
81
47
25
333
2
3
1
1
Homicide Homicide Homicide Homicide Homicide Homicide
Cut/pierce Suffocation Unspecified Suffocation Cut/pierce Cut/pierce
1
2
1
1
46
46
6
Homicide
Homicide
Other Spec.,
Cut/pierce
classifiable
1
1
7
Homicide
Drowning
1
8
Homicide
Fire/burn
1
Homicide
Firearm
89
65+
Homicide Homicide
Suicide
Unspecified Unspecified Poisoning
1
16
24
Homicide
Suicide
Homicide Homicide
Suicide
Transportati
Poisoning Unspecified Unspecified
Poisoning
on Related
63
29
14
213
20
Homicide
Cut/pierce
44
Homicide
Firearm
28
Homicide Homicide Homicide
Cut/pierce Unspecified Cut/pierce
10
16
183
Suicide
Homicide
Homicide Homicide
Suicide Fall
Suicide Fall Suicide Fall
Suicide Fall
Poisoning
Cut/pierce
Cut/pierce Unspecified
1
22
23
10
14
23
12
124
Suicide
Firearm
1
Suicide
Homicide Homicide
Suicide Fall Homicide
Drowning Unspecified Unspecified
19
Firearm 8
8
19
18
Homicide
Suicide Fall
Firearm
108
8
9
Homicide Homicide Homicide
Suicide
Homicide
Suicide
Homicide
Other Spec., Other Spec.,
Suicide Fall Other Spec., Other Spec., Other Spec.,
Unspecified
Suffocation
NECN
NECN
NECN
NECN
NECN
8
1
6
16
11
16
8
65
10
Homicide Homicide
Suicide
Homicide Homicide
Suicide
Homicide
Other Spec., Other Spec.,
Cut/pierce Suffocation Suffocation Cut/pierce
Suffocation
NECN
NECN
4
9
10
9
45
5
7
* Not elsewhere classifiable.
Produced by: Office of Statistics and Programming, National Center for Injury Prevention and Control, CDC.
Data Source: National Center for Health Statistics (NCHS) Vital Statistics System.
34
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Special
Populations
Saving Lives in New York Volume 2: Approaches and Special Populations
Adolescents
Madelyn Gould, Ph.D., M.P.H.
Professor in Clinical Public Health (Epidemiology) in Psychiatry,
College of Physicians and Surgeons & Mailman School of Public Health,
Columbia University & Research Scientist, New York State Psychiatric Institute
James C. MacIntyre, M.D.
Chief of Psychiatry & Clinical Director (Emeritus)
Bureau of Children & Families,
New York State Office of Mental Health.
Marcia Fazio
Division of Quality Management,
New York State Office of Mental Health
I. FINDINGS
•
The majority of youth who die by suicide do not receive treatment for their
psychiatric disorder. This is particularly
distressing because dialectical behavior
therapy, cognitive- behavior therapy,
and treatment with antidepressants
have been identified as promising treatments of youth suicide.
Over the past two decades, research on
youth suicide has yielded invaluable information on who is at risk for suicide, shaping our prevention strategies. The key findings are:
A. Overall Rates and Secular Patterns
in New York State
•
Over 150,000 New York State teenagers
attempt suicide each year, and approximately 70 die by suicide.
•
A prior suicide attempt is one
of the strongest predictors of
completed suicide.
•
More than 1 out of 10 tenth graders in
New York State will attempt suicide this
year.
•
•
New York State ranks fourth in the
nation on the number of suicide deaths
among 10 to 24 year olds (See Table 1).
•
During the past decade, there has been
little change in the youth suicide death
rates in New York State. However,
there has been a slight tapering off
among boys and whites since 1994,
paralleling the decrease in national
rates (See Tables 3 and 4).
Although suicidal ideation and
attempts are more common among
girls, five times more teenage boys than
girls commit suicide. This may partly
reflect a sex-related method preference:
methods favored by girls and women,
such as overdoses, tend to be less
lethal in the U.S. Boys are apt to use
more lethal means, such as firearms.
•
The most common diagnoses in young
people who die by suicide are mood
disorder, alcohol or drug abuse (in
boys), and conduct disorder.
•
Most suicide deaths are triggered by
getting into trouble – leading to a legal
or disciplinary problem – or breaking
up with a girlfriend or boyfriend.
•
Many suicidal teens have parents and
other family members who have been
B. Risk Factors
•
90% of adolescents who die by suicide
have a mental disorder at the time of
their death.
Adolescents
37
Saving Lives in New York Volume 2: Approaches and Special Populations
grappling with their own suicidality and
mental health problems.
•
A disproportionate number of teen suicides are either school dropouts or
youngsters who have had difficulties at
school.
•
Same-sex sexual orientation is a risk
factor for suicidal behavior. However,
most gay and lesbian youth report no
suicidality at all.
•
Sexual and physical abuse are associated with an increased risk of suicidal
behavior, but other social and psychological factors may account for much of
the increased risk.
•
Teenagers are more susceptible to suicide contagion/imitation than adults.
C. Protective Factors
Protective factors are influences that buffer
the impact of risk factors. They are not
merely the opposite or low end of risk factors, but different factors that actively promote positive behavior that insulates
against the consequence of risk factors.
Despite the burgeoning research literature
during the past two decades on risk factors
for youth suicide, there remains a paucity
of empirical information on protective factors. Promising protective factors identified
from recent research include:
•
•
38
Family cohesion: Increasing family
cohesion appears protective for suicide
attempts. Teenagers who describe family life in terms of a high degree of
mutual involvement, shared interests,
and emotional support were several
times less likely to be suicidal than are
adolescents from less cohesive families, even those with the same levels of
depression or life stress.
Religiosity: The protective value of religiosity against suicide, suicidal
ideation, and perceived acceptability of
suicide among adolescents has recently
been reported. Furthermore, maternal
religiosity appears to be a protective
factor against offspring depression,
independent of maternal bonding,
social functioning, implying that maternal religiosity might protect against suicide also.
II. Action Steps
These recommended action steps are
based on the key risk factors for youth suicide, which provide a set of identified, modifiable risk factors to target, and the recognition that vulnerable youth are often not
identified nor referred for appropriate mental health services. Those action steps that
are supported by the largest body of empirical evidence have been selected. The
action steps include a range of options for
implementation by either health or mental
health departments, hospital and emergency rooms, schools, community organizations and advocacy groups, schools,
and/or parent groups. An illustrative, but
not exhaustive, set of resources follow
each action step, to guide those interested
in implementing a particular recommendation in their clinical or community setting.
A. Enhance Support Systems
for Vulnerable Youth
(1). Parent Education Programs
Stakeholder: Parents and Other Adults
Psychoeducational programs are critical for
parents of youth who have declared their
risk vis-a-vis a suicide attempt or by
engaging in risky behaviors, such as alcohol or drug use. An emergency room contact provides a prime opportunity to target
these parents. Parents should be trained to
be key support persons by educating them
about adolescent psychopathology, treatment, signs of risk, availability of professional resources and emergency services,
and communication/support strategies.
Such psychoeducational programs would
supplement usual mental health services.
Resource: Youth-Nominated Support Team (YST), Cheryl King,
Ph.D (Kingca@med. Umich.edu).
(2) School Re-entry Guidelines
and Training
Stakeholder: Schoold
A teenager’s re-entry into school after a suicide attempt and/or psychiatric hospitalization is a particular stressful time for the ado-
Adolescents
Saving Lives in New York Volume 2: Approaches and Special Populations
lescent. Rumors among the study body often
arise in the aftermath of such an event,
making re-entry a time of potential humiliation and increased stigmatization. School
guidance personnel are often at a loss as to
how best to meet the needs of the returning
student. Enhanced liaison between the
treatment provider/team and a designated
case manager at the school would be essential components of the guidelines.
Resource: Intensive Day Treatment (IDT) Program, Rockland
Children’s Psychiatric Center (Dr. Barry Kutok, RCCSBLK@
omh.state.ny.us;www.sharingsuccess.org/code/eptw/
pdf_profiles/idt.pdf).
(3) Peer-Helper Programs
Stakeholder: Schoold
Although empirical evaluations of peerhelper programs are quite limited, they
could potentially provide a source of support for a vulnerable youth. For example,
peer-helper procedures incorporated into a
school- reentry program could enhance the
levels of support provided to the returning
student. The responsibilities of the peer
helper are best limited to listening and
reporting and possibly warning signs,
rather than counseling. It is imperative that
peer helpers be carefully supervised by
school guidance personnel who have
undergone extensive suicide prevention
training to determine the level of risk, and
to make referrals.
Resource: Youth-Nominated Support Team (YST) (Cheryl King,
Ph.D.) (kingca@med.umich.edu).
(4) Post-Attempt Treatment Program
Stakeholder: Rarents and Other Adults
Following a suicide attempt, it is essential
that clinicians and staff in Emergency
Departments/E.R.s are adequately trained
to assess continued risk. In addition, these
staff have a critical role in immediately
linking the teen and family to mental
health resources for follow-up and continued treatment. They must be knowledgeable about the availability of and access to
specific resources in their particular community. Community mental health treatment providers must also have systems in
place to prioritize follow-up appointments
for teens who have made a suicide
attempt.
Adolescents
Resource: The American Foundation for Suicide Prevention (AFSP
website: www.afsp.org) has developed educational posters
highlighting suicide risk factors and management guidelines
for staff in Emergency Departments and E.R.s.
B. Implement Case-Finding with
Accompanying Referral and Treatment
(1.) Screening Programs
Stakeholder: Service Providers
One valuable case-finding strategy to
increase the recognition and referral of suicidal youth involves direct screening of
children and teens in various settings (e.g.,
schools, pediatricians’ offices). A questionnaire or other screening instrument, whch
targets depression, substance abuse, and
suicidal ideation and behavior, can be used
as a universal prevention tool to identify
high-risk adolescents and young adults
from among a general population of student/patients, or can be used as targeted
prevention strategy by providing an assessment to youngsters already thought to be
at possible risk by school guidance counselors or pediatricians. Two vulnerable
populations of teenagers, often neglected
in suicide prevention efforts, include
youngsters who have dropped out of
school or are at risk for dropping out and
those youth who are in county level probation, detention, and correctional programs
and facilities. Recognition and identification
of heightened suicide risk in these
teenagers, with accompanying treatment
plans, is critical.
Resources: Teen Screen (Leslie McGuire, MSW, www.teen
screen.org); Signs of Suicide (SOS) Prevention Program
(Douglas Jacobs, MD djacobs@mentalhealthscreening.org)
(2.) Gatekeeper/Caregiver
Training Programs
Stakeholder: Service Providers
The inability of potential gatekeepers/caregivers to be “first-aid” resources to youth at
risk of suicide has been an impetus for the
development of training programs for community-based caregivers, including school
personnel, clergy, police, and community
volunteers. Such programs aim to develop
the knowledge, attitudes and skills to identify individuals at risk, determine the levels
of risk, and to make referrals.
Resources: Applied Suicide Intervention Skills Training (ASSIST),
“Living Works Education” (www.livingworks.net)
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Saving Lives in New York Volume 2: Approaches and Special Populations
(3.) Professional Education Programs
Stakeholder: Service Providers
Training primary care physicians and pediatricians about suicide risk, assessment and
treatment is an essential suicide prevention
strategy. Despite the frequent prescription of
SSRIs by primary care physicians and pediatricians, they admit to inadequate training
in the treatment of childhood depression.
Training medical professionals in the appropriate use of antidepressant and mood-stabilizing drugs has been found to reduce the
suicide rate, at least among female adults.
The demonstrated effectiveness of such
educational programs should encourage
their dissemination.
Resources: American Foundation for Suicide Prevention (2003).
The Suicidal Patient: Assessment and Care. A film available
at AFSP.org/index-1.htm; American Academy of Child and
Adolescent Psychiatry Workgroup on Quality Issues.
Practice parameters for the assessment and treatment of
children and adolescents with suicidal behavior. Journal of
the American Academy of Adolescent and Child Psychiatry,
40 (7), 24s-51s, (2001)
(4.) Postvention/Crisis Intervention
in Schools
Stakeholder: Schools
A timely response to a suicide is likely to
reduce subsequent depression and suicidal
ideation and behavior in fellow students.
The major goals of postvention/crisis intervention programs is to assist survivors in
the grief process, identify and refer those
individuals who may be at risk following
the suicide, provide accurate information
about suicide while attempting to minimize
suicide contagion, and implement a structure for ongoing prevention efforts.
Resource: Services for Teens at Risk (STAR) Center Postvention.
Standards Guidelines (Mary Margaret Kerr, Ed.D. Director,
STAR- Center Outreach (kerrmm@msx.upmc.edu)
C. Develop Risk Reduction Plans
(1). School-Based Risk Reduction Plans
Stakeholder: Schools
Teaching cognitive and social problemsolving techniques to children as they enter
puberty can yield a “psychological immunization” against depressive symptoms.
Cognitive interventions begun in late childhood may prevent depressive symptoms
from developing in early adolescence. Mid-
40
dle school aged children are targeted for
this prevention strategy.
Resource: Penn Resiliency Project (PRP) 3815 Walnut Street,
Philadelphia, PA 19104 (215) 573-4128
(2). Firearms Restriction Procedures
Stakeholder: Parents and Other Adults
Firearms used in youth suicides are often
obtained from the home environment.
Firearm safety counseling to parents of
high-risk youth is one essential strategy for
youth suicide prevention. Such programs
emphasize safe storage and/or removal of
firearms from the home. Injury prevention
education in emergnecy rooms can lead
parents to take new action to limit access
to lethal means. The adult male in the
household or the actual gun owner has
been found to be the most appropriate person to counsel.
Resource: Love Our Kids, Lock Your Guns (LOK)
(tamera_coyne-beasley@med.unc.edu)
(3). Alcohol Restriction Policies
Stakeholder: Government
Substance abuse is a significant risk factor
for suicidal behavior, particularly among
older adolescent males. Strategies to “tighten” teenage access to alcohol have successfully decreased youth suicidal behavior.
Such efforts have included increasing the
minimum drinking age from 18 to 21 years,
which resulted in a substantial decrease in
youth suicide deaths. Additional efforts to
make drinking more difficult among
teenagers include stricter enforcement of
such laws in bars, liquor stores, and other
establishments selling beer. Increased surveillance of cases of drinking while intoxicated may also enhance case finding of atrisk teens.
Resource: Reducing Underage Drinking: A Collective
Responsibility. Richard Bonnie and Mary Ellen O’Connell,
Editors, Committee on Developing a Strategy to Reduce and
Prevent Underage Drinking, National Research Council,
Institute of Medicine. (www.nap.edu/catalog/10729.html)
(4). Media Education
Stakeholder: Youth/Peers
Given the substantial evidence for suicide
contagion and imitative behavior among
teenagers, recommended prevention
strategies involve educating media profes-
Adolescents
Saving Lives in New York Volume 2: Approaches and Special Populations
sionals. Such action steps are described
elsewhere in the Media section of the New
York State Suicide Prevention Plan.
•
Opportunities to make a contribution to
one’s community and develop a sense
of mattering.
D. Enhance Protective Factors
(1) Promoting Youth Development
Stakeholder: Schools
•
Strong links between families, schools
and broader community resources.
Experience and research have shown that
young people need a set of personal and
social assets that will increase their healthy
development and well-being, and facilitate
a successful transition from childhood
through adolescence into adulthood. These
essential assets have been grouped into
four broad categories: physical, intellectual,
psychological and social development
(Community Programs to Promote Youth
Development, 2002). Continued exposure
to positive experiences, settings, and people as well as opportunities to gain and
refine life skills support youth in the acquisition of these assets. In addition, it helps
them gain strategies to deal with the many
challenges they will be confronted with in
life. Examples of opportunities that can
assist youth in acquiring and building these
assets include:
Resources: New York State Office of Children and Family
Services, New York Youth: The Key to Our Economic and
Social Future. Blueprint for State and Local Action, Albany,
NY. National Research Council and Institute of Medicine
(2002), Community Programs to Promote Youth
Development, National Academy Press, Washington, DC.
•
Clear expectations for behavior
as well as opportunities to make
decisions, to participate in governance
and rule making, and to take on
leadership roles as they mature.
•
Opportunities for young people to experience supportive adult relationships.
•
Opportunities to learn how to form
close, durable relationships with peers
that support and reinforce healthy
behaviors.
•
Opportunities to feel a sense
of belonging and feeling valued.
•
Opportunities to develop positive
social values and norms.
•
Opportunities for skill building
and mastery.
•
Opportunities to develop confidence
in his or her ability to master
the environment.
Adolescents
Resource
Comprehensive reviews of research on youth suicide risks and
preventive interventions, which provide an empirical base
for the findings and action steps for this portion of the New
York State Suicide Prevention Plan include the following:
Gould, M.S. Greenberg, T., Velting, D.W., Shaffer, D., Youth suicide risk and preventive interventions: A review of the past
10 years. Journal of the American Academy of Child and
Adolescent Psychiatry, 2003, 42 (4) 386-405. (See the
Appendix to this section)
Gould, M.S. & Kramer, R.A. Youth suicide prevention. Suicide and
Life-Threatening Behavior, 31 (supplement), Spring: 6-31.
Shaffer, D., Gould, M.S., Greenberg, T., Fisher, P., Hicks, R.,
McGuire, L., Mufson, L. Teen Suicide Fact Sheet. (2003)
Department of Child Psychiatry, New York State Psychiatric
Institute, Columbia College of Physicians & Surgeons.
(http://childpsych.columbia.edu/Disorders/Suicide/suicide.
html.
41
Saving Lives in New York Volume 2: Approaches and Special Populations
42
Adolescents
Saving Lives in New York Volume 2: Approaches and Special Populations
Adolescents
43
Saving Lives in New York Volume 2: Approaches and Special Populations
Appendix
RESEARCH
UPDATE
REVIEW
Youth Suicide Risk and Preventive Interventions:
A Review of the Past 10 Years
MADELYN S. GOULD, PH.D., M.P.H., TED GREENBERG, M.P.H., DREW M. VELTING, PH.D.,
AND DAVID SHAFFER, M.D.
ABSTRACT
Objective: To review critically the past 10 years of research on youth suicide. Method: Research literature on youth suicide
was reviewed following a systematic search of PsycINFO and Medline. The search for school-based suicide prevention programs was expanded using two education databases: ERIC and Education Full Text. Finally, manual reviews of articles’ reference lists identified additional studies.The review focuses on epidemiology, risk factors, prevention strategies, and treatment
protocols. Results: There has been a dramatic decrease in the youth suicide rate during the past decade. Although a number of factors have been posited for the decline, one of the more plausible ones appears to be the increase in antidepressants being prescribed for adolescents during this period. Youth psychiatric disorder, a family history of suicide and
psychopathology, stressful life events, and access to firearms are key risk factors for youth suicide. Exciting new findings have
emerged on the biology of suicide in adults, but, while encouraging, these are yet to be replicated in youths. Promising prevention strategies, including school-based skills training for students, screening for at-risk youths, education of primary care
physicians, media education, and lethal-means restriction, need continuing evaluation studies. Dialectical behavior therapy, cognitive-behavioral therapy, and treatment with antidepressants have been identified as promising treatments but
have not yet been tested in a randomized clinical trial of youth suicide. Conclusions: While tremendous strides have been
made in our understanding of who is at risk for suicide, it is incumbent upon future research efforts to focus on the development and evaluation of empirically based suicide prevention and treatment protocols. J. Am. Acad. Child Adolesc.
Psychiatry, 2003, 42(4):386–405. Key Words: suicide, epidemiology, risk factors, prevention, treatment, adolescence.
The research contributing to our understanding of who
is at risk for suicide and how to prevent and treat suicide
will be critically evaluated. A comprehensive understanding
of this information is critical to clinicians who deal with
the mental health problems of children and adolescents.
Each year, one in five teenagers in the United States seriAccepted December 3, 2002.
Dr. Gould is a Professor at Columbia University in the Division of Child and
Adolescent Psychiatry (College of Physicians & Surgeons) and Department of
Epidemiology (School of Public Health) and a Research Scientist at the New York
State Psychiatric Institute (NYSPI). Mr. Greenberg is with the Division of Child
and Adolescent Psychiatry, Columbia University, NYSPI. Dr. Velting is an Assistant
Professor at Columbia University in the Division of Child and Adolescent Psychiatry
(College of Physicians & Surgeons), and Dr. Shaffer is Irving Philips Professor
of Child Psychiatry and Pediatrics at the College of Physicians & Surgeons at
Columbia University.
The expert assistance of Margaret Lamm in the preparation of this manuscript is gratefully acknowledged.
Reprint requests to Dr. Gould, Division of Child and Adolescent Psychiatry,
NYSPI, 1051 Riverside Drive, Unit 72, New York, NY 10032; e-mail:
gouldm@childpsych.columbia.edu.
0890-8567/03/4204–0386䉷2003 by the American Academy of Child
and Adolescent Psychiatry.
DOI: 10.1097/01.CHI.0000046821.95464.CF
386
Adolescents (Appendix)
ously considers suicide (Grunbaum et al., 2002); 5% to
8% of adolescents attempt suicide, representing approximately 1 million teenagers, of whom nearly 700,000
receive medical attention for their attempt (Grunbaum
et al., 2002); and approximately 1,600 teenagers die by
suicide (Anderson, 2002). Only by recognizing who is at
risk for suicide, and knowing how to prevent suicidal
behavior and provide treatment for suicidal individuals,
will mental health practitioners and those designing educational and public health prevention programs have sufficient armamentaria to combat this major public health
and clinical problem in youths. The current review is
based on a comprehensive, but not exhaustive, review of
the research on youth suicide conducted in the past decade.
Preference was given to population-based epidemiological and longitudinal investigations and controlled prevention/intervention studies.
OVERALL RATES AND SECULAR PATTERNS
Suicide was the third leading cause of death among
10- to 14-year-olds and 15- to 19-year-olds in the United
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YOUTH SUICIDE RISK AND INTERVENTIONS
States in 2000 (Anderson, 2002). While the rates of completed suicide are low (1.5 per 100,000 among 10- to 14year-olds and 8.2 per 100,000 among 15- to 19-year-olds),
when nonlethal suicidal behavior and ideation are taken
into account, the magnitude of the problem becomes obvious. The surge of general population studies of suicide
attempts and ideation has yielded reliable estimates of
their rates (e.g., Andrews and Lewinsohn, 1992; Fergusson
and Lynskey, 1995; Fergusson et al., 2000; Garrison et al.,
1993; Gould et al., 1998; Grunbaum et al., 2002;
Lewinsohn et al., 1996; Roberts and Chen, 1995; Sourander
et al., 2001; Swanson et al., 1992; Wichstrom, 2000;
Windle et al., 1992). Of these studies, the largest and the
most representative is the Youth Risk Behavior Survey
(YRBS) (Grunbaum et al., 2002), conducted by the
Centers for Disease Control and Prevention (CDC). The
YRBS indicated that during the past year, 19% of high
school students “seriously considered attempting suicide,”
nearly 15% made a specific plan to attempt suicide, 8.8%
reported any suicide attempt, and 2.6% made a medically
serious suicide attempt that required medical attention.
These results are consistent with those cited in the epidemiological literature.
Age
Suicide is uncommon in childhood and early adolescence. Within the 10- to 14-year-old group, most suicides occur between ages 12 and 14. Suicide incidence
increases markedly in the late teens and continues to rise
until the early twenties, reaching a level that is maintained
throughout adulthood until the sixth decade, when the
rates increase markedly among men (Anderson, 2002).
In 2000, the suicide mortality rate for 10- to 14-yearolds in the United States was 1.5 per 100,000. Although
10- to 14-year-olds represented 7.2% of the U.S. population, the 300 children who committed suicide represented only 1.0% of all suicides. The suicide mortality
rate for 15- to 19-year-olds was 8.2 per 100,000, five times
the rate of the younger age group.
The rarity of completed suicide before puberty is a
universal phenomenon (World Health Organization,
2002). Shaffer et al. (1996) suggested that the most likely
reason underlying the age of onset of suicide is that depression and exposure to drugs and alcohol, two significant
risk factors for suicide in adults (e.g., Barraclough et al.,
1974; Robins et al., 1959) and adolescents (e.g., Brent
et al., 1993a; Shaffer et al., 1996), are rare in very young
children and become prevalent only in later adolescence.
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46
Like completed suicides, suicide attempts are relatively
rare among prepubertal children and increase in frequency
through adolescence (Andrus et al., 1991; Velez and
Cohen, 1988). However, unlike completed suicides,
attempts peak between 16 and 18 years of age, after which
there is a marked decline in frequency (Kessler et al.,
1999), particularly for young women (Lewinsohn et al.,
2001).
Gender
Paradoxically, although suicidal ideation and attempts
are more common among females (Garrison et al., 1993;
Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn
et al., 1996) in the United States, completed suicide is
more common among males. Five times more 15- to 19year-old boys than girls commit suicide (Anderson, 2002).
The same pattern of sex differences does not exist in all
countries (World Health Organization, 2002). While
completed suicide is more common in 15- to 24-year old
males than females in North America, Western Europe,
Australia, and New Zealand, sex rates are equal in some
countries in Asia (e.g., Singapore), and in China, the
majority of suicides are committed by females.
The YRBS (Grunbaum et al., 2002) indicated that
girls were significantly more likely to have seriously considered attempting suicide (23.6%), made a specific plan
(17.7%), and attempted suicide (11.2%) than were boys
(14.2%, 11.8%, 6.2%, respectively); however, no significant difference by gender in the prevalence of medically
serious attempts (3.1% females, 2.1% males) was found.
Both psychopathological factors and sex-related method
preferences are considered to contribute to the pattern of
sex differences (Shaffer and Hicks, 1994). Completed suicide is often associated with aggressive behavior and substance abuse (see discussion below), and both are more
common in males. Methods favored by women, such as
overdoses, which account for 30% of all female suicides
yet only 6.7% of all male suicides (CDC, 2002), tend to
be less lethal in the United States. However, in societies
where treatment resources are not readily available or
when the chosen ingestant is untreatable, overdoses are
more likely to be lethal. Whereas in the United States,
only 11% of completed suicides in 1999 resulted from
an ingestion, in some South Asian and South Pacific countries, the majority of suicides are due to ingestions of herbicides, such as paraquat, for which no effective treatment
is available (Haynes, 1987; Shaffer and Hicks, 1994).
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GOULD ET AL.
Ethnicity
Youth suicide is more common among whites than
African Americans in the United States (Anderson, 2002),
although the rates are highest among Native Americans
and generally the lowest among Asian/Pacific Islanders
(Anderson, 2002; Shiang et al., 1997; Wallace et al., 1996).
Latinos are not overrepresented among completed suicides in the United States (Demetriades et al., 1998; Gould
et al., 1996; Smith et al., 1985). The historically higher
suicide rate among Native Americans is not fully understood, but proposed risk factors include low social integration, access to firearms, and alcohol or drug use
(Borowsky et al., 1999; Middlebrook et al., 2001). The
historically lower suicide rate among African Americans
has been attributed to greater religiosity and differences
in “outwardly” rather “inwardly” directed aggression
(Gibbs, 1997; Shaffer et al., 1994). However, the difference in suicide rates between whites and African Americans
has decreased during the past 15 years because of a marked
increase in the suicide rate among African-American males
between 1986 and 1994.
The YRBS (Grunbaum et al., 2002) found that AfricanAmerican students were significantly less likely (13.3%)
than white or Latino students (19.7% and 19.4%, respectively) to have considered suicide or to have made a specific plan (African-Americans: 10.3%; whites: 15.3%;
Latinos: 14.1%). Latino students (12.1%) were significantly more likely than either African-American or white
students to have made a suicide attempt (8.8% and 7.9%,
respectively); however, there was no preponderance of
medically serious attempts among Latinos (3.4%) compared with whites (2.3%) or African Americans (3.4%).
Although some studies have found higher rates of suicidal ideation and attempts among Latino youths
(Roberts et al., 1997; Roberts and Chen, 1995), Grunbaum
et al. (1998) and Walter et al. (1995) did not find a higher
prevalence of either among Latinos. These equivocal findings highlight the need for further research in this area.
Secular Trends
Secular changes in the incidence of a disease are important because they may give an indication of causal and/or
preventive factors. Following a nearly threefold increase
in the adolescent male suicide rate between 1964 and
1988, the consistent increase in the white male suicide
rate ceased and in the mid 1990s started to decline. Rates
in African-American males, while still lower than among
whites, showed no sign of a plateau or decrease until 1995.
388
Adolescents (Appendix)
At that time the decline gathered pace and included both
white and African-American males and females. The rate
among white males, nearly 20/100,000 in 1988, had fallen
to approximately 14/100,000 by the year 2000 (Fig. 1).
The reasons for the decline are by no means clear. One
of the more plausible reasons for the earlier increase had
been the effects of greater exposure of the youth population to drugs and alcohol. Alcohol use had been noted
to be a significant risk factor for suicide since the first
psychological autopsy study (Robins et al., 1959), and at
least in some studies (Shaffer et al., 1996) it has been a
significantly more important risk factor for males, the
group that had showed the dramatic increase. However,
repeat benchmark studies that use similar measures and
sampling methods such as the YRBS (CDC, 1995, 1996,
1998, 2000; Grunbaum et al., 2002) give no indication
of a decline in alcohol or cocaine use during this time.
Another reason posited for the earlier increase was an
increased availability of firearms (Brent et al., 1991).
Legislation restricting access to firearms was passed in
1994 (Ludwig and Cook, 2000), at the time that the
decrease became more marked and the rate of handling
firearms among high school students declined (CDC,
1995, 1996, 1998, 2000; Grunbaum et al., 2002). However,
the proportion of suicides by firearms, a plausible proxy
for method availability (Cutright and Fernquist, 2000),
did not change between 1988 and 1999. There has been
a decline ranging from 20% to 30% in the youth suicide
rates in England, Finland, Germany, and Sweden, where
firearms account for very few suicides (Krug et al., 1998),
and a systematic examination of the proportion of suicides committed with firearms over a long period of time
has shown that the proportion is only weakly related to
overall changes in the rate (Cutright and Fernquist, 2000).
Another plausible cause of the reduction has been the
extraordinary increase in antidepressants being prescribed
for adolescents during this period. Olfson et al. (2002b)
showed that between 1987 and 1996 the annual rate of
antidepressant use increased from approximately 0.3%
to 1.0% of those aged 6 to 19 years in the United States.
Selective serotonin reuptake inhibitors (SSRIs) affect not
only depression (see “Psychopharmacological Interventions”
below), but also aggressive outbursts, and have been shown
in adults to reduce suicidal thinking. It is unlikely that
the increase in the prescription of antidepressants is an
indication of a more general increase in access or use of
mental health services. During the period from 1987 to
1997, the number of adolescents who received psychoJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3
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Fig. 1 Teen suicide rates, 1964–2000: United States, ages 15–19 years. Sources: Anderson, 2002; CDC, 2002;
National Center for Health Statistics, 1999. *Crude rates; prior to 1979, African-American data not broken out.
therapy actually declined (Olfson et al., 2002a). The delay
in the onset of the decline in African-American suicides
is compatible with a treatment effect because of African
Americans’ greater difficulty in accessing treatment resources
(Goodwin et al., 2001). Another indication that antidepressant treatment may be a factor in the recent decline
is the finding in Sweden that the proportion of suicide
victims who received antidepressant treatment is lower
than the rest of the depressed population (Isacsson, 2000).
Firm conclusions, however, are not possible given the
ecological nature of the supporting data. Randomized
clinical trials will be necessary before the decline in rates
can be confidently attributed to treatment with antidepressants.
RISK FACTORS
Personal Characteristics
Psychopathology. More than 90% of youth suicides have
had at least one major psychiatric disorder, although
younger adolescent suicide victims have lower rates of
psychopathology, averaging around 60% (Beautrais, 2001;
Brent et al., 1999; Groholt et al., 1998; Shaffer et al.,
1996). Depressive disorders are consistently the most
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48
prevalent disorders among adolescent suicide victims,
ranging from 49% to 64% (Brent et al., 1993a; Marttunen
et al., 1991; Shaffer et al., 1996). The increased risk of
suicide (odds ratios) for those with an affective disorder
ranges from 11 to 27 (Brent et al., 1988, 1993a; Groholt
et al., 1998; Shaffer et al., 1996; Shafii et al., 1988). Female
victims are more likely than males to have had an affective disorder (Brent et al., 1999; Shaffer et al., 1996).
Substance abuse is another significant risk factor, especially among older adolescent male suicide victims
(Marttunen et al., 1991; Shaffer et al., 1996). A high
prevalence of comorbidity between affective and substance abuse disorder has consistently been found
(Brent et al., 1993a; Shaffer et al., 1996). Disruptive disorders are also common in male teenage suicide victims
(Brent et al., 1993a; Shaffer et al., 1996). Approximately
one third of male suicides have had a conduct disorder,
often comorbid with a mood, anxiety, or substance abuse
disorder. Discrepant results have been reported for bipolar disorder: Brent et al. (1988, 1993a) reported relatively
high rates, whereas others reported no or few bipolar cases
(Apter et al., 1993a; Marttunen et al., 1991; Rich et al.,
1990; Runeson, 1989; Shaffer et al., 1994). Despite the
generally high risk of suicide among people with schizo389
Adolescents (Appendix)
Saving Lives in New York Volume 2: Approaches and Special Populations
GOULD ET AL.
phrenia, schizophrenia accounts for very few of all youth
suicides (Brent et al., 1993a; Shaffer et al., 1996).
The psychiatric problems and gender-specific diagnostic profiles of youth suicide attempters are quite similar to the profiles of those who complete suicide (e.g.,
Andrews and Lewinsohn, 1992; Beautrais et al., 1996,
1998; Gould et al., 1998). However, despite the overlap
between suicidal attempts and ideation (Andrews and
Lewinsohn, 1992; Reinherz et al., 1995) and the significant prediction of future attempts from ideation (Lewinsohn et al., 1994; McKeown et al., 1998; Reinherz et al.,
1995), the diagnostic profiles of attempters and ideators
are somewhat distinct (Gould et al., 1998). Substance
abuse/dependence is more strongly associated with suicide attempts than with ideation (Garrison et al., 1993;
Gould et al., 1998; Kandel, 1988). Recent studies have
found an association between posttraumatic stress disorder and suicidal behavior among adolescents (Giaconia
et al., 1995; Mazza, 2000; Wunderlich et al., 1998), but
in the largest and most representative of the studies
(Wunderlich et al., 1998), the association was not maintained after adjusting for comorbid psychiatric problems.
Panic attacks have also been reported to be associated
with an increased risk of suicidal behavior in adolescents,
even after adjusting for comorbid psychiatric disorders
and demographic factors (Gould et al., 1996; Pilowsky
et al., 1999). The negative finding by Andrews and
Lewinsohn (1992) may be due to a gender specificity of
the association: panic attacks may increase suicide risk
for girls only (Gould et al., 1996). Inconsistent findings
have been reported in the adult literature (Johnson et al.,
1990; Warshaw et al., 2000; Weissman et al., 1989)
Prior Suicide Attempts. A history of a prior suicide
attempt is one of the strongest predictors of completed
suicide, conferring a particularly high risk for boys (30fold increase) and a less elevated risk for girls (3-fold
increase) (Shaffer et al., 1996). Between one quarter to
one third of youth suicide victims have made a prior suicide attempt (see Groholt et al., 1997). Similarly strong
associations between a history of suicidal behavior and
future attempts have been reported in general population surveys and longitudinal studies (Lewinsohn et al.,1994;
McKeown et al., 1998; Reinherz et al., 1995; Wichstrom,
2000) and clinical samples (Hulten et al., 2001; Pfeffer
et al., 1991), with risk for an attempt increasing between
3 and 17 times for those with prior suicidal behavior.
Cognitive and Personality Factors. Hopelessness has been
linked with suicidality (Howard-Pitney et al., 1992;
390
Adolescents (Appendix)
Marcenko et al., 1999; Overholser et al., 1995; Rubenstein et al., 1989; Russell and Joyner, 2001; Shaffer et al.,
1996); however, it has not consistently proven to be an
independent predictor, once depression is taken into
account (Cole, 1988; Howard-Pitney et al., 1992; Lewinsohn
et al., 1994; Reifman and Windle, 1995; Rotheram-Borus
and Trautman, 1988). Poor interpersonal problem-solving ability has also been reported to differentiate suicidal
from nonsuicidal youths (Asarnow et al., 1987; RotheramBorus et al., 1990), even after adjusting for depression
(Rotheram-Borus et al., 1990). Social problem-solving
has been found to partially mediate the influence of life
stress on suicide, although life stress was a stronger predictor than social problem-solving (Chang, 2002). Aggressiveimpulsive behavior has also been linked with an increased
risk of suicidal behavior (Apter et al., 1993b; McKeown
et al., 1998; Sourander et al., 2001). In a Finnish school
study (Sourander et al., 2001), aggressive 8-year-olds were
more than twice as likely to think about or attempt suicide at age 16.
Sexual Orientation. Recent cross-sectional and longitudinal epidemiological studies found a significant twoto sixfold increased risk of nonlethal suicidal behavior for
homosexual and bisexual youths (Blake et al., 2001; Faulkner
and Cranston, 1998; Garofalo et al., 1998; Remafedi et al.,
1998; Russell and Joyner, 2001; see McDaniel et al., 2001,
for a recent review). In a study of a nationally representative sample of nearly 12,000 adolescents, those who
reported same-sex sexual orientation also exhibited significantly higher rates of other suicide risk factors (Russell
and Joyner, 2001). After adjusting for these risks, the
effects of same-sex sexual orientation on suicidal behavior remained, but were substantially mediated by depression, alcohol abuse, family history of attempts, and
victimization. Notably, most youths who reported samesex sexual orientation reported no suicidality at all: 84.6%
of males and 71.7% of females.
Biological Factors. Over the past 25 years, a substantial
body of knowledge has accrued, indicating abnormalities of serotonin function in suicidal and in impulsive,
aggressive individuals, regardless of psychiatric diagnosis. Earlier studies focused on simple indices of serotonin activity, such as the reduced concentration of serotonin
metabolites in the brain and cerebrospinal fluid (CSF) in
suicide victims or among suicide attempters compared
with age- and gender-matched controls (see Oquendo
and Mann, 2000). More recently, neuroanatomical studies have shown a reduction in the overall density of seroJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3
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tonin 1A receptors and serotonin transporter receptors
(which regulate serotonin uptake) in the prefrontal cortex. Most recently, Arango and her colleagues (2001)
found significant reductions in the number and binding
capacity of serotonin 1A receptors in the dorsal raphe
nucleus, from which serotonin innervation of the prefrontal cortex arises (Arango et al., 2001).
To explain the often-replicated finding that serotonin
dysregulation is associated with suicidality regardless of
diagnosis, Mann et al. (1999) suggested that the dysregulation is a biological trait that predisposes to suicide—
a stress-diathesis model. Thus a mentally ill person with
the diathesis is more likely to respond to a stressful experience in an impulsive fashion that may include a decision to commit suicide.
Despite the great volume of work, unanswered questions remain. The behavioral correlates of low-serotonin
states are assumed to include irritability, impulsivity, and
emotional volatility, but most studies address diagnosis
rather than specific symptoms and the correlation has yet
to be explored in the general population. An absence of
representative studies has meant that neither the relative
risk of serotonin dysfunction nor the fraction of suicides
attributable to serotonin underfunctioning is yet known.
Finally, the examination of the association of serotonin
metabolism with suicide has largely been limited to studies of adults.
The documented suicide risk associated with family
history (see “Family History of Suicidal Behavior” below)
has led to an active investigation of candidate genes,
attempting to identify what suicidogenic factor might be
inherited. Given the substantial body of data that point
to reduced serotonin neurotransmission in suicide (see
above), the target of most recent association studies has
been polymorphisms in three genes that play important
roles in the regulation of serotonin. One gene is tryptophan hydroxylase (TPH), the rate-limiting enzyme for
the biosynthesis of serotonin. Early studies (Mann and
Stoff, 1997; Nielsen et al., 1994, 1998) reported a relationship between attempted suicide and a polymorphism
on intron 7 of the TPH gene. Since then, a large number of studies with inconsistent findings have been carried out on suicidal patients with various diagnoses with
and without suicidality. The Utah Youth Suicide Study
has been the main study to have examined adolescents
(Bennet et al., 2000), and it has failed to find an association. There are several possible reasons for the inconsistent findings, including the probable heterogeneity and
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complexity of the suicide phenotype; that the genetic
effect is small and requires examination of large samples;
or because a single genetic variant is less important than
patterns of variance (Marshall et al., 1999). Support for
this is offered by haplotype analyses (haplotypes are clusters of genes that are usually found together) that have
shown a distinctive profile among both suicide completers
(Turecki et al., 2001) and attempters (Rotondo et al.,
1999) in samples in which single-gene polymorphisms
did not differ significantly from those of controls.
The other two candidate genes that have been studied
are the serotonin transporter (SERT ) gene and the serotonin A receptor gene. Polymorphisms in these genes have
been reported in completed and attempted suicide
(Arango et al., 2001; Courtet et al., 2001; Du et al., 2001;
Neumeister et al., 2002).
While biological findings currently have little impact
on clinical practice, Nordstrom and colleagues’ (1994)
finding that suicide attempters with low levels of CSF 5hydroxyindoleacetic acid have a significantly higher likelihood of making further suicide attempts and/or committing
suicide, coupled with the promising research on candidate genes, may eventually take suicide prediction and
prevention to new, more precise levels and/or may lead to
specific interventions that will reduce the impact of the
predisposing trait.
Family Characteristics
Family History of Suicidal Behavior. A family history
of suicidal behavior greatly increases the risk of completed suicide (Agerbo et al., 2002; Brent et al., 1988,
1994a, 1996; Gould et al., 1996; Shaffer, 1974; Shafii
et al., 1985) and attempted suicide (Bridge et al., 1997;
Glowinski et al., 2001; Johnson et al., 1998). Because
suicide and psychiatric illness almost always co-occur,
account has to be taken of whether apparent familiality
reflects suicide specifically or instead an association with
parental psychiatric illness (Brent et al., 1996). Most
recently, the Danish Registry study (Agerbo et al., 2002)
found youth suicide to be nearly five times more likely
in the offspring of mothers who have completed suicide
and twice as common in the offspring of fathers, adjusting for parental psychiatric history.
The Missouri Adolescent Twin Study (Heath et al.,
2002) addressed the question of inheritance versus environment among teenage suicide attempters. One hundred thirty twin pairs had been affected by a suicide
attempt within the total representative sample of 3,416
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female adolescent twins. After controlling for other psychiatric risk factors, the twin/cotwin odds ratio was 5.6
(95% confidence interval [CI] 1.75–17.8) for monozygotes and 4.0 (95% CI 1.1–14.7) for dizygotes, suggesting a degree of inheritance for suicidality (Glowinski
et al., 2001). The heritability of youth suicide gains further support from a meta-analysis by McGuffin et al.
(2001), who reexamined a large body of published twin
data (all ages). They concluded that first-degree relatives
of suicides have more than twice the risk of the general
population, with the relative risk increasing among identical cotwins of suicides to about 11. The estimated heritability for completed suicide was 43% (95% CIs 25–60).
Parental Psychopathology. High rates of parental psychopathology, particularly depression and substance abuse,
have been found to be associated with completed suicide
(Brent et al., 1988, 1994a; Gould et al., 1996) and with
suicidal ideation and attempts in adolescence (e.g.,
Fergusson and Lynskey, 1995; Joffe et al., 1988; Kashani
et al., 1989). Brent and his colleagues (1994a) reported
that a family history of depression and substance abuse
significantly increased the risk of completed suicide, even
after controlling for the victim’s psychopathology. They
concluded that familial psychopathology adds to suicide
risk by mechanisms other than merely increasing the liability for similar psychopathology in an adolescent. In
contrast, Gould and her colleagues (1996) found that the
impact of parental psychopathology no longer contributed
to the youth’s suicide risk after the study controlled for
the youth’s psychopathology. To date, it is unclear precisely how familial psychopathology increases the risk for
completed suicide.
Parental Divorce. Suicide victims are more likely to come
from nonintact families of origin (Beautrais, 2001; Brent
et al., 1993a, 1994a; Gould et al., 1996; Groholt et al.,
1998; Sauvola et al., 2001). However, the association
between separation/divorce and suicide decreases when
accounting for parental psychopathology (Brent et al.,
1994a; Gould et al., 1996). Similarly, although many
population-based studies have found significant univariate associations (e.g., Andrews and Lewinsohn, 1992;
Fergusson and Lynskey, 1995), these associations are no
longer evident or are markedly attenuated once psychosocial
risk factors are taken into account (e.g., Beautrais et al.,
1996; Fergusson et al., 2000; Groholt et al., 2000).
Parent–Child Relationships. Impaired parent–child relationships are associated with increased risk of suicide and
suicide attempts among youths (Beautrais et al., 1996;
392
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Brent et al., 1994a, 1999; Fergusson and Lynskey, 1995;
Fergusson et al., 2000; Gould et al., 1996; Lewinsohn
et al., 1993, 1994; McKeown et al., 1998; Tousignant
et al., 1993). However, because an underlying psychiatric problem in the youth may precipitate impaired parent–child relationships, it is necessary to disentangle these
factors. While Gould et al. (1996) found that suicide victims still had significantly less frequent and less satisfying communication with their mothers and fathers than
community controls, even after adjusting for their psychiatric disorders, others have found that the associations
between nonlethal suicidal behavior and poor attachment
and family cohesion are not independent of the youth’s
psychological problems (Fergusson et al., 2000; McKeown
et al., 1998). Similarly, parent–child conflict has been
found to be no longer associated with completed suicide
(Brent et al., 1994a) or attempts (Lewinsohn et al., 1993)
once the youth’s psychopathology is taken into account.
Adverse Life Circumstances
Stressful Life Events. Life stressors, such as interpersonal
losses (e.g., breaking up with a girlfriend or boyfriend)
and legal or disciplinary problems, are associated with
completed suicide (Beautrais, 2001; Brent et al., 1993c;
Gould et al., 1996; Marttunen et al., 1993; Rich et al.,
1988; Runeson, 1990) and suicide attempts (Beautrais
et al., 1997; Fergusson et al., 2000; Lewinsohn et al.,
1996), even after adjusting for psychopathology (Brent
et al., 1993c; Gould et al., 1996) and antecedent social,
family, and personality factors (Beautrais et al., 1997).
The prevalence of specific stressors among suicide victims varies by age: parent–child conflict is a more common precipitant for younger adolescent victims, whereas
romantic difficulties are more common in older adolescents (Brent et al., 1999; Groholt et al., 1998). Stressors
also vary by psychiatric disorder: interpersonal losses are
more common among suicide victims with substance
abuse disorders (Brent et al., 1993c; Gould et al., 1996;
Marttunen et al., 1994; Rich et al., 1988), and legal or
disciplinary crises are more common in victims with disruptive disorders (Brent et al., 1993c; Gould et al., 1996)
or substance abuse disorders (Brent et al., 1993c). Bullying,
whether as victim or perpetrator, has also recently been
demonstrated to increase the risk for suicidal ideation
(Kaltiala-Heino et al., 1999).
Physical Abuse. The association between physical abuse
and suicide reported in case-control psychological autopsy
studies (Brent et al., 1994a, 1999) has been replicated in
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prospective longitudinal community studies (Brown et al.,
1999; Johnson et al., 2002; Silverman et al., 1996), the
most methodologically rigorous design to examine this
issue. Childhood physical abuse has been found to be
associated with an increased risk of suicide attempts in
late adolescence or early adulthood, even after adjusting
for demographic characteristics, psychiatric symptoms
during childhood and early adolescence, and parental
psychiatric disorders (Johnson et al., 2002). Interpersonal
difficulties during middle adolescence, such as frequent
arguments with adults and peers and having no close
friends, were found to mediate the association between
child abuse and later suicide attempts (Johnson et al.,
2002). Johnson and his colleagues (2002) suggested that
children who are physically abused may have difficulty
developing the social skills necessary for healthy relationships, which leads to social isolation and/or antagonistic interactions with others, which in turn puts them
at increased risk for suicidal behavior.
Sexual Abuse. Longitudinal community studies are also
the most methodologically rigorous design to examine
the association between child sexual abuse (CSA) and
subsequent suicidality due to the serious problems of retrospective recall in this area. Two such studies have found
self-reported CSA to be significantly associated with an
increased risk of suicidal behavior in adolescence
(Fergusson et al., 1996; Silverman et al., 1996). Because
CSA may be associated with reported risk factors for suicide (e.g., parental substance abuse), it is necessary to
control for such factors. Fergusson et al. (1996) found
that the association between CSA and suicidality was
greatly reduced but was not eliminated, after controlling
for a wide range of potentially confounding factors. This
suggests that the increased risk of suicide from CSA may
be partly, but not entirely, accounted for by other factors.
Socioenvironmental and Contextual Factors
Socioeconomic Status. Studies of suicide victims generally have found no or small effects of socioeconomic disadvantage (Agerbo et al., 2002; Brent et al., 1988).
Specifically, Agerbo et al. (2002) noted that the effect of
socioeconomic disadvantage decreased after adjustment
for family history of mental illness or suicide. Gould et al.
(1996) also found no effect of socioeconomic status for
white or Latino victims, but African-American victims
had a significantly higher socioeconomic status than their
general population counterparts. Youth suicide attempters,
compared with community controls, have consistently
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been found to have higher rates of sociodemographic disadvantage, even after controlling for other social and psychiatric risk factors (Beautrais et al., 1996; Fergusson
et al., 2000; Wunderlich et al., 1998).
School and Work Problems. Difficulties in school, neither working nor being in school, and not going to college pose significant risks for completed suicide (Gould
et al., 1996). Beautrais et al. (1996) reported that serious
suicide attempters were also more likely to drop out of
high school or not attend college, and Wunderlich and
colleagues (1998) reported that German school dropouts
were 37 times more likely to attempt suicide, even after
adjusting for diagnostic and social risk factors.
Contagion/Imitation. Evidence continues to amass from
studies of suicide clusters and the impact of the media,
supporting the existence of suicide contagion. Several
studies have reported significant clustering of suicides,
defined by temporal-spatial factors, among teenagers and
young adults (Brent et al., 1989; Gould et al., 1990a,b,
1994), with only minimal effects beyond 24 years of age
(Gould et al., 1990a,b). Similar age-specific patterns have
been reported for clusters of attempted suicides (Gould
et al., 1994). Since 1990, the effect of the media on suicide rates has been documented in many other countries
besides the United States, including Australia (e.g., Hassan,
1995), Austria (e.g., Etzersdorfer et al., 1992), Germany
(e.g., Jonas, 1992), Hungary (e.g., Fekete and Macsai,
1990), and Japan (Ishii, 1991; Stack, 1996), adding to
the extensive work prior to 1990 in the United States on
newspaper articles, television news reports, and fictional
dramatizations. Overall, the magnitude of the suicide
increase is proportional to the amount, duration, and
prominence of media coverage, and the impact of suicide stories on subsequent completed suicides appears to
be greatest for teenagers (see Gould, 2001; Schmidtke
and Schaller, 2000; Stack, 2000).
Stack’s (2000) review of 293 findings from 42 studies
indicates that methodological differences among studies are
strong predictors of differences in their findings. For example, although a highly publicized recent study (Mercy et al.,
2001) found that exposure to media accounts of suicidal
behavior and exposure to suicidal behavior in friends or
acquaintances were associated with a lower risk of youth
suicide attempts, the interpretability of the findings is limited because (1) the media exposure factor was a conglomerate of different types of media stories; (2) attempters may
have had less exposure to media generally (e.g., read fewer
books, fewer newspapers, etc.); (3) attempters had signifi393
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cantly more proximal stressors, possibly overshadowing their
recollection of media exposure; (4) the timing of exposure
was a 30-day interval, in contrast to most other studies,
which examined a shorter interval following the exposure;
and (5) nearly half of the sample was between 25 and 34
years of age, a group not particularly sensitive to imitation.
Another study finding—no effect of parental suicide—was
also inconsistent with the prevailing research literature. A
summary of interactive factors that may moderate the impact
of media stories, including characteristics of the stories,
individual reader/viewer attributes, and social context of
the stories, is presented by Gould (2001).
PROTECTIVE FACTORS
Family Cohesion
Family cohesion has been reported as a protective factor for suicidal behavior among adolescents in a longitudinal study of middle school students (McKeown et al.,
1998) and cross-sectional community studies of high
school (Rubenstein et al., 1989, 1998) and college students (Zhang and Jin, 1996). Students who described family life in terms of a high degree of mutual involvement,
shared interests, and emotional support were 3.5 to 5.5
times less likely to be suicidal than were adolescents from
less cohesive families who had the same levels of depression or life stress (Rubenstein et al., 1989, 1998).
Religiosity
Since Durkheim’s (1966) formulation of a social integration model, the protective role of religiosity on suicide has been a focus of scientific investigation (e.g.,
Hovey, 1999; Lester, 1992; Neeleman, 1998; Neeleman
and Lewis, 1999; Sorri et al., 1996; Stack, 1998; Stack
and Lester, 1991). As noted previously, greater religiosity has been posited as underlying the historically lower
suicide rate among African Americans. However, only
recently has the protective value of religiosity against suicidal behavior (Hilton et al., 2002; Siegrist, 1996; Zhang
and Jin, 1996) and depression (Miller et al., 1997b) been
documented in adolescents and young adults. Regrettably,
these studies have not controlled for potential confounders,
such as substance abuse, which may be less prevalent
among religious youths.
PREVENTION STRATEGIES
Youth suicide prevention strategies have primarily been
implemented within three domains—school, commu394
Adolescents (Appendix)
nity, and health-care systems—and generally have one of
two general goals: case finding with accompanying referral and treatment or risk factor reduction (CDC, 1994;
Gould and Kramer, 2001).
School-Based Suicide Prevention Programs
Suicide Awareness Curriculum. These programs seek to
increase awareness of suicidal behavior in order to facilitate self-disclosure and prepare teenagers to identify atrisk peers and take responsible action (Kalafat and Elias,
1994). The underlying rationale of these programs is that
teenagers are more likely to turn to peers than adults for
support in dealing with suicidal thoughts (Hazell and
King, 1996; Kalafat and Elias, 1994; Ross, 1985).
Several studies evaluated school-based suicide awareness
programs in the past decade (Ciffone, 1993; Kalafat and
Elias, 1994; Kalafat and Gagliano, 1996; Shaffer et al.,
1991; Silbert and Berry, 1991; Vieland et al., 1991). While
improvements in knowledge (Kalafat and Elias, 1994;
Silbert and Berry, 1991), attitudes (Ciffone, 1993; Kalafat
and Elias, 1994; Kalafat and Gagliano, 1996), and helpseeking behavior (Ciffone, 1993) have been found, other
studies reported either no benefits (Shaffer et al., 1990,
1991; Vieland et al., 1991) or detrimental effects of suicide prevention education programs (Overholser et al.,
1989; Shaffer et al., 1991). Detrimental effects included a
decrease in desirable attitudes (Shaffer et al., 1991); a reduction in the likelihood of recommending mental health evaluations to a suicidal friend (Kalafat and Elias, 1994); more
hopelessness and maladaptive coping responses among
boys after exposure to the curriculum (Overholser et al.,
1989); and negative reactions among students with a history of suicidal behavior, including their not recommending
the programs to other students and feeling that talking
about suicide in the classroom “makes some kids more
likely to try to kill themselves” (Shaffer et al., 1990). Other
limitations of this strategy are that baseline knowledge and
attitudes of students are generally sound (Kalafat and Elias,
1994; Shaffer et al., 1991), changes in attitudes and knowledge are not necessarily highly correlated with behavioral
change (Kirby, 1985; McCormick et al., 1985), and the
format and content of some programs might inadvertently
stimulate imitation (Gould, 2001).
To date there is insufficient evidence to either support
or not support curriculum-based suicide awareness programs in schools (Guo and Harstall, 2002). Accordingly,
emphasis has shifted toward alternative school-based
strategies that will be presented below.
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Skills Training. In contrast to suicide awareness curriculum in schools, skills training programs emphasize
the development of problem-solving, coping, and cognitive skills, as suicidal youths have deficits in these areas
(e.g., Asarnow et al., 1987; Cole, 1989; Rotheram-Borus
et al., 1990). It is hoped that an “immunization” effect
can be produced against suicidal feelings and behaviors.
The reduction of suicide risk factors (e.g., depression,
hopelessness, and drug abuse) is also a targeted outcome.
Several evaluation studies have shown promising results,
with some evidence for reductions in completed and
attempted suicides (Zenere and Lazarus, 1997) and
improvements in attitudes, emotions, and distress coping skills (Klingman and Hochdorf, 1993; Orbach and
Bar-Joseph, 1993). The most systematic evaluations have
been conducted by a team of researchers (Eggert et al.,
1995; Randell et al., 2001; Thompson et al., 2000, 2001)
who have focused on skills training and social support
programs for students at high risk for school failure or
dropout. Enhancements of protective factors and reductions in risk factors following the “active” interventions
were consistently found, while the control “intervention
as usual” did not yield an increase of protective factors.
However, “intervention as usual” sometimes produced
significant reductions in suicide risk behaviors (Eggert
et al., 1995; Randell et al., 2001). Thus it is not clear
which aspects of the skills training program were responsible for risk reduction, a limitation of other studies also
(Zenere and Lazarus, 1997). While these studies yield
encouraging data, additional research is sorely needed to
refine the evaluation of this type of intervention.
Screening. A prevention strategy that has received
increased attention is case-finding through direct screening of individuals. Self-report and individual interviews
are used to identify youngsters at risk for suicidal behavior (Joiner et al., 2002; Reynolds, 1991; Shaffer and Craft,
1999; Thompson and Eggert, 1999). School-wide screenings, involving multistage assessments, have focused on
depression, substance abuse problems, recent and frequent suicidal ideation, and past suicide attempts. The
few studies that have examined the efficacy of schoolbased screening (Reynolds, 1991; Shaffer and Craft, 1999;
Thompson and Eggert, 1999) found that the sensitivity
of the screens ranged from 83% to 100%, while the specificities ranged from 51% to 76%. Thus, while there were
few false-negatives, there were many false-positives.
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ousness of missing a suicidal individual precludes this
scheme. Thus a tolerance for false-positives is essential
for such endeavors (Thompson and Eggert, 1999), necessitating second-stage assessments to determine who is not
actually at risk for suicide. Second-stage assessments usually employ systematic clinical evaluations, using interviews such as the Suicidal Behaviors Interview (Reynolds,
1990) or the Diagnostic Interview Schedule for Children
(DISC), now available in a spoken, self-completion (VoiceDISC) version (Shaffer and Craft, 1999).
Although a screening strategy appears to be quite
promising, a number of dilemmas still need to be addressed.
First, because suicide risk “waxes and wanes” over time,
multiple screenings may be necessary in order to minimize “false-negatives” (Berman and Jobes, 1995). Second,
school-wide student screening programs have been rated
by high school principals as significantly less acceptable
than curriculum-based and staff in-service programs,
although most respondents in this study have had either
no or minimal exposure to screening programs (Miller
et al., 1999). Finally, the ultimate success of this strategy
is dependent on the effectiveness of the referral. Considerable
effort must be made to assist the families and adolescents
in obtaining help if it is needed.
Gatekeeper Training. Programs to train school personnel as gatekeepers are based on the premise that suicidal
youths are underidentified and that we can increase identification by providing adults with knowledge about suicide. Only 9% of a national random sample of U.S. high
school teachers believed they could recognize a student
at risk for suicide, and while the overwhelming majority
of counselors knew the risk factors for suicide, only one
in three believed they could identify a student at risk
(King et al., 1999).
The purpose of gatekeeper training is to develop the
knowledge, attitudes, and skills to identify students at
risk, determine the levels of risk, and make referrals when
necessary (Garland and Zigler, 1993; Kalafat and Elias,
1995). Research examining the effectiveness of gatekeeper
training is limited, but the findings are encouraging, with
significant improvements in school personnel’s knowledge, attitudes, intervention skills, preparation for coping with a crisis, referral practices (Garland and Zigler,
1993; King and Smith, 2000; Mackesy-Amiti et al., 1996;
Shaffer et al., 1988; Tierney, 1994), and general satisfaction with the training (Nelson, 1987). As previously noted,
in-service training programs are significantly more acceptable by principals than school-wide screening programs
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GOULD ET AL.
(Miller et al., 1999). This is consistent with the finding
that 46% of school districts in Washington have gatekeeper training programs, while no districts use group
screening of students (Hayden and Lauer, 2000).
Peer Helpers. The rationale underlying these programs
is similar to that of suicide awareness programs: Suicidal
youths are more likely to confide in a peer than an adult
(e.g., Kalafat and Elias, 1994). The role that peers play
varies considerably by program, with some limited to listening and reporting any possible warning signs and others involving counseling responsibilities. Many programs
address serious mental health problems, such as drug
abuse, eating disorders, and depression, with 24% of programs in Washington State involving some suicide prevention role (Lewis and Lewis, 1996). Empirical evaluations
of these programs are quite limited (Lewis and Lewis,
1996) and often confined to student satisfaction measures (Morey et al., 1993). Potential negative side effects
are rarely examined. To date, there is not a sufficient body
of evidence documenting the efficacy or safety of peer
helping programs, despite their widespread use (Lewis
and Lewis, 1996).
Postvention/Crisis Intervention. The rationale for schoolbased postvention/crisis intervention is that a timely response
to a suicide is likely to reduce subsequent morbidity and
mortality in fellow students, including suicidality, the onset
or exacerbation of psychiatric disorders (e.g., posttraumatic
stress disorder, major depressive disorder), and other symptoms related to pathological bereavement (Brent et al.,
1993b,e, 1994b). The major goals of postvention programs
are to assist survivors in the grief process, identify and refer
those individuals who may be at risk following the suicide,
provide accurate information about suicide while attempting to minimize suicide contagion, and implement a structure for ongoing prevention efforts (Hazell, 1993; Underwood
and Dunne-Maxim, 1997).
The existing research on school-based postvention programs is sparse. Hazell and Lewin (1993) examined the
efficacy of 90-minute group counseling sessions offered to
groups of 20 to 30 students on the seventh day following
a suicide. No differences in outcome were found between
counseled subjects and matched controls. It was unclear
whether this finding was due to inclusion criteria for postvention counseling (close friends of deceased student), the
intervention itself, or the duration of the distress, or whether
short-term effects dissipated by the assessment at 8 months
after the death. An encouraging, though small and methodologically limited, study by Poijula et al. (2001) found that
396
Adolescents (Appendix)
no new suicides took place during a 4-year follow-up period
in schools where an adequate intervention took place,
whereas the number of suicides significantly increased after
suicides with no adequate subsequent crisis intervention.
It is imperative for crisis interventions to be well planned
and evaluated; otherwise, not only may they not help survivors, but they may potentially exacerbate problems through
the induction of imitation.
Community-Based Prevention Programs
Crisis Centers and Hotlines. The rationale for crisis hotlines (Mishara and Daigle, 2001; Shaffer et al., 1988;
Shneidman and Farberow, 1957) is that suicidal behavior is often associated with a crisis (Brent et al., 1993c;
Gould et al., 1996; Marttunen et al., 1993; Rich et al.,
1988, Runeson, 1990) and telephone crisis services can
provide the opportunity for immediate support at these
critical times by offering services that are convenient,
accessible, and available outside of usual office hours.
Evidence of their efficacy on adult suicide is equivocal (Lester, 1997), and few studies have examined the utilization or efficacy of hotlines among teenagers (Boehm
and Campbell, 1995; King, 1977; Slem and Cotler, 1973).
Overall, between 1% and 6% of adolescents in the community use hotlines (Offer et al., 1991; Slem and Cotler,
1973; Vieland et al., 1991) and only 4% of calls concern
suicide (Boehm and Campbell, 1995). However, between
14% and 18% of suicidal youths have used hotlines
(Beautrais et al., 1998; Shaffer et al., 1990). There is a
dearth of information about the efficacy of telephone crisis services for teenagers and whether they adequately
address suicide risk.
Restrictions of Firearms. The underlying rationale for
means restrictions is that suicidal individuals are often
impulsive, they may be ambivalent about killing themselves, and the risk period for suicide is transient (Hawton
et al., 2001; Miller and Hemenway, 1999). Restricting
access to lethal methods during this period may prevent
suicides, although it is not clear that method restriction
has substantially contributed to the recent secular change
in youth suicide.
Because the most common method of committing suicide in the United States is by firearms (CDC, 2002),
this review will focus on restricting their access. The presence of firearms in the home is a significant risk factor
for suicide in youths (Brent et al., 1988, 1991, 1993d,
1999) and adults (Kellermann et al., 1992). Several studies have found that restrictions on guns reduced the overJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3
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all suicide rate, as well as firearm-related suicides (e.g.,
Boor and Bair, 1990; Carrington and Moyer, 1994; Lester
and Murrell, 1980, 1986; Loftin et al., 1991; Medoff and
Magaddino, 1983), while others have found no overall
effect (Rich et al., 1990) or equivocal results (Cantor and
Slater, 1995; Cummings et al., 1997; Sloan et al., 1990).
The equivocal findings largely reflected age-specific effects
(Cantor and Slater, 1995; Sloan et al., 1990), in that
restrictive gun laws had a greater impact on adolescents
and young adults. Unfortunately, recent legislative initiatives such as the 1994 Brady Bill, which imposes a delay
in purchasing a handgun, did not find promising results:
A comparison of states that did and did not pass Brady
Bill statutes showed no impact on the proportion of suicides attributable to firearms except in elderly males
(Ludwig and Cook, 2000).
Less controversial means-restriction measures in the
United States involve education to parents of high-risk
youths. Kruesi and colleagues (1999) demonstrated that
injury prevention education in emergency rooms led parents to take new action to limit access to lethal means,
such as locking up their firearms. Unfortunately, Brent
et al. (2000) found that parents of depressed adolescents
were frequently noncompliant with recommendations to
remove firearms from the home.
A common concern is that method substitution will
occur following a means-restriction program. Some evidence of method substitution exists (Lester and Leenaars,
1993; Lester and Murrell, 1982; Rich et al., 1990); however, method substitution does not appear to be an inevitable
reaction to firearms restriction (Cantor and Slater, 1995;
Carrington and Moyer, 1994; Lester and Murrell, 1986;
Loftin et al., 1991). Moreover, even if some individuals
do substitute other methods, the chances of survival may
be greater if the new methods are less lethal (Cantor and
Baume, 1998).
Media Education. Given the substantial evidence for
suicide contagion, a recommended suicide prevention strategy involves educating media professionals about contagion, in order to yield stories that minimize harm. Moreover,
the media’s positive role in educating the public about risks
for suicide and shaping attitudes about suicide should be
encouraged.
A set of recommendations on reporting of suicide were
recently developed by an international workgroup headed
by the American Foundation for Suicide Prevention and
the Annenberg School of Communication and Public
Policy (American Foundation for Suicide Prevention,
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2001). Guidelines for media reporting now exist in several countries. Recommendations generally include descriptions of factors that should be avoided because they are
more likely to induce contagion (e.g., front page coverage) and suggestions on how to increase the usefulness of
the report (e.g., describing treatment resources).
Following the implementation of media guidelines in
Austria, suicide rates declined 7% in the first year, nearly
20% in the 4-year follow-up period, and subway suicides
(a particular focus of the media guidelines) decreased by
75% (Etzersdorfer et al., 1992; Etzersdorfer and Sonneck,
1998; Sonneck et al., 1994). In Switzerland, Michel et al.
(2000) found that following the implementation of guidelines, the number of articles increased but they were significantly shorter and less likely to be on the front page;
headlines, pictures, and text were less sensational; there
were relatively fewer articles with pictures; and their overall “Imitation Risk Scores” were lower. Given the successful strategy of engaging the media in Austria and
Switzerland, efforts to systematically disseminate and
evaluate media recommendations in the United States
are recommended.
Health Care-Based Prevention Programs
Educational/Training Programs for Primary Care Physicians
and Pediatricians. The need for training primary care physicians and pediatricians in the United States is highlighted
by the finding that while 72% of 600 family physicians
and pediatricians in North Carolina had prescribed a SSRI
for a child or adolescent patient, only 8% said they had
received adequate training in the treatment of childhood
depression and only 16% reported that they felt comfortable treating children for depression (Voelker, 1999).
Furthermore, although many suicidal young people (15–34
years) seek general medical care in the month preceding
their suicidal behavior (Pfaff et al., 1999), fewer than half
of physicians surveyed reported that they routinely screen
their patients for suicide risk (Frankenfield et al., 2000).
Pfaff et al. (2001) demonstrated that after a 1-day training workshop for 23 primary care physicians in Australia,
inquiry about suicidal ideation increased by 32.5% and
identification of suicidal patients increased by 130%,
although no significant change in patient management
resulted and referrals of suicidal youths to mental health
specialists remained low. The effectiveness of educational
programs for health care professionals has also been demonstrated by the Gotland study (Rutz et al., 1992). After the
implementation of an intensive postgraduate training pro397
Adolescents (Appendix)
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GOULD ET AL.
gram aimed at improving general practitioners’ diagnosis
and treatment of depression on the island of Gotland,
Sweden, the adult suicide rate significantly declined. The
decline was almost totally due to decreases in female suicides with major depression (the number of male suicides
was unchanged). Three years after the project ended, the
suicide rate returned almost to baseline rates (Rihmer et al.,
1995), suggesting that ongoing repetition of the educational program is warranted. A similar educational program for pediatricians could be an effective youth suicide
prevention strategy; however, other adjunctive approaches
to reach at-risk males should be considered.
TREATMENT
Recent reviews (e.g., Hawton et al., 1998, 2002; Rudd,
2000) note that few studies have systematically evaluated
interventions aimed at reducing suicidal ideation and
behavior in children and adolescents, i.e., randomized
controlled trials that obtain reliable and valid measures of
outcome variables during pretreatment, posttreatment,
and follow-up periods. Most treatment efficacy studies of
adolescent psychiatric populations exclude suicidal individuals, possibly because the potential risks of treating
high-risk youths outweigh benefits. The National Institute
of Mental Health recently published guidelines that highlight a number of ethical, legal, and safety considerations
associated with such studies (Pearson et al., 2001).
Treatment Service Utilization
Many adolescents contact a mental health professional
before their suicidal behavior. Among suicide completers,
rates of contact vary from 7% to 15% within the previous month, 20% to 25% within the previous year, and
25% to 35% over the lifetime (Brent et al., 1993a; Groholt
et al., 1997; Marttunen et al., 1992; Shaffer et al., 1996).
Contact rates were higher, between 59% and 78%, in a
New Zealand sample of attempters admitted for 24-hour
hospital stay (Beautrais et al., 1998).
Emergency/Crisis-Service Interventions and Triage
Procedures for the acute care of suicidal adolescents
have been described elsewhere (American Academy of
Child and Adolescent Psychiatry, 2001). These recommendations are largely based on common sense approaches
and expert clinical consensus. Such guidelines emphasize
that certain preconditions must be satisfied before children and adolescents are discharged from the emergency
service, e.g., the need to “sanitize” the home—make
398
Adolescents (Appendix)
firearms and/or lethal medications inaccessible to the
child (Kruesi et al., 1999).
Similarly, a written or verbal “no-suicide” contract is
commonly negotiated at the start of treatment in the hope
that it will improve treatment compliance and reduce the
likelihood of further suicidal behavior (Brent, 1997;
Rotheram, 1987). However, no empirical studies have evaluated the effectiveness of no-suicide contracts (Reid, 1998).
Rotheram-Borus et al. (1999) found that the implementation of a brief set of specialized emergency room
procedures increased eventual treatment adherence among
Latina adolescent suicide attempters. The procedures augmented typical emergency room care by (1) using a standardized protocol for training emergency room staff, (2)
presenting a 20-minute videotape to patients and their
families that models realistic expectations for aftercare
treatment, and (3) providing a bilingual crisis therapist
to promote compliance with outpatient therapy. Suicidal
adolescents receiving the specialized emergency room
procedure attended 3.8 more outpatient follow-up sessions than those receiving standard aftercare. The research
was not able to identify which of these components were
responsible for the increase in compliance.
Inpatient Care and Partial Hospitalization
While inpatient and partial hospitalization offer intensive multidisciplinary treatments and skilled observation
and support, there is no empirical evidence that either of
these interventions is effective in reducing rates of suicidal ideation, nonlethal attempts, or completed suicide
among adolescents.
Outpatient Follow-up Treatment
Generally low rates of compliance with outpatient
treatment among adolescent suicide attempters (e.g.,
Piacentini et al., 1995) make such investigations difficult
to implement. Dropout rates as high as 59% have been
reported (Spirito et al., 1992). King et al. (1997) found
that compliance rates were highest for medication follow-up (66.7%), relative to rates for individual therapy
(50.8%) and family therapy/parent psychoeducation
(33.3%). Results of that study also indicate that noncompliance is associated with parental psychopathology
and family dysfunction.
Psychotherapy
Hawton et al. (1998, 2002) reviewed all randomized
controlled trials targeting suicide attempters. Of 23 studJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3
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ies, only two explicitly obtained an adolescent sample
(Cotgrove et al., 1995; Harrington et al., 1998). Unsuccessful
treatments included problem-solving (e.g., Rudd et al.,
1996), enhanced access to clinical service (e.g., Cotgrove
et al., 1995; van der Sande et al., 1997), and home-based
family therapy (Harrington et al., 1998). The only psychotherapy that has been shown to reduce repeat attempts
in a randomized clinical trial is dialectical behavior therapy (DBT), a 12-month cognitive-behavioral intervention
designed for adults with borderline personality disorder
(Linehan et al., 1991). This study found that adults assigned
to DBT engaged in fewer and less severe parasuicidal behaviors post-treatment than patients assigned to treatmentas-usual, but this may partly be attributable to higher
baseline attempt rates characteristic of patients with borderline personality disorder. Downward extensions of DBT
such as DBT-A (Miller et al., 1997a) may be of value; however, they have not yet been systematically evaluated in this
age group or in males, who are most at risk for suicide
(Anderson, 2002). No studies of cognitive-behavioral therapy with adolescent suicide attempters have been published, although it has been used successfully in adolescent
patients with depression (Brent et al., 1997; Harrington
and Clark, 1998).
Psychopharmacological Interventions
To our knowledge, there have been no psychopharmacological studies that have specifically targeted suicidal
adolescents. However, it is likely that in spite of the absence
of documented support, the use of SSRIs is common
among teenagers who have been referred for suicidal
ideation or after they have made an attempt. Rates of prescription of antidepressants among teenagers are extremely
high (Olfson et al., 2002b) and almost certainly include
adolescents who have attempted suicide. Indeed, this practice may be a factor leading to the dramatic and encouraging decline in youth suicide rates over the past decade
(Isacsson, 2000). There are few a priori reasons not to treat
suicidal adolescents with SSRIs, providing their progress
and response to the medication is closely monitored.
SSRI antidepressants have been shown to reduce suicidal ideation in both depressed (Letizia et al., 1996) and
nondepressed adults with cluster B personality disorders
(Verkes et al., 1998) and in individuals who have made
a limited number of previous suicide attempts. SSRIs
have been shown to be more effective than placebo in
treating depressed teenagers (Emslie and Mayes, 2001;
Emslie et al., 1997; Keller et al., 2001), they are considJ . A M . A C A D . C H I L D A D O L E S C . P S YC H I AT RY, 4 2 : 4 , A P R I L 2 0 0 3
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erably less dangerous in overdose than are tricyclic antidepressants (Ryan and Varma, 1998), and there is evidence that they reduce the frequency of impulsive and
aggressive behaviors (Coccaro and Kavoussi, 1997), which
are a common occurrence in suicidal teenagers.
In rare instances, ruminative suicidal ideation combined with akathisia can occur during the course of antipsychotic (Hamilton and Opler, 1992) or SSRI treatment
(King et al., 1991; Teicher et al., 1990). This complication has been reported to respond to propranolol (Adler
et al., 1985; Chandler, 1990). When SSRI treatment is
started, parents should be routinely advised to inform the
psychiatrist if akathisia develops; the suicidal teenager
should likewise be advised to inform parents or physicians if there is an upsurge in suicidal ideation.
In adults with bipolar or other major affective disorders, long-term lithium treatment significantly reduces
the recurrence of suicide attempts (Tondo et al., 1997)
and sudden withdrawal from lithium increases the risk of
suicide independent of any effect on other symptoms of
mania (Tondo and Baldessarini, 2000). Similarly, clozapine is effective in reducing suicidality in adults with schizophrenia even when there is no apparent effect or impact
on other symptoms of schizophrenia (see Meltzer, 2001).
The antisuicidal effects of lithium and clozapine have not
been assessed in children or adolescents. If lithium is being
used to treat an adolescent, it would be wise to observe
the same degree of caution as has been used in adults with
respect to sudden withdrawal of the medication.
CONCLUSIONS
The past decade has witnessed a surge in research on
youth suicide risk. The current review has underscored
youth psychiatric disorder, a family history of suicide and
psychopathology, stressful life events, and access to firearms
as key risk factors for youth suicide. Exciting new findings have emerged on the biology of suicide in adults,
but, while encouraging, these are yet to be replicated in
youths. Factors that had been previously thought to be
risks for youth suicide, such as divorce and impaired parent–child relationships, have been found to be largely
explained by underlying psychiatric problems in the youth
and/or parents, whereas other risk factors, such as samesex sexual orientation and sexual abuse, while mediated
by other psychosocial risks, have recently been found to
make an independent contribution to youth suicide.
Despite the burgeoning research literature on risk factors, there remains a paucity of information on protec399
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GOULD ET AL.
tive factors. Family cohesiveness and religiosity may be
somewhat protective, but much more work needs to be
done before we can have confidence that they mitigate
the impact of accumulating risk factors. Future research
needs to increasingly identify factors that protect against
suicidal behavior so that they may be enhanced.
Several promising empirically based prevention strategies have been identified, including school-based skills
training for students, screening for at-risk youths, education of primary care physicians, media education, and
lethal-means restriction; however, these strategies need
continuing evaluation studies before their efficacy can be
established.
Because the decline in youth suicide seems likely to be
a product of more widely administered and more effective treatment, the burden on professionals to identify
depressed and suicidal teenagers and bring them to treatment is greater than ever before. Well-designed studies
on candidate medications and psychotherapies must be
conducted as a matter of urgency.
Given the complexity of the mechanism of youth suicide, it seems likely that no one prevention/intervention
strategy, by itself, is enough to combat this critical problem. Rather, a comprehensive, integrated effort, involving multiple domains—the individual, family, school,
community, media, and health care system—is needed.
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Adolescents (Appendix)
Saving Lives in New York Volume 2: Approaches and Special Populations
College Students
Ann Pollinger Haas, Ph.D., Research Director
American Foundation for Suicide Prevention
Morton M. Silverman, M.D., Senior Consultant
American Foundation for Suicide Prevention
Bethany Koestner, B.S., Research Administrator
American Foundation for Suicide Prevention
I. FIindings
An estimated 14 million students presently
attend more than 4,500 colleges and universities in the U.S. This includes about 8
million students between the ages of 18-24,
representing about one-quarter of all 18-24
year-olds in the country. Because college
student suicide rates are not officially
tracked on either a national or state level,
the current knowledge base on suicide and
suicidal behavior among this population is
based on studies of selected universities,
surveys of university officials, and surveys
of college students themselves. The key
findings of this accumulated research are:
A. Overall Rates and Secular Patterns
in the U.S.
•
•
Suicide appears to be only about half
as frequent among college and university students as among an age, gender,
and race-matched population. Students
are estimated to have a suicide rate of
7.5 per 100,000, compared to 15 per
100,000 for young adults in the general
population.
At this rate, about 1,100 suicides are
estimated to occur each year, placing
suicide as the second leading cause of
death among college students, following accidents. Suicide is the third leading cause of death among all youth
ages 15-24, following accidents and
homicides.
College Students
•
Based on self-report data collected by
the CDC in 1995 (National College
Health Risk Behavior Survey), about
11% of college students ages 18-24
have seriously considered suicide within the past year. About 8% have made a
suicide plan, and almost 2% have made
a suicide attempt.
•
In a 2002 survey of college and university counseling center directors, 85%
reported increasing numbers of students with serious mental health problems and increased demands for campus-based psychological services.
B. Overall Rates in New York State
•
Over 1.1 million students are currently
enrolled in 264 institutions of higher
education in New York State.
•
80% are enrolled as undergraduates
and 20% as graduate or professional
students. 70% attend full time and 30%
part time. About 42% are male and 58%
are female.
•
Based on national estimates, approximately 83 suicides are likely to occur
each year among college and university
students in New York State, 59 among
undergraduates and 24 among graduate and professional students.
•
Extrapolating from CDC’s National College Health Risk Behavior Survey, more
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Saving Lives in New York Volume 2: Approaches and Special Populations
than 122,000 college students in New
York State are estimated to seriously
consider suicide each year. It is expected
that almost 89,000 have a suicide plan,
and over 22,000 make a suicide attempt.
•
There is considerable diversity among
institutions of higher education in New
York State (see Tables 1 and 2). The 61
campuses of the State University (SUNY)
constitute about 23% of the 264 colleges
and universities in NY State, and enroll
about 37% of the total number of students. The 19 campuses of the City University (CUNY) constitute about 7% of
the institutions and enroll over 19% of all
students. 184 private colleges and universities, which make up 70% of the
higher education institutions in the state,
enroll the remaining 44% of students.
Almost 35% of NY State’s colleges and
universities are located within the five
boroughs of New York City. Demographic differences among institutions likely
have an impact on the distribution of
suicide deaths and suicidal behavior
among the state’s college and university
population.
and an inability to tolerate failure may
also be risk factors for this population.
•
Suicidal ideation in college students is
associated with other injury-related risk
behaviors, such as carrying a weapon,
engaging in physical fights, and not
using seat belts. More than 75% of
those who seriously consider suicide
drink alcohol, often heavily. Students
who report suicidal ideation are significantly more likely than students who
do not to drive after drinking, ride with
someone who has been drinking, and
boat or swim after drinking.
•
Many college students who die by suicide, however, appear to be largely
depressed, quiet, socially isolated, and
may draw little attention to themselves.
•
A number of special groups within the
overall college population have particular risk factors. These include international students, who may have little
social or emotional support at a time
that they are making a major life transition; gay, lesbian, bisexual and transgendered students, who on some campuses may experience discrimination
and social isolation; and older students,
who often experience difficulties in
returning to school.
•
Graduate students appear to have a
much higher suicide rate than undergraduates (10.6/100,000 vs.
6.6/100,000). Although undergraduate
males have a much higher rate than
undergraduate females (9.3/100,000 vs.
3.4/100,000), the suicide rate for
female graduate students approaches
that for male graduate students
(9.1/100,000 vs. 11.6/100,000). Intense
academic competition, mounting financial burdens and uncertainties about
future employment are likely contributing factors for all graduate students.
•
Overall, it is estimated that only 20% of
suicidal students are receiving psychotherapy or antidepressant medication. In 2002, schools with active counseling centers reported that less than a
C. Risk Factors
66
•
As with all adolescents and young adults,
over 90% of college students who die by
suicide are believed to have a mental disorder at the time of their death.
•
The most common diagnoses in college
students who die by suicide appear to
be depression, bipolar disorder, schizophrenia, and substance abuse.
•
Overall, the suicide rate for male students is estimated to be more than
twice that for females (10.0/100,000 vs.
4.5/100,000), and 75% of college student suicide deaths occur among males.
Few gender differences are seen, however, in suicide attempts and suicidal
ideation among this population.
•
Suicide deaths among college students
are frequently triggered by relationship
losses or difficulties adjusting to new
expectations and settings. Perfectionism
College Students
Saving Lives in New York Volume 2: Approaches and Special Populations
third of students who died by suicide
had received treatment at their centers.
•
College students appear to be particularly susceptible to suicide
contagion/imitation. In recent years, a
number of suicide clusters, usually
involving jumping from heights, have
been reported on college campuses.
Within New York State, apparent suicide clusters have occurred at Cornell
University and New York University.
D. Protective Factors
Although to date few, if any, factors have
been definitively established to protect college students from suicide risk, factors
thought to be particularly important for this
population include:
•
Availability of effective and appropriate
clinical services for mental disorders,
including alcohol and drug use.
•
A campus atmosphere that encourages
help-seeking and early identification of
problems that may put students at risk
for mental disorders and suicide.
•
A sense of campus community and
social connectedness.
•
Restricted access to lethal methods of
suicide, including barriers to jumping
and prohibitions against possession of
firearms on campus.
II. Action Steps
Based on what is currently known about
risk and protective factors related to college suicide, the following action steps are
recommended for implementation by campus officials. Relatively few suicide prevention programs have been developed specifically for college students, and thus available resources to guide campuses in implementing a particular recommendation are
limited. Where such resources are available, they are noted. Although the recommendations focus on a number of discrete
actions, the most effective approach to suicide prevention on college and university
campuses is a comprehensive strategy that
includes multiple coordinated activities tar-
College Students
geting one or more constituencies within
the overall campus community (e.g.,
administrators, faculty, counselors, students). Such a comprehensive approach
has been endorsed by the American Foundation for Suicide Prevention and by the
Jed Foundation.
A. Enhance Support Systems
for Vulnerable Students
(1). Efforts to Stimulate Change
in Campus Culture
Broad efforts aimed at bringing about
changes in the way mental illness and suicide are perceived on campus are an
essential component of suicide prevention.
Social marketing strategies can be effectively employed by campus leaders including the President’s Office, Student Affairs
administrators, deans, mental health services personnel, and campus media, to destigmatize mental illness, remove barriers
to identifying and treating students in need
of mental health services, and encourage
help-seeking.
Resources: National Mental Health Association/Jed Foundation,
Safeguarding your students against suicide: expanding the
safety network. Alexandria, VA. 2002.
Higher Education Center for Alcohol and Other Drug
Prevention (www.edc.org/hec).
Suicide Prevention Resource Center (www.sprc.org).
(2) Post-Attempt Treatment Programs
It is essential that campuses establish clear,
non-punitive procedures for assessing a
student’s continued risk following a suicide
attempt. Campus personnel should be
specifically trained to link the suicidal student to evaluation and treatment
resources, either on or off campus. These
individuals must be thoroughly knowledgeable about the availability of and access to
all campus and community resources.
Campus mental health services should
have clear procedures in place to ensure
that students who have made a suicide
attempt are given priority access to evaluation and treatment services.
Resource: The American Foundation for Suicide Prevention (AFSP)
(www.afsp.org) has developed educational posters highlighting suicide risk factors and management guidelines for
emergency personnel.
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Saving Lives in New York Volume 2: Approaches and Special Populations
(3) Campus Policies Regarding Students
with Mental Illness
Campus leadership should initiate a comprehensive review of existing policies that
affect students with identified mental
health needs, including those who have
made a suicide attempt or expressed suicidal ideation or attempt. Policies that are
discriminatory or punitive should be
revised and, where lacking, clear policies
should be established to provide medical
leaves for students with mental health
needs and non-punitive procedures for
subsequent re-entry. Relevant personnel
should be fully trained to comply with such
policies, and in matters pertaining to confidentiality and related legal issues.
(5) Outreach to Students Who Leave
Campus for Mental Health Reasons
Policies regarding campus-based treatment
services should also be reviewed and
revised as needed to insure that the quantity and quality of available services are
appropriate to the needs of seriously disturbed students. Colleges and universities
which are unable to provide such services
should develop appropriate community
referral networks.
B. Implement Case-Finding with Accompanying Referral and Treatment
(1.) Screening Programs
Resource: National Mental Health Association/Jed Foundation,
2002.
(4) Peer-Helper and Other
Support Programs
Programs are needed that provide support
to students who have made a suicide
attempt or are struggling with depression
or other mental disorders. Such programs,
focusing on support from peers, residence
advisers, student affairs personnel, or others within the campus community, might
be effectively incorporated into a campus
reentry program. The responsibilities of
peers and other lay helpers are best limited
to listening and reporting possible warning
signs, rather than counseling. It is imperative that lay helpers be carefully supervised
by fully trained mental health professionals,
preferably those within the campus’s own
mental health services.
Resource: Youth-Nominated Support Team (YST) (Cheryl King,
Ph.D.) (kingca@med.umich.edu)
68
Students who leave college following a suicide attempt or because of mental health
problems often struggle with their own
responses to perceived failure (shame,
guilt, embarrassment, etc.). In addition,
they may face negative reactions from parents, siblings and friends at home, as well
as increased social and emotional isolation. In light of research evidence that
youth who are “drifting” - neither in school
or working - are at particular risk for suicide, efforts should be made by colleges to
maintain links with students who leave for
mental health reasons, and encourage
them to re-enter at the appropriate time.
Screening programs are an important strategy in a campus suicide prevention program. Currently, screening techniques lack
precision to identify with certainty those
who will attempt suicide or die by suicide.
However, screening for specific disorders
associated with suicide (particularly depression and substance abuse) can identify students at risk for suicide and facilitate referral to appropriate treatment services.
Screening can be either universal (targeting
all students on campus) or directed towards
particular groups most at risk (e.g. male
students, graduate students, international
students, etc.). The Internet provides an
excellent mechanism for reaching college
students because of high access and usage.
Screening programs that allow the student
to maintain anonymity until he or she is
ready to self-identify, and that provide a
personalized response from a trained clinician appear to be most successful.
Resources: American Foundation for Suicide Prevention’s College
Screening Program (www.afsp.org). Depression Screening
Day Program (Douglas Jacobs, MD djacobs@mentalhealthscreening.org). ULifeline, Jed Foundation (www.jedfoundation.org).
(2.) Residence Advisor and Other Gatekeeper/Caregiver Training Programs
Training programs that increase the ability
of potential gatekeepers to identify and
refer for treatment at-risk students are an
College Students
Saving Lives in New York Volume 2: Approaches and Special Populations
important part of campus suicide prevention. Because of their daily proximity to a
substantial number of students, residence
hall advisers are in a unique position to
recognize signs of suicide risk. Other gatekeepers might include faculty, athletic personnel and student life personnel. Suicide
prevention training should focus on developing the knowledge, attitudes and skills to
identify individuals at risk, determine the
levels of risk, and to make referrals.
Resources: Question, Persuade and Refer (QPR) (www.qprinstitute.com). Applied Suicide Intervention Skills Training
(ASIST), Living Works Education (www.livingworks.net).
(3.) Student Education to Increase
Recognition of Depression
and Other Disorders
An important aspect of a campus suicide
prevention strategy is increasing students’
recognition of depression and other mental
disorders that convey risk, both in themselves and their friends. The structure of college and university life offers numerous
opportunities to educate students about
depression and suicide: student orientation
sessions, classrooms, residence hall meetings, Greek organizations, and other student
groups and extracurricular activities. Films,
lectures, discussions and question-andanswer sessions are all helpful strategies for
raising students’ awareness of suicide, suicide risk factors, available treatment options,
and strategies for peer support.
Resource: Film: The Truth About Suicide: Real Stories of
Depression in College, and accompanying Facilitator’s
Guide, developed by the American Foundation for Suicide
Prevention (www.afsp.org/collegefilm).
(4.) Postvention/Crisis Intervention
on Campuses
Given the very real potential for contagion
and imitation, it is critical that campuses
respond effectively and appropriately following a student suicide. The major goals of
postvention/crisis intervention programs
are to assist students in the grief process,
identify and refer those individuals who
may be at risk following the suicide, provide
accurate information about suicide while
attempting to minimize suicide contagion,
and implement a structure for ongoing prevention efforts. Particularly helpful are individual or small group sessions in which stu-
College Students
dents have an opportunity to talk about the
suicide decedent and explore their own
emotional reactions to the suicide. Campuswide memorials or other large- scale gatherings that honor the decedent may have
the unintended consequence of encouraging imitation among vulnerable students.
Although such events can provide an
opportunity to deliver the message that
depression and other conditions that
heighten suicide risk are treatable conditions, it is perhaps safest for campuses to
avoid them wherever possible.
Resource: Services for Teens at Risk (STAR) Center Postvention.
Standards Guidelines (Mary Margaret Kerr, Ed.D. Director,
STAR- Center Outreach, kerrmm@msx.upmc.edu)
C. Develop Risk Reduction Programs
(1). Means Restriction on Campus
College and university officials should
undertake a comprehensive analysis of all
structures and activities that may provide an
opportunity for suicide, and take appropriate
actions to limit students’ access to potentially lethal means. This may involve a range of
activities including constructing barriers on
balconies, rooftops and bridges; and establishing clear policies and procedures that
restrict the availability and use of alcohol,
illicit drugs and firearms on campus.
Resources: Reducing Underage Drinking: A Collective
Responsibility. Richard Bonnie and Mary Ellen O’Connell,
Editors, Committee on Developing a Strategy to Reduce and
Prevent Underage Drinking, National Research Council,
Institute of Medicine. (www.nap.edu/catalog/10729.html).
National Strategy for Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp).
(2). Media Education
Given the substantial evidence for suicide
contagion and imitative behavior
among students, students and relevant
community personnel involved in print,
radio and television media that serve the
campus population should be educated in
how to responsibly report on suicide. Such
action steps are described elsewhere in the
Media section of the New York State Suicide Prevention Plan.
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Saving Lives in New York Volume 2: Approaches and Special Populations
D. Enhance Protective Factors
(1) Social Network Promotion
Promoting a sense of belonging among all
students is an important element of suicide
prevention. Administrators, faculty, staff
and student leaders should explore ways of
encouraging the development of smaller
groups within the larger campus community, and reaching out to student groups who
may experience isolation and a lack of
connectedness (e.g. racial and ethnic
minorities, international students, gay and
lesbian students, commuter students, older
students, etc.).
Resources: National Mental Health Association/Jed Foundation,
2002. National Strategy for Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp).
(2) Life Skills Development
Programs to improve students’ management of the rigors of college life, and to
equip students with tools to recognize and
manage triggers and stressors should be
developed and incorporated into student
orientation, residence hall meetings and
other student life venues.
Resource: National Mental Health Association/Jed Foundation,
2002.
E. Enhance Effectiveness of Campus
Mental Health Services
(1) Professional Education Programs
Training campus mental health personnel
about suicide risk, assessment and treatment is an essential suicide prevention
strategy. Many mental health professionals
have inadequate training in working with
seriously depressed or suicidal individuals.
On-going professional education by suicide
experts, and opportunities to collaborate
with colleagues in the treatment of seriously disturbed students can improve the effectiveness of campus mental health services.
Resources: American Foundation for Suicide Prevention (2003).
The Suicidal Patient: Assessment and Care. A film available
at AFSP.org/index-1.htm.
American Academy of Child and Adolescent Psychiatry
Workgroup on Quality Issues. Practice parameters for the
assessment and treatment of children and adolescents with
suicidal behavior. Journal of the American Academy of
Adolescent and Child Psychiatry, 40 (7), 24s-51s, (2001).
Practice guidelines for the assessment and treatment of patients
70
with suicidal behavior. American Journal of Psychiatry, 160:
1-60 (2003).
Recommendations/Action Steps
by Stakeholder Group
The following recommendations/action
steps are taken from the preceding section
(II). In this section they have been organized under different stakeholder groups.
Administration
Efforts to Stimulate Change in Campus
Culture (II A.1)
Broad efforts aimed at bringing about
changes in the way mental illness and suicide are perceived on campus are an
essential component of suicide prevention.
Social marketing strategies can be effectively employed by campus leaders including the President’s Office, Student Affairs
administrators, deans, mental health services personnel, and campus media, to destigmatize mental illness, remove barriers
to identifying and treating students in need
of mental health services, and encourage
help-seeking.
Resources: National Mental Health Association/Jed Foundation,
Safeguarding your students against suicide: expanding the
safety network. Alexandria, VA. 2002. Higher Education
Center for Alcohol and Other Drug Prevention
(www.edc.org/hec). Suicide Prevention Resource Center
(www.sprc.org).
Screening Programs (II B.1)
Screening programs are an important strategy in a campus suicide prevention program. Currently, screening techniques lack
precision to identify with certainty those
who will attempt suicide or die by suicide.
However, screening for specific disorders
associated with suicide (particularly
depression and substance abuse) can identify students at risk for suicide and facilitate
referral to appropriate treatment services.
Screening can be either universal (targeting
all students on campus) or directed
towards particular groups most at risk (e.g.
male students, graduate students, international students, etc.). The Internet provides
an excellent mechanism for reaching college students because of high access and
usage. Screening programs that allow the
student to maintain anonymity until he or
she is ready to self-identify, and that provide a personalized response from a
College Students
Saving Lives in New York Volume 2: Approaches and Special Populations
trained clinician appear to be most successful.
Resources: American Foundation for Suicide Prevention’s College
Screening Program (www.afsp.org).
Depression Screening Day Program (Douglas Jacobs, MD
djacobs@mentalhealthscreening.org).
ULifeline, Jed Foundation (www.jedfoundation.org).
Means Restriction on Campus (II C.1)
College and university officials should
undertake a comprehensive analysis of all
structures and activities that may provide an
opportunity for suicide, and take appropriate
actions to limit students’ access to potentially lethal means. This may involve a range of
activities including constructing barriers on
balconies, rooftops and bridges; and establishing clear policies and procedures that
restrict the availability and use of alcohol,
illicit drugs and firearms on campus.
Resources: Reducing Underage Drinking: A Collective
Responsibility. Richard Bonnie and Mary Ellen O’Connell,
Editors, Committee on Developing a Strategy to Reduce and
Prevent Underage Drinking, National Research Council,
Institute of Medicine. (www.nap.edu/catalog/10729.html).
National Strategy for Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp).
Outreach to Students Who Leave Campus for Mental Health Reasons (II A.5)
Students who leave college following a suicide attempt or because of mental health
problems often struggle with their own
responses to perceived failure (shame,
guilt, embarrassment, etc.). In addition,
they may face negative reactions from parents, siblings and friends at home, as well
as increased social and emotional isolation. In light of research evidence that
youth who are “drifting” - neither in school
or working - are at particular risk for suicide, efforts should be made by colleges to
maintain links with students who leave for
mental health reasons, and encourage
them to re-enter at the appropriate time.
Deans and Academic Advisors
Campus Policies Regarding Students with
Mental Illness (II A.3)
Campus leadership should initiate a comprehensive review of existing policies that
affect students with identified mental
health needs, including those who have
made a suicide attempt or expressed suicidal ideation or attempt. Policies that are
College Students
discriminatory or punitive should be
revised and, where lacking, clear policies
should be established to provide medical
leaves for students with mental health
needs and non-punitive procedures for
subsequent re-entry. Relevant personnel
should be fully trained to comply with such
policies, and in matters pertaining to confidentiality and related legal issues.
Policies regarding campus-based treatment
services should also be reviewed and
revised as needed to insure that the quantity and quality of available services are
appropriate to the needs of seriously disturbed students. Colleges and universities
which are unable to provide such services
should develop appropriate community
referral networks.
Resource: National Mental Health Association/Jed Foundation,
2002.
Outreach to Students Who Leave Campus for Mental Health Reasons (II A.5)
Students who leave college following a suicide attempt or because of mental health
problems often struggle with their own
responses to perceived failure (shame,
guilt, embarrassment, etc.). In addition,
they may face negative reactions from parents, siblings and friends at home, as well
as increased social and emotional isolation. In light of research evidence that
youth who are “drifting” - neither in school
or working - are at particular risk for suicide, efforts should be made by colleges to
maintain links with students who leave for
mental health reasons, and encourage
them to re-enter at the appropriate time.
Faculty/Staff
Residence Advisor and Other Gatekeeper/Caregiver Training Programs (II B.2)
Training programs that increase the ability
of potential gatekeepers to identify and
refer for treatment at-risk students are an
important part of campus suicide prevention. Because of their daily proximity to a
substantial number of students, residence
hall advisers are in a unique position to
recognize signs of suicide risk. Other gatekeepers might include faculty, athletic personnel and student life personnel. Suicide
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Saving Lives in New York Volume 2: Approaches and Special Populations
prevention training should focus on developing the knowledge, attitudes and skills to
identify individuals at risk, determine the
levels of risk, and to make referrals.
Resources: Question, Persuade and Refer (QPR)
(www.qprinstitute.com).
Applied Suicide Intervention Skills Training (ASIST),
Living Works Education (www.livingworks.net).
Public Safety Department
Means Restriction on Campus (II C.1)
College and university officials should
undertake a comprehensive analysis of all
structures and activities that may provide
an opportunity for suicide, and take appropriate actions to limit students’ access to
potentially lethal means. This may involve
a range of activities including constructing
barriers on balconies, rooftops and bridges;
and establishing clear policies and procedures that restrict the availability and use of
alcohol, illicit drugs and firearms on campus.
Resources: Reducing Underage Drinking: A Collective
Responsibility. Richard
Promoting a sense of belonging among all
students is an important element of suicide
prevention. Administrators, faculty, staff
and student leaders should explore ways of
encouraging the development of smaller
groups within the larger campus community, and reaching out to student groups who
may experience isolation and a lack of
connectedness (e.g. racial and ethnic
minorities, international students, gay and
lesbian students, commuter students, older
students, etc.).
Resources: National Mental Health Association/Jed Foundation,
2002. National Strategy for Suicide Prevention (www.mentalhealth.samhsa.gov/suicideprevention/strategy.asp).
Life Skills Development (II D.2)
Programs to improve students’ management of the rigors of college life, and to
equip students with tools to recognize and
manage triggers and stressors should be
developed and incorporated into student
orientation, residence hall meetings and
other student life venues.
Bonnie and Mary Ellen O’Connell, Editors, Committee on
Developing a Strategy to Reduce and Prevent Underage
Drinking, National Research Council, Institute of Medicine.
(www.nap.edu/catalog/10729.html). National Strategy for
Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp).
Resource: National Mental Health Association/Jed Foundation,
2002.
Residential Life Staff
Residence Advisor and Other Gatekeeper/Caregiver Training Programs (II B.2)
It is essential that campuses establish clear,
non-punitive procedures for
Training programs that increase the ability
of potential gatekeepers to identify and
refer for treatment at-risk students are an
important part of campus suicide prevention. Because of their daily proximity to a
substantial number of students, residence
hall advisers are in a unique position to
recognize signs of suicide risk. Other gatekeepers might include faculty, athletic personnel and student life personnel. Suicide
prevention training should focus on developing the knowledge, attitudes and skills to
identify individuals at risk, determine the
levels of risk, and to make referrals.
Resources: Question, Persuade and Refer (QPR) (www.qprinstitute.com).
Applied Suicide Intervention Skills Training (ASIST), Living Works
Education (www.livingworks.net).
72
Social Network Promotion (II D.1)
Student Counseling Services/Campus
Mental Health Professionals
Post-Attempt Treatment Programs (II A.2)
assessing a student’s continued risk following a suicide attempt. Campus personnel
should be specifically trained to link the
suicidal student to evaluation and treatment resources, either on or off campus.
These individuals must be thoroughly
knowledgeable about the availability of and
access to all campus and community
resources. Campus mental health services
should have clear procedures in place to
ensure that students who have made a suicide attempt are given priority access to
evaluation and treatment services.
Resource: The American Foundation for Suicide Prevention (AFSP)
(www.afsp.org) has developed educational posters highlighting
suicide risk factors and management guidelines for emergency personnel.
College Students
Saving Lives in New York Volume 2: Approaches and Special Populations
Postvention/Crisis Intervention on Campuses (II B.4)
Outreach to Students Who Leave Campus for Mental Health Reasons (II A.5)
Given the very real potential for contagion
and imitation, it is critical that campuses
respond effectively and appropriately following a student suicide. The major goals of
postvention/crisis intervention programs are
to assist students in the grief process, identify
and refer those individuals who may be at
risk following the suicide, provide accurate
information about suicide while attempting to
minimize suicide contagion, and implement a
structure for ongoing prevention efforts. Particularly helpful are individual or small group
sessions in which students have an opportunity to talk about the suicide decedent and
explore their own emotional reactions to the
suicide. Campus-wide memorials or other
large- scale gatherings that honor the decedent may have the unintended consequence
of encouraging imitation among vulnerable
students. Although such events can provide
an opportunity to deliver the message that
depression and other conditions that heighten suicide risk are treatable conditions, it is
perhaps safest for campuses to avoid them
wherever possible.
Students who leave college following a suicide attempt or because of mental health
problems often struggle with their own
responses to perceived failure (shame,
guilt, embarrassment, etc.). In addition,
they may face negative reactions from parents, siblings and friends at home, as well
as increased social and emotional isolation. In light of research evidence that
youth who are “drifting” - neither in school
or working - are at particular risk for suicide, efforts should be made by colleges to
maintain links with students who leave for
mental health reasons, and encourage
them to re-enter at the appropriate time.
Resource: Services for Teens at Risk (STAR) Center Postvention.
Standards Guidelines (Mary Margaret Kerr, Ed.D. Director, STARCenter Outreach, kerrmm@msx.upmc.edu)
Professional Education Programs (II E.1)
Training campus mental health personnel
about suicide risk, assessment and treatment is an essential suicide prevention
strategy. Many mental health professionals
have inadequate training in working with
seriously depressed or suicidal individuals.
On-going professional education by suicide
experts, and opportunities to collaborate
with colleagues in the treatment of seriously disturbed students can improve the effectiveness of campus mental health services.
Resources: American Foundation for Suicide Prevention (2003).
The Suicidal Patient: Assessment and Care. A film available
at AFSP.org/index-1.htm.
American Academy of Child and Adolescent Psychiatry
Workgroup on Quality Issues. Practice parameters for the
assessment and treatment of children and adolescents with
suicidal behavior. Journal of the American Academy of
Adolescent and Child Psychiatry, 40 (7), 24s-51s, (2001).
Practice guidelines for the assessment and treatment of
patients with suicidal behavior. American Journal of
Psychiatry, 160: 1-60 (2003).
College Students
Students
Peer-Helper and Other Support Programs (II A.4)
Programs are needed that provide support
to students who have made a suicide
attempt or are struggling with depression
or other mental disorders. Such programs,
focusing on support from peers, residence
advisers, student affairs personnel, or others within the campus community, might
be effectively incorporated into a campus
reentry program. The responsibilities of
peers and other lay helpers are best limited
to listening and reporting possible warning
signs, rather than counseling. It is imperative that lay helpers be carefully supervised
by fully trained mental health professionals,
preferably those within the campus’s own
mental health services.
Resource: Youth-Nominated Support Team (YST) (Cheryl King,
Ph.D.) (kingca@med.umich.edu)
Student Education to Increase Recognition of Depression and Other Disorders
(II B.3)
An important aspect of a campus suicide
prevention strategy is increasing students’
recognition of depression and other mental
disorders that convey risk, both in themselves and their friends. The structure of college and university life offers numerous
opportunities to educate students about
depression and suicide: student orientation
sessions, classrooms, residence hall meetings, Greek organizations, and other student
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Saving Lives in New York Volume 2: Approaches and Special Populations
groups and extracurricular activities. Films,
lectures, discussions and question-andanswer sessions are all helpful strategies for
raising students’ awareness of suicide, suicide risk factors, available treatment options,
and strategies for peer support.
Resource: Film: The Truth About Suicide: Real Stories of
Depression in College, and accompanying Facilitator’s
Guide, developed by the American Foundation for Suicide
Prevention (www.afsp.org/collegefilm).
Media Education (II. C.2)
Given the substantial evidence for suicide
contagion and imitative behavior among
students, students and relevant community
personnel involved in print, radio and television media that serve the campus population should be educated in how to
responsibly report on suicide. Such action
steps are described elsewhere in the Media
section of the New York State Suicide Prevention Plan.
Social Network Promotion (II D.1)
Promoting a sense of belonging among all
students is an important element of suicide
prevention. Administrators, faculty, staff
and student leaders should explore ways of
encouraging the development of smaller
groups within the larger campus community, and reaching out to student groups who
may experience isolation and a lack of
connectedness (e.g. racial and ethnic
minorities, international students, gay and
lesbian students, commuter students, older
students, etc.).
Resources: National Mental Health Association/Jed Foundation,
2002. National Strategy for Suicide Prevention (www.mentalhealth.samhsa.gov/suicideprevention/strategy.asp).
Life Skills Development (II D.2)
Programs to improve students’ management of the rigors of college life, and to
equip students with tools to recognize and
manage triggers and stressors should be
developed and incorporated into student
orientation, residence hall meetings and
other student life venues.
Resource: National Mental Health Association/Jed Foundation,
2002.
74
Outreach to Students Who Leave Campus for Mental Health Reasons (II A.5)
Students who leave college following a suicide attempt or because of mental health
problems often struggle with their own
responses to perceived failure (shame,
guilt, embarrassment, etc.). In addition,
they may face negative reactions from parents, siblings and friends at home, as well
as increased social and emotional isolation. In light of research evidence that
youth who are “drifting” - neither in school
or working - are at particular risk for suicide, efforts should be made by colleges to
maintain links with students who leave for
mental health reasons, and encourage
them to re-enter at the appropriate time.
Parents
Efforts to Stimulate Change
in Campus Culture (II A.1)
Broad efforts aimed at bringing about
changes in the way mental illness and suicide are perceived on campus are an
essential component of suicide prevention.
Social marketing strategies can be effectively employed by campus leaders including the President’s Office, Student Affairs
administrators, deans, mental health services personnel, and campus media, to destigmatize mental illness, remove barriers
to identifying and treating students in need
of mental health services, and encourage
help-seeking.
Resource: National Mental Health Association/Jed Foundation,
Safeguarding your students against suicide: expanding the
safety network. Alexandria, VA. 2002. Higher Education
Center for Alcohol and Other Drug Prevention (
www.edc.org/hec).
Suicide Prevention Resource Center (www.sprc.org).
Outreach to Students Who Leave Campus for Mental Health Reasons (II A.5)
Students who leave college following a suicide attempt or because of mental health
problems often struggle with their own
responses to perceived failure (shame,
guilt, embarrassment, etc.). In addition,
they may face negative reactions from parents, siblings and friends at home, as well
as increased social and emotional isolation. In light of research evidence that
youth who are “drifting” - neither in school
or working - are at particular risk for sui-
College Students
Saving Lives in New York Volume 2: Approaches and Special Populations
cide, efforts should be made by colleges to
maintain links with students who leave for
mental health reasons, and encourage
them to re-enter at the appropriate time.
Local Community Means Restriction
on Campus (II C.1)
Resources: Reducing Underage Drinking: A Collective
Responsibility. Richard Bonnie and Mary Ellen O’Connell,
Editors, Committee on Developing a Strategy to Reduce and
Prevent Underage Drinking, National Research Council,
Institute of Medicine. (www.nap.edu/catalog/10729.html).
National Strategy for Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp).
College and university officials should
undertake a comprehensive analysis of all
structures and activities that may provide an
opportunity for suicide, and take appropriate
actions to limit students’ access to potentially lethal means. This may involve a range of
activities including constructing barriers on
balconies, rooftops and bridges; and establishing clear policies and procedures that
restrict the availability and use of alcohol,
illicit drugs and firearms on campus.
College Students
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Saving Lives in New York Volume 2: Approaches and Special Populations
Families
Robert Allen, Director
Bureau of Psychiatric Services
New York State Office of Mental Health
I. Findings
The relationship between the family unit
and a suicidal adolescent family member is
both complex and compelling. Despite a
historical bias that emphasized how a negative family life could pose a risk to their
offspring’s mental health, there is growing
evidence that a family’s influence can and
should be considered as a protective factor
against their adolescent’s suicidal behavior.
The key seems to turn on whether family
influences - genetic, biological or environmental - are, on balance, essentially positive or negative for the family member’s
mental health. The capacity of the family
unit to exert influence is undeniable; the
content of that relationship varies from
family to family. It is also not static, in that
like individuals, family life can change over
time in response to inner growth and external forces. Research has begun to examine
the under-studied half of the equation - that
of families as protective forces against suicidal behavior, including repeated attempts
by their adolescent members.
•
A 1996 report that adolescent suicide
victims had significantly less frequent
and less satisfying communication with
their mothers and fathers;
•
Family aggression has been noted to be
prevalent in suicidal children in the
general community and in clinical settings.
•
A family history of suicidal behavior
greatly increases the risk of completed
suicide by an offspring. It may reflect a
genetic factor rather than family chaos
and psychopathology.
•
Families of suicide attempters and
completers share an increased risk of
affective illness, substance abuse,
assaultive behavior and suicide
attempts. (Brent, 1997)
•
The families of adolescent suicide
attempters are characterized by substantial levels of dysfunction (Spirito et
al., 1989)
•
There is a strong and specific association between deliberate self- poisoning
in adolescence and family dysfunction
(Harrington et al., 1998)
•
A family history of suicidal behavior
has been shown to increase suicide
risk even when controlled for poor
The Family as Risk Factor
Psychiatric research has well established a
family history of mental illness or suicide
and general family dysfunction presently
both increase the risk that an adolescent
will become suicidal.
Families
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Saving Lives in New York Volume 2: Approaches and Special Populations
parent-child relationships and parental
psychopathology.
•
exerts a critical influence - environmentally, genetically, and biologically upon their offspring.
High rates of parental psychopathology,
especially depression and substance
abuse, have been associated with completed suicide in adolescence.
While school personnel, mental health
professionals, and others with whom
the suicidal adolescent interacts must
be part of any comprehensive suicide
prevention strategy, it is arguably family
members who are in the best position
to reduce the risk of repeated attempts
because they are there, with the at-risk
adolescent.
The Family as Protective Factor
Psychiatric research has long established
that a past suicide attempt is a powerful
predictor of a subsequent attempt at virtually any age. Regrettably, psychiatric research
has not paid sufficient attention to:
•
•
The interrelationships between family
variables, adolescent feelings and
behaviors, and adolescent suicidality.
(Brinkman et al., 2000)
•
The impact the return of an adolescent
to the family after a suicide attempt has
on the family’s system and dynamics.
•
The positive role the adolescent’s family
can play in the prevention of another
suicide attempt. While many studies
have investigated the communication
and behaviors of the family as background to the initial suicide attempt by
an adolescent, very few have gone on to
evaluate the post-suicide attempt family
environment, or to gauge the family’s
capacity to serve as a protective force
against a repetition of the first attempt.
•
Brinkman-Sull et al., (2000) observed
that adolescent suicide risk factors
focused primarily on psychiatric symptoms of the suicide attempter, neglecting
the impact of the family. They further
point out that in the follow-up period
following a first attempt, the suicidal
adolescent is more likely than not to be
living apart from a parent or parents.
•
78
The scant attention afforded the family
as a primary source of prevention for
the adolescent who has attempted suicide is remarkable, in view of the fact
that it is the family with which an adolescent spends much, if not most, of
his/her time; the family that knows the
adolescent best; and the family that
Gould et al, (2003) point out that adolescent suicide prevention strategies
have .”..primarily been implemented
within three domains - school, community, and health-care system.” Many of
these strategies, including suicide
awareness curricula, skills training,
screening and gatekeeper training, are
undoubtedly valuable. However, corresponding research on and implementation efforts with the family’s role in the
secondary prevention of adolescent
suicide has not been done. Moreover,
little research has been done on the
closely related question of the impact
of the adolescent’s first suicide attempt
on the family. As Magne-Ingvar and
Ojehagen, (1999) observed, “Most follow-up studies after a suicide attempt
focus on the situation of the patient
(but)...a suicide attempt also affects significant others.”
Because the family is the first line of
defense in the secondary prevention of
adolescent suicide, it is the family that
bears the stress of adapting to the suicidal
adolescent and acting to prevent another
attempt. This adaptation can take the form
of constant, close observation of the adolescent, driven by concern, fear and guilt,
as well as by practical need; insistence on
the adolescent’s compliance with outpatient treatment, including medication management and making scheduled appointments with therapists.
Both adaptation and action inevitably
exhaust family members, and underscore
Families
Saving Lives in New York Volume 2: Approaches and Special Populations
the need for both respite care and treatment.
II. Action Steps.
I. Modifying Suicidal Behavior.
To overcome the propensity for first suicide
attempts to lead to subsequent others will
require a coordinated strategy by the family
employing a range of protective elements.
Ideally, evidence-based models of how
families succeed in preventing adolescent
suicide attempts can guide families and
treatment professionals alike. The reality is
given the paucity of both evidence and
models, family members must depend on
their own experience and intuition to prevent another attempt.
While invariably each family will respond
differently to this challenge, there are recommended practices that have worked for
other families faced with this challenge.
•
Closely observe the adolescent’s behavior and mood.
•
Pay Close Attention to all the adolescent’s references to suicide. Pay particular attention to any reference to another
attempt.
•
Encourage the adolescent to attend outpatient treatment.
•
Facilitate the adolescent’s compliance
with treatment recommendations,
including taking medication as prescribed.
•
Communicate often with the treatment
professionals involved.
•
Remove all firearms from the home.
•
Secure other potentially lethal agents,
e.g. poisons and prescribed and overthe-counter medications, away from
the adolescent.
•
Attempt to keep the adolescent away
from alcohol and illegal drugs.
Implementing any of these measures with
an adolescent is likely to be very difficult.
Families
Individuals who have attempted suicide
tend to be non-compliant with treatment,
and many, perhaps most adolescents do
not readily share their thoughts and feelings with parents. Moreover, these suggested steps require the family to vigilantly
observe the adolescent’s behavior and
affect - observation which the adolescent
may interpret as interference and control.
For the family, there is no easy or sure path
to the prevention of a second suicide
attempt.
III. The Need for more Knowledge.
There is a need for more research on the
impact of an adolescent’s suicide attempt
on their family. Similarly, there is a need for
more research on the ways that families
cope in the aftermath of such an attempt.
Much research has been focused on the
family’s role, both genetic and environmental, in the etiology of adolescent suicide.
Similarly, there has been research on the
effect of a completed adolescent suicide on
surviving family members. Yet the family
system after the adolescent returns home
from an initial suicide attempt remains
largely unknown.
Once an adolescent has attempted suicide,
the risk of a second attempt increases dramatically. Once the adolescent has
attempted suicide, parents and other family
members are directly confronted with the
very real possibility that they might lose
their loved one to another attempt. Families may well be key to preventing another
such attempt. Many, if not most, families
are willing to face their fear and meet the
challenge, but they need the guidance that
can only come from the psychiatric
research community, and the support that
must come from their extended family,
communities and the wider society.
III. Action Steps
1. Respite care for families having a suicidal individual is a critical service, as is
therapy for family members and other
care-providers. Respite care comes in
many forms, including natural supports
such as that provided by family and
close friends. Whenever possible, such
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Saving Lives in New York Volume 2: Approaches and Special Populations
resources should be the first option
sought.
2. Much research has been focused on
the family’s role, both genetic and environmental in the etiology of adolescent
suicide. However, there has been scant
research conducted on the
positive/protective role that families
can play in recovery of a suicidal adolescent family member. This gap in our
knowledge should be filled.
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Saving Lives in New York Volume 2: Approaches and Special Populations
Suicide Survivors
Mary Jean Coleman, MSW, President
Samaritans USA
Sorrow
Sorrow is a word that I never knew
till I thought about the gun, the trigger you
placed at your temple as you defied strife.
These are where my feelings of agony dwell
As I wonder if death wasn’t more of a hell.
Not only for you, but also for me
‘cause I couldn’t help you and I’ll never be free...
Steadily pulling the trigger, you ended your life.
I’ll never be free of this feeling which haunts
I wish little brother, as you’d marched tall to die
that you’d stopped for a moment to whisper
“goodbye.”
‘Cause sometimes when I’m lonely and missing
you most
an agonizing feeling seems to clutch at my throat.
Which clutches my throat and constantly taunts
that I couldn’t help you enough just to give
you faith in tomorrow - give you faith just to live.
I’ll pray that the angels have now taken you home
And have found you true happiness, true peace
of your own.
This feeling that I speak of is quite common now...
And I’ll pray I’ll find peace - so that one day I’ll be
breathing becomes difficult as I think about how
set free of the haunting of your memory...
much sorrow it took for you to choose death.
Are you peaceful now Eddie, are you finally
at rest?
Mary Jean Reed-Coleman,
December 1979
Has the land of the dead made up for your pain?
Did the sacrifice of living prove more of a gain?
Or, as the bullet of death fiercely slammed through
your head
did you whimper and beg to be living instead?
Suicide Survivors
81
Saving Lives in New York Volume 2: Approaches and Special Populations
one of the most devastating losses of all
to bear (Bailey, Kral & Dunham, 1999;
Campbell, 1997; Hogan, 2001; Kneiper,
1999; Jamison, 1999; Leenaars and
Wenckstern, 1998). It has long been
believed that survivors of a loved one’s
suicide anguish in feelings of blame,
anger, responsibility, guilt, and abandonment (Ellenbogen and Gratton, 2001).
I.Findings
“On October 30, 1979, Edgar Francis
Reed celebrated his 17th birthday. Three
weeks later, on November 20, he went
out alone into the wooded area behind
his grandmother’s house. With him, he
carried a very heavy heart and his dad’s
hunting rifle. In a single, deafening blast with one bullet to the head - he took
his own life. In that single decision, when
he became a statistic, I became a survivor. Shame, sorrow, stigma, silence, survivor; I didn’t choose it. It chose me.”
Mary Jean Reed-Coleman, July 2003
•
Survivors tend to possess greater psycho-social vulnerabilities that cause
specific complications in the grieving
and recovery process. The Surgeon
General’s Call To Action to Prevent Suicide (1999) notes that suicide evokes
complicated and uncomfortable reactions in most of us. Too often, blame is
placed on the victim. This stigmatizes
the surviving family members and
friends. These reactions add to the survivors’ burden of hurt, intensify their
isolation, and shroud suicide in mystery. Unfortunately, secrecy and silence
only diminishes the accuracy and
amount of information available about
persons who have completed suicide information that might help prevent
other suicides (Satcher, 1999).
•
To understand the complicated
bereavement associated with suicide,
one must first acknowledge the long
history of the stigma of suicide and the
litany of acts and rituals practiced
throughout the world to “mark the
shameful act.” To prevent the suicide’s
ghost from wandering, corpses have be
decapitated, buried outside the city limits or in tribal territories, burned, beaten
with chains, thrown to wild beasts, or
buried at crossroads with a stake
through the heart. (Berman and Jobes,
1991).
•
Survivors of suicide were often forced
to forfeit goods and property (theirs as
well as the victim’s) and on occasion,
family survivors of the victim were
required to pay a fine to the suicide’s
in-laws in redemption for the “shame
brought to their name” (Berman and
Jobes, 1991).
A. Prevalence
•
Based on over 752,000 suicides from
1972 - 1997, it is estimated that the
number of survivors of suicides in
America is 4.5 million (1 of every 59
Americans in 1997). (Hoyert, Kochanek
& Murphy, 1999)
•
Centers for Disease Control and Prevention (CDC) reported 28,322 American deaths as suicides in the year 2000.
Conservative estimates are that 6-10
people are intimately affected by each
death. However, a study by the Baton
Rouge, LA Crisis Intervention Center
(Bland, 1994), the combination of possibly affected individuals reached over
28 people per suicide. In some families,
the estimated numbers exceed 50 people (Coleman, 2003). Since, on average,
1,200 New Yorkers die by suicide each
year, the latter estimate means approximately 60,000 people qualify as suicide
survivors each and every year. This is
equivalent to the population of the city
of Utica (pop. 59,947, July 1, 2002).
B. Bereavement
“Death by suicide is not a gentle
deathbed gathering; it rips apart lives
and beliefs, and it sets its survivors on a
prolonged and devastating journey.”
(Dr. Kay Redfield Jamison, 1999)
•
82
Research suggests that for those left
behind, losing a loved one to suicide is
Suicide Survivors
Saving Lives in New York Volume 2: Approaches and Special Populations
•
•
Early theologians regarded suicide as a
taboo. Over time, these theological perspectives were translated into both
criminal and civil laws (Grollman,
1988). Statutes were enacted to deter
others from attempting suicide. Not
until 1961 was the act of suicide
removed by the English Parliament as a
type of felony. While recently, the belief
that suicide is a crime has been
changed, it continues to plague those
left behind in its wake. Too often, “suicide became the family secret, the
neighbor’s gossip, and a source of
blame and public shunning.” (Berman
and Jobes, 1991) Despite eradication
from the law books, these pressing
social stigma issues are lingering leftovers from the Victorian era (18401900). Although society no longer
openly punishes suicide survivors, it is
still profoundly difficult for them to
break their silence and give their sorrow words (Knieper, 1999).
Does suicide bereavement differ from
mourning after other types of death?
Comparative research has yet to establish
a difference in kind. There are three
facets to consider: different grief reactions, postvention and needs assessment.
•
C. Responding to Bereavement: A
Practice Model
•
Research on the needs of suicide survivors is limited. Within this population,
it is hard to obtain random samples,
quantitative data is incomplete and a
low response rate is characteristic.
Ellenbogen and Gratton found that
research was hampered by concepts
that are not operationalized, sample
sizes that are too small, measures misused, underlying theories left unclear,
refusal rates are high, and white,
upper/middle class female grievers
over- represented. Besides, why should
we presume that a specific set of reactions will be elicited by every act of
completed suicide? (Ellenbogen and
Gratton, 2001)
•
Provini, Everett and Pfeffer, 2000 state:
“relatively little is known about the perceptions of the needs and types of help
desired by adults who have experienced suicides by relatives.” We do
know that survivors ask the same
questions, search for motives, and the
reason for the death. They often deal
with issues of sin and whether their
loved one has an afterlife. Many even
deny that it was a suicide. Because of
guilt and often little social support,
many do not share the suicide with
those around them. However, research
suggests that a primary need of survivors is to share thoughts and feelings
in a ‘safe’ environment where they will
not be judged.
•
Kay Redfield Jamison poses the questions: “How do people survive such
impassable grief and rage? How do
they keep from being destroyed by guilt
and sorrow that they sacrifice the
remainder of their own lives for the
1. Different grief reaction: Are there any
significant trends within the survivors’
population? The grief response may
indeed run deeper for suicide than for
other modes of death.
2. Postvention: Postvention consists of
activities that help reduce the after
effects of the traumatic event in the
lives of survivors. “Postvention is
prevention for the next generation”
(Schneidman, 1997).
3. Needs Assessment: Survivors’ needs
will tell us if there are any unique problems and kinds of help required. “If we
can identify what is different about suicide from other losses, yet common to
most or all suicide bereavement, we
should be able to plan more targeted
and effective interventions in the population.” (Jordan, 2001).
Suicide Survivors
Future research that addresses these
and related questions will certainly
assist social workers working to help
guide people through what is one of
the most difficult grief experiences. And
it may even help suicide survivors find
answers to the one question that does
unite them – “why?”
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Saving Lives in New York Volume 2: Approaches and Special Populations
one lost earlier to suicide?” There are
many ways: the support of family and
friends, religious faith, the passage of
time, psychotherapy or counseling. One
of the most effective has been through
the establishment of self-help groups
for those who have survived another’s
suicide.” (Jamison, 2001) (See chapter
on Resilience)
Support groups are effective for at least
four reasons:
1.
Normalization. One of the most significant and helpful realizations for a survivor of suicide to have is that his feelings are normal, given the situation. In a
group setting, it is reassuring to hear that
others share their fears and their losses,
and that it is not pathological to feel this
way. In fact, it is perfectly normal.
2. Understanding. This begins when the
person starts to open up. By telling
his/her story – by verbalizing it - they
are beginning a process of organizing
thoughts and feelings. This may be the
first step in understanding the “whys,”
“what ifs,” and “why didn’t I?”
3. Monitoring. The third benefit is monitoring suicide risk. Given the link
between the suicide of a family member and the increased risk for other
family members, this is a critical benefit. Peer support groups may simultaneously provide healthy role models for
grieving survivors while increasing
social support.
4. Finally, making sense of the suicide of a
loved one is an emotional journey.
Support groups provide educational
resources to help educate survivors
regarding the nature of suicide and suicide bereavement. Coming together to
share and interact with other survivors
may be their first step in the journey
toward healing.
There are three issues to consider regarding the impact on survivors of the mode of
death:
84
1. Results suggest bereaved suicide
survivors endure overwhelming psychosocial changes, placing them at a
higher health risk than those whose
loved ones died of natural causes
(Constantino, Sekula, and Rubinstein, 2001). Suicide survivors may
avoid intense emotional or stressful
situations, but when they can’t be
avoided the individual may shut
down emotionally. This can lead to
additional health problems. A wide
range of symptoms has been identified: tearfulness, sleep disturbances,
irrational behavior and depression.
Regarding this latter condition, up to
50% of bereaved individuals can
develop major depression.
2. Those working in suicide postvention must recognize that the cognitive sets of the individuals and
his/her thoughts about the current
situation can serve to increase or
decrease their own susceptibility to
suicide. Survivors may fear the possibility that they too will complete
suicide. A family history of suicide is
a significant risk factor. In 1864, Professor John Ordronaux lectured an
audience of students at Columbia
College in New York City “so potent
in fact is the influence of hereditary
transmission in the production of
suicide that not less than one-sixth
of all recorded cases have been
traced to this source.” This statistic
has transcended time. (Jamison,
1999)
3. Survivors are left to sort out the complex emotions of trying to understanding what has happened. They
may over or under-react to daily life
situations, perhaps in socially unacceptable ways. These reactions can
pose obstacles to daily functioning
and interfere with personal happiness and relationships. Some survivors suffer from low self-esteem,
not only from the reactions and stigma of family and friends, but from
misunderstanding their own grief
related responses. Some may abuse
Suicide Survivors
Saving Lives in New York Volume 2: Approaches and Special Populations
drugs and alcohol as a maladaptive
way of coping with their loss.
The problem: How do we best offer emotional support, compassion, assist in promoting self-help and resiliency, and
encourage family and community networks?
in need. It is critical to find way to
reach them using police, EMTs, coroners, funeral home directors – rather
than waiting for them to call.
•
Outcome measures should help identify
if the time schedule and means of
engagement are reaching those who
actually need assistance. Process evaluation is critical to gauge the effectiveness of the intervention.
•
Success in suicide postvention will
probably arise by tailoring interventions
to specific client needs. Most important,
there is no cookbook.There is no universal principle regarding how to
respond in postvention. One can speak
of understanding, but never with precision. When the subject matter is
postvention after suicide, we can be no
more accurate or scientific than the
available ways of responding and the
subject matter permit. Yet, understandably, the yearning for a universal prevention law persists. A sweeping psychological statement with a ring of
truth, such as ‘postvention is group
therapy’ becomes a dictum, a platitude.
The search for a singular universal
response to trauma is chimera. There is
no one method of postvention.
(Leenaars & Wenck, 1998).
•
One survivor has concluded after 20
plus years of life after a suicide: Grief is
something that never truly goes away.
It remains one of the few things that
still has the power to silence us. Loss is
forever and two decades after Eddie’s
death, I still find myself sometimes crying out at his continuous presence of
his absence. However, what was once
a massive, weighty ball of grief has
now become smaller and more manageable. It gets tucked away into one of
my pockets. It’s there so I remember
that I must not forget. But certainly the
outcome of any postvention support
may well be the reaching out of “old
survivors” to “new survivors” as they
begin their journey...” (Coleman, 2003)
IV. Action Steps:
•
We must understand that surviving the
loss of a loved one is a slow process
that doesn’t come easily or painlessly.
The survivor must be heard, feel understood, to be able to reconnect to a
community.
•
Science of biology has enabled a deeper understanding of suicide and the factors that correlate with suicidal behavior, and the possibility of a genetic
foundation. Those who lose loved ones
to suicide are at greater risk for complicated grief. The impact of suicide and
the isolation from support networks
places survivors of suicide at much
greater risk for suicide themselves.
•
Survivors need short and long term
help themselves. Communities need to
be pro-active and not reactive to the
needs of survivors. Social supports and
the access to them are important considerations. A service contract for
working with groups of suicide survivors must ensure availability, accessibility, accountability, integrity, quality,
and comprehensive coordination.
•
Survivors may need a variety of services, including a mix of access to suicide
prevention/crisis hotlines; support
groups composed of others who share
grief experience; referrals to professional counselors; destigmatizing suicide
through education.
•
Implementation is not a one-time
effort. Postvention programs must
extend over a number of months and
require constant monitoring and
improvement. The biggest hurdle may
be that their grief is so absorbing that
survivors do not seek help when most
Suicide Survivors
85
Saving Lives in New York Volume 2: Approaches and Special Populations
Appendix
Eddie
I found myself sad, when asked if I had any poems
about my brother.
I wish he could, have seen something good,...that
the demons didn’t bind him.
I’d not written a one, since he picked up that gun,
..nor had I written of mother.
Because today he would be, a father probably, with
the torment he felt behind him.
She too passed away, though not the same way;
death’s hand still won the deal.
We’d all have spaghetti, with Uncle Eddie, invited
for dinner at 3:00.
Brought now to attention, I sit down with intention, to share the thoughts that I feel.
And then after we ate, we’d all stay up late, and
watch a little t.v.
My feelings is, that his life was his, and...I guess
that gave him the right,
And occasionally, he might share with me a football game, or a beer.
What I don’t understand, with a gun in his hand,
was why he wasn’t willing to fight.
But his horrible choice, silenced the voice, which I
now would treasure to hear.
As his lowest level, he turned to the devil, without
even knowing he had.
I know what he hated, but I wish he had waited,
because life often turns on a dime.
He hated here, I say through a tear, as I too have
felt that sad.
And I now wouldn’t be, presently, grieving my
brother in rhyme.
So I can see, how it came to be, but that doesn’t
lesson the pain.
So I guess you could say, that still today, some
twenty years after the fact,
And I have to ask, regarding the past, was there all
that much to gain?
I mourn him still, and always will, until I get him
back.
A mother destroyed, a family’s void, and they all
say “rest in peace.”
Then that is that, no going back; it’s all in the
suicide lease.
86
Sandi Reed-Barrett
November 2001
Suicide Survivors
Saving Lives in New York Volume 2: Approaches and Special Populations
References
Bailley, S., Dunham, K., & Kral, M. (2000). Factor structure of the
grief experience questionnaire. Death Studies. 24 (8), 721739.
Bongar, B. (1996). The Suicidal Patient: Clinical and legal standards of care. Washington, DC: American Psychological
Association.
Berman, A.L., & Jobes, D. (1997). Adolescent Suicide:
Assessment and intervention. Washington DC: American
Psychological Association.
Bland, D. (1994). The Experiences of Suicide Survivors 1989-June
1994. Baton Rouge, LA: Baton Rouge Crisis Intervention
Center.
Cain, A.C. (Ed.). (1972). Survivors of Suicide. Springfield, IL:
Charles C. Thomas.
Callahan, J. (2000). Predictors and correlates of bereavement in
suicide support group particiants. Suicide and Life
Threatening Behavior, 30 (2), 102-124.
Campbell, F. (1997). Changing the legacy of suicide. Suicide and
Life Threatening Behavior, 27, (4), 329-338.
Carlson, T. (2000). Suicide Survivors Handbook. Duluth, MN:
Benline Press.
Constantino, R., Sejula, K., & Rubenstein, E. (2001). Group intervention for widowed survivors of suicide. Suicide and Life
Threatening Behavior, 31 (4), 428-441.
Doka, K. & Gordan, J. (1996). Living with Grief After Sudden Loss.
Bristol, PA: Taylor & Francis.
Ellenbogen, S. & Gratton, F. (2001). Do they suffer more?
Reflections on research comparing suicide survivors to other
survivors. Suicide and Life Threatening Behavior, 31 (1), 8390.
Gilbert, K. (1996). We’ve had the same loss, why don’t we have
the same grief? Loss and differential grief in families. Death
Studies, (20), 269-283.
Grollman, E. (1998). Suicide: Prevention, intervention, postvention.
Boston, MA: Beacon Press.
Hoff, L.A. (1995). People in Crisis: Understand and Helping. San
Francisco, CA: Jossey-Bass Publishers.
Hoyert, D.L., Kochanek, K.D., & Murphy, S.L. (1999). Deaths: Finals
data for 1997. National Vital Statistics Report, 47 (19).
Hyattsville, MD: National Center for Health Statistics.
DHHS Publication No. (PHS) 99-1120.
Jamison, K. (1999). Night falls fast: Understanding Suicide. New
York, NY: Random House, Inc.
Suicide Survivors
Jordan, J. (2001). Is suicide bereavement different? A reassessment of the literature. Suicide and Life Threatening
Behavior, 31 (1), 91-102.
Knieper, A. (1999). The suicide survivor’s grief and recovery.
Suicide and Life Threatening Behavior, 29, (4), 353-364.
Leeners, A. & Wenckstern, S. (1998). Principles of postvention:
Applications to suicide and trauma in schools. Death
Studies, (22), 357-391.
Lott, D. (2000). Risk management with the suicidal patient.
Psychiatric Times, 17 (8)
Murphy. (2000). The use of research findings in bereavement programs: a case study. Death Studies, 24 (7), 585-603.
Parkes, C. (2002). Grief: lessons from the past. Death Studies,
(26), 367-385.
Provini, C., Everett, J.R. & Pfeffer, C.P. (2000). Adults mourning suicide: Self-reported concerns about bereavement, need for
assistance, and help seeking behavior. Death Studies, 24
(1), 1-19.
Range, L. & Knott, E. (1997). Twenty suicide assessment instruments: evaluations and recommendations. Death Studies,
21 (1), 25-51.
Reed, M. (1998). Predicting grief symptomology among the suddenly bereaved. Suicide and Life Threatening Behavior, 28
(3), 285-301.
Stevens, R. (1995). Everybody Hurts: Coping with our son’s
suicide. Hong Kong: Kings Time.
Stillion, J. & McDowell, E. (1996). Suicide Across the Lifespan:
Premature Exits. (2nd Ed). Washington, DC: Taylor and
Francis.
U.S. Public Health Service, The Surgeon General’s Call to Action
to Prevent Suicide. Washington, DC: 1999.
Williams, J. & Ell, K. (1998). Mental Health Research.
Washington DC: NASW Press.
Yalom, I. (1995). The Theory and Practice of Group Psychotherapy.
New York, NY: Harper Collins Publishers, Inc.
World Wide Web References:
http://www.cdc.gov
http://www.hhs.gov
http://www,mentalhealth.org/suicideprevention/survivorfacts.asp
http://www.psych.org/public_info/teenag~1.cfm
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Saving Lives in New York Volume 2: Approaches and Special Populations
New Mothers
Janet Chassman
Bureau of Public Education and Outreach
New York State Office of Mental Health
I. Findings
There were 258,455 births in New York in
2000. While new mothers are not generally
considered to be at high risk of suicide,
serious postpartum mood disorders that
require hospitalization are associated with
death from natural and unnatural causes.
•
Like all health and mental health services, screening and treatment for PPD
must be culturally appropriate to be
effective.
B. Risk Factors for PPD
•
Previous incidence of PPD (50%
will re-develop PPD)
Postpartum depression (PPD) is the
most common disorder after childbirth.
More women develop depression following birth than at any other time.
•
Previous depression (25% will
develop PPD)
•
Previous bipolar disorder
•
PPD is a treatable illness, but it is often
unidentified by health care professionals.
•
Depression during pregnancy
•
•
50-80% of new mothers get the “baby
blues,” depressive symptoms which
resolve within 12 days after birth. 20%
of these women will develop PPD.
Depression or bipolar disorder
in the family
•
Previous significant premenstrual
syndrome (PMS)
•
Stressful situations, including difficult
childbirth, health problems in the baby
or mother, marital discord, lack of
assistance with baby care, and lack
of emotional support
A. Prevalence and Patterns
•
•
10-15% of mothers - 22% of multiethnic
inner city mothers -develop PPD.
•
.1%-.2% (one in 1,000 or 2 in 1,000) of
new mothers develop postpartum psychosis, a serious disorder characterized
by paranoia, mood shifts, and/or hallucinations or delusions. Immediate medical attention is required.
•
Besides the symptoms experienced by
the mother, PPD may affect the mother-infant interaction and may lead to
problems as the baby grows.
New Mothers
C. Barriers to Identifying
and Treating PPD
•
In general, those who screen for PPD
(e.g. obstetricians) do not provide evaluation and treatment (e.g. mental
health clinics). This makes access to
appropriate care more complex.
89
Saving Lives in New York Volume 2: Approaches and Special Populations
•
Stigma of mental health treatment
•
Medical personnel receive little or no
training in identifying PPD
•
Family members may fail to recognize
PPD
•
Mothers may not seek treatment due to
lack of energy caused by the illness,
stigma and/or feeling guilty about
being depressed when she is supposed
to be “happy.”
•
A prenatal depression question was
added to the Statewide Perinatal Data
System.
III. Action Steps
II. Current State Efforts
•
•
90
The Healthy Families New York (HFNY)
program provides home visiting services
by trained home visitors who work with
expectant families and families with
newborns who have certain risk factors
that may lead to child abuse and neglect
and poor health outcomes. Home Visitors provide weekly home visits until the
child is at least six months old and may
continue less frequently based on the
needs of the family until the child is five
years old or in school or Head Start. Visits are aimed at promoting positive parent-child interaction and optimal child
health and development. Home visitors
also assist in linkage to other services to
increase the families’ self-sufficiency.
The HFNY program is currently located
in 28 sites serving high need areas
across the state.
Association of Perinatal Networks of
New York received a grant to create
training programs and resources to
increase awareness of PPD and
increase service utilization.
•
Information on PPD has been added to
the Maternity Information leaflet, disseminated to all obstetrical hospitals
statewide, and to “Your Guide to a
Healthy Birth,” which is also available
to pregnant women statewide.
•
The Pregnancy Risk Assessment Monitoring System (PRAMS), a national
screening program, now includes a
question on PPD.
1. There are strong risk factors for postpartum depression (PPD), and prenatal/perinatal screening can help to
identify those most likely to develop it
as well as deliver services to them in
the hospital with follow-up to start right
after delivery. Obstetricians, pediatricians and other medical personnel in
contact with new mothers should
screen mothers for PPD during the
child’s first year.
2. Home visiting services have been
shown to be effective in improving outcomes for children. All at-risk new
mothers should receive home visitations services and be screened for postpartum depression, including follow-up
care for women who screen positive
and an emergency protocol for women
in a peri-suicidal state or homicidal
state. Involvement of the new mother’s
partner or support person in their treatment is highly desirable.
3. A media campaign that highlights the
prevalence and risk factors for postpartum depression, linkages to service
providers and training inevidencebased treatment for post-partum
depression are necessary ingredients of
a prevention program.
References
American Association of Health Plans: Current Issues Report,
Approaches to Depression Care. Washington, DC; AAHP,
2000.
American College of Obstetricians and Gynecologists, Answers to
Common Questions about PPD. January 2002.
www.acog.org
Georgiapoulos, AM, Bryan, TL; Wollan, P; Yawn, BP. Routine
Screening for PPD Journal of Family Practice, 50 (2), 2001.
Moline, ML; Kah, DA; Ross, RW; Altshuler, LL; Cohen, LW. PPD: A
Guide for Patients and Families, Expert Consensus
Guideline Series. A Postgraduate Medicine Special Report,
March 2001, 112-113.
Sobey, WS, Barriers to PPD Prevention and Treatment: A Policy
Analysis Journal of Midwifery & Women’s Health, Vol.47,
no.5, Sept/Oct. 2002, 331-336.
New Mothers
Saving Lives in New York Volume 2: Approaches and Special Populations
New York Men
in the Middle Years
Gary L. Spielmann, M.A., M.S.
Director of Suicide Prevention
New York State Office of Mental Health
In late August, 2003, the 55 year old president and chief executive officer of a major
bank in western New York, who was also
chairman of a university board of trustees,
went home from work and killed himself. It
was the second suicide of a prominent
local resident in less than three weeks. Colleagues and friends said both men were
hard workers and high achievers who had
been troubled recently by public embarrassments. While it is tempting to say that
these upsetting circumstances caused the
men’s suicides, experts warn, it’s not that
simple. (Neville: 2003)
It is not surprising that both victims were
males. Men outrank women in all of the 15
leading causes of death, except one:
Alzheimer’s disease. In fact, men’s death
rates are at least twice as high as women’s
for suicide, homicide, and cirrhosis of the
liver. At every age, according to a study
published in the May 2003 issue of the
American Journal of Public Health, American
males have poorer health and a higher risk
of mortality than females. (DR Williams,
The Health of Men: Structured Inequalities
and Opportunities) More of them smoke
(although women are catching up), drink
heavily and are far more likely to engage in
behaviors that put their health at risk, from
abusing drugs to driving without a seat
belt. Men also drive more rollover-prone
SUVs and suffer more motorcycle fatalities.
(Sanjay Gupta, M.D.: 2003)
Men in the Middle Years
Another reason may be deeply rooted cultural belief: a “macho” world view that
rewards men for taking risks and tackling
danger head on. (Ibid.) In other words,
males are praised for “being in control” of
the situation, even when it is inherently
dangerous or challenging. Could the suicide of these prominent western New Yorkers have been prompted by their sense of
loss of control over a situation they were
expected to master, but could not? Could
they, like thousands of other successful
people who die from suicide seemingly out
of the blue, have actually suffered from
depression? It’s likely to have been a contributing factor, if not the root cause, since
mental disorders are involved in 90-95% of
all suicides.
According to Dr. Richard Carmona, Surgeon General of the United States, about 6
million men have clinical depression, but
research shows they are less likely to seek
treatment than women. Many men do not
realize that some health symptoms may be
caused by depression. For generations,
men have been told that they have to act
tough. As a result, men tend to self-medicate, and avoid going to see a physician,
even when their symptoms are acute. The
result: men are four times more likely to
die from suicide as women in New York. Is
it another manifestation of men wanting to
control the situation that they typically use
more lethal means to die, thereby leaving
less to chance?
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Saving Lives in New York Volume 2: Approaches and Special Populations
Figure 1
Figure 2
New York Suicides by Gender
2002, all races, all ages
New York Suicide Rates
by Age and Gender
2002, all races.
16
Males
(n=989) (81%)
14
14.63
13.62
12
Rate per 1,000
11.62
Females
(n=239) (20%)
10
8
6
4
2
2.62
0.38
0
The differences between males and
females with respect to suicidal behavior
holds across the life course as shown in the
following chart of suicide rates.
In terms of sheer numbers of deaths, middle year males experience by far the largest
number of suicides in New York. This is
shown in Figure 3.
15-24
Years
25-54
Years
55-85+
Years
Males
Females
Source: CDC, WISQARS, 2005
Figure 3
New York Suicide Prevalence
by Age and Gender
2002, all races.
600
562
500
400
Actual
The typical suicide death in New York is a
white, middle-age male who resides alone,
upstate, suffers from depression, and uses a
firearm to end his life. Forty percent of all
suicides in New York in 2000 fit this demographic profile. While elderly white males
(>65) die at a higher rate, those in the middle
years die in the largest numbers. (NYSDOH:
2001) By contrast, there were zero suicides
among black women older than 65 and
none among Hispanic women, ages 25-34
and older than age 75. (NYSDOH: 2001)
3.56
0.17
1-14
Years
Source: CDC, WISQARS, 2005
3.25
300
267
200
153
100
10
0
1-14
Years
140
33
63
3
15-24
Years
Males
25-54
Years
55-85+
Years
Females
Source: CDC, WISQARS, 2005
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Men in the Middle Years
Saving Lives in New York Volume 2: Approaches and Special Populations
There are significant differences in the suicide rates of males depending on their race
as illustrated by the following:
Figure 4
New York Suicide Rates
in Males by Race
2002, ages 25-54.
These men died at a rate (13.63/100,000)
more than twice the statewide average for
the general population (6.42). The rates in
descended order by race:
White (15.38/100,000)
African-American (9,41)
Native-american (7.19)
Others (6.3)
Source: CDC, WISQARS, 2005
16
15.38
14
Rate per 1,000
12
10
8
6
9.41
7.19
6.3
4
2
0
African
Native
American American
White
Other
Source: CDC, WISQARS, 2005
Based on the foregoing:
In 2002, death by suicide among New York
males, ages 25-54:
•
Was the 3rd leading cause of death for
those ages 25-34; 5th leading cause of
death for those ages 35-44; and 6th
leading cause of death for those ages
45-54.;
•
Comprised 45.7% of all suicides in New
York that year (562/1228);
•
Constituted 57% of all male suicides
across the lifespan (562/989); and
•
Occurred at a rate (13.63/100,000) that
was 29% higher than for all males
(10.7); 4x the rate for female cohorts
(25-54), and nearly 6x the rate for
females overall (2.42).
Men in the Middle Years
Risk factors common to both males and
females in the middle years are: Major psychopathology, Depression and alcohol
use/dependence, Interpersonal disruptions,
Social isolation, Poor work performance
and unemployment, Violence and legal
problems, Variable impact of marital and
parental status, Prior suicide attempts and
Family history of suicide(ED Caine, MD,
2005)
A distinct sub-population of would-be suicides are white males who appear to harbor little suicidal risk. For them, untreated
depression can magnify a personal reversal
such as bankruptcy, arrest, a career setback
or a personal scandal, and propel a person
into a death spiral. Many of these individuals are outwardly successful and their
record of achievement can find them illprepared for a perceived failure. Lacking
experience in coping with “failure,” and
feeling a sense of shame at letting others
down - of losing all they have achieved they see their deaths as relieving their families of a burden. In such cases, an underlying mental illness can and does distort their
thinking and lead them to rationalize their
self-destruction.
The fear of emotional disintegration - of
lives unraveling, collapsing or falling apart
- has been described as greater than the
fear of death itself. For many desperate
people, death seems to be the only way to
attain both relief and control. (Hendin et al:
2004) A similar scenario has unfolded on
college campuses where high-achieving,
even brilliant students from privileged
backgrounds become trapped by selfimposed perfectionistic expectations and
resort to suicide.
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Saving Lives in New York Volume 2: Approaches and Special Populations
The impact of premature death is immeasurable in many ways, especially for family
and loved ones. It is also an enormous loss
for the society and economy in which they
live. Dr. Eric Caine and colleagues have
calculated the economic value of such losses in terms of lost earnings. These lost
earnings peak in value nationally at about
age 37, to the sum of $1.8 billion. The YPLL
for American women are fewer due to their
much lower suicide rate, higher health consciousness, and less risk-taking. Overall,
women are “early adopters” of good health
habits, whereas men tend to be “late
adopters.”
career and family responsibilities grow.
“Central to this task (of preventing suicide)
will be the installation of interventions earlier in the course of individual episodes of
(mental) illness, such that the emergence of
a suicidal state is precluded... (Such activities could take place) at work sites, mental
health and chemical dependency treatment
settings, primary medical settings, religious
and community programs, the courts and
criminal justice sites, as well as state and
federal supported program sites.” (Caine
and Conwell: 2003) However, even as one
embraces this population-based approach,
it is critical to maintain a focus on those
with greatest needs (i.e. high-risk groups).
Preventive Interventions
Drs. Eric Caine and Yeates Conwell at the
University of Rochester Center for the Study
and Prevention of Suicide (CSPS) have
advanced a multi-layer prevention strategy
for men, ages 25-54. Following the National Strategy for Suicide Prevention, they
advocate a comprehensive approach to
saving men’s lives. These involve universal
measures (covering the whole male population), selective (for those at risk), and
indicated measures (for those in imminent
danger). Taken together, these are intended
to diminish the risk factors leading to suicide, and enhance the protective factors
leading to life-affirming behavior.
As men move out of the early adult years
into middle age, issues regarding work,
Past suicide prevention efforts were decidedly one-sided, focusing almost entirely on
those who were imminently suicidal and in
great distress. Interventions were often in a
personal crisis environment, often in emergency rooms (ERs), intensive care units
(ICUs), psychiatry clinics, inpatient services,
or the offices of mental health clinicians.
Little attention was focused on the much
larger number of asymptomatic males in
the general population, who were at risk
for suicide but unrecognized to be as such.
As noted, compared to women, males are
disinclined to seek regular checkups and
physicals. Even if they did, primary care
practitioners are sometimes reluctant or
unable to bring up issues of mood, suicidal
Figure 5
Suicide Prevention for Men, Ages 25-54
Peri-suicidal state
Symptoms,
Resiliency
Role changes, medical illness, acute and chronic stress
Suicide
Risk
Depression, hopelessness
Personality factor, social ecology, cultural values and perceptions
ìDistal ”
Risk factors
Time
94
“Proximal”
Source: Caine and Cronwell CSPS, 2003
Men in the Middle Years
Saving Lives in New York Volume 2: Approaches and Special Populations
thoughts or behaviors that could lead to a
diagnosis of clinical depression.
Depression Among Men
Depression remains a subject that neither
physician nor patient seems eager to tackle. It is the leading cause of disability
worldwide among persons older than 5
years. (NIMH: 2001) Major depression is
second only to ischemic heart disease in
terms of disease burden (morbidity and
mortality) in the developed world, including
the United States. The cost of reduced productivity in the workforce from untreated
depression is $52 billion nationwide. (J.
Clin. Psych: 2002) Major depression is the
psychiatric condition most associated with
suicide. (AAS: 2001) 60% of suicides occur
in the context of a depressive episode and
most were not being treated with antidepressants at the time of death (Mann:
2002). Depression is treatable in 80 to 90%
of cases, yet only 30 to 50% of depressed
individuals are diagnosed properly by their
primary care physicians. A majority are
“half-treated” (Kessler: 2003) There seems
to be a treatment gap between what is
needed for recovery and what is available.
New York health consumers are not satisfied with the situation. Last year, enrollees
in New York’s health plans rated treatment
of depression among the lowest of 18
physical or behavioral health condition in
their coverage. According to the New York
State Health Accountability Foundation,
only 23% of patients on average had multiple followup visits in the first three months
after being diagnosed with depression and
only 44% were treated with antidepressants
for at least six months.
antidepressant prescription rates and have
4 times the suicide rate of females. Most of
those who die by suicide are found to have
major depressive disorder at the time of
death as either untreated or receiving subtherapeutic doses of antidepressants.
(Grunebaum, M.F., Ellis, S.P.,Li, S, Oquendo,
M.A., Mann, J.J., MD,: 2004) . For all types of
antidepressant (SSRI, TCA, and others),
women’s usage exceeds their male counterparts use by a wide margin, as shown in
the following :
Figure 6.
Prescription Antidepressant Use
by Medication and Gender,
1997-2000
In response, the New York Health Plan
Association, which represents 19 HMO’s
and eight prepaid health service plans, said
they were “aggressively addressing depression treatments with providers, and future
report cards should reflect improvement in
that area.” (New York State HMO Report
Card: 2004)
A recent nationwide study concluded that
depression intervention strategies should
address the fact that males have lower
Men in the Middle Years
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Saving Lives in New York Volume 2: Approaches and Special Populations
The following shows that this ‘usage gender gap’ holds true across the lifespan:
Figure 7.
Antidepressant Prescription Usage
by Gender.
The ‘gender gap’ in antidepressant usage
has grown in recent years, as SSRI’s have
come to dominate the market of prescribed
medications for depressive disorders.
Figure 8.
SSRI antidepressant drug visits
among adults 18 years of age
and over by sex: United States,
1995-2002.
Inadequate treatment for depression is not
confined to New York or to the male population. Evidence indicates that primary care
physicians tend to under-recognize and
under-treat mood disorders in general.
(IOM: 2002) Even when properly diagnosed, one recent study published in the
Archives of Internal Medicine found that
many depressed people were not receiving
the care they need. While prescribing antidepressants remains a sound course of
treatment, many doctors failed to appropriately monitor their patients, many of whom
did not feel better after weeks and months
of drug therapy. Previous research has
found that appropriate diagnosis and quality care are lagging in the primary care setting. A lack of resources and time, reluctance on the part of primary care physicians to screen for depression, and unfamiliarity with how to administer drugs for
depression are some of the reasons for this
“treatment gap.” (Altan: 2004)
This inadequate treatment results in a phenomenon known as “presenteeism” whereby people show up for work but are largely
unproductive because they are depressed.
This problem could stem from the lack of
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Men in the Middle Years
Saving Lives in New York Volume 2: Approaches and Special Populations
follow-up monitoring by doctors, the high
cost of continuing treatment, or the fact
that many reluctant patients don’t like to
see themselves as having chronic depression and drop out of treatment too soon.
(Munoz: 2003)
Adding to the gravity of the situation is the
recent finding that the risk of suicide is
greatest when patients begin taking an
antidepressant medication. Previous thinking was that the risk was greatest in the
days after antidepressant therapy was discontinued. The study found no difference in
risk between newer and older drugs. “It’s
starting treatment itself, more than what
drug you start with, that’s the important
factor.” (Carey: 2004)
Disorders of the central nervous system,
such as Epilepsy, AIDS, Huntington’s Disease, head injuries and cerebrovascular
accidents, carry a much higher relative risk
of suicide. Many of these occur after age
25. They may trigger depression and suicidal ideation and may impair restraint or
inhibition of the desire to act on such
thoughts. (Mann: 2002) Moreover, a history
of physical or sexual abuse during childhood, a history of head injury or neurological disorder, and cigarette smoking
increase the risk of suicide. (Mann: 2002)
Public health officials in Washington
appear to be following the lead of former
Surgeon General David Satcher who did
much to raise the profile of suicide as a
national health issue. The National Institute
of Mental Health has launched a campaign
to raise awareness that men, too, suffer
from depression and that they need to seek
help (See Appendix). Called Real Men, Real
Depression, the campaign includes a series
of multi-media public service announcements featuring people telling their personal stories about how they confronted their
own depression. Its intent is to attack the
stigma that “tough guys can’t seek help.”
They can and they should, according to Dr.
Richard Carmona, Dr. Satcher’s successor.
“Today we’re saying to men, it’s OK to talk
to someone about what you’re thinking, or
how you’re feeling, or if you’re hurting.”
(MSNBC: 2003)
Men in the Middle Years
By taking an integrated approach - combining attention to high-risk individuals
and the broader population that has not yet
manifested suicidal thoughts or deeds - we
can hopefully reduce the overall suicide
rate for men in the middle years. In addition, an educational intervention for primary care physicians to improve recognition and treatment of mood disorders may
lower suicide rates, (Ibid.) Finally, the study
supports the need for enhanced screening
and treatment.
We need not wait for more fundamental
research findings to begin our suicide prevention work with the male population. We
know enough about the risks and precursors of suicide to intervene actively and
encourage those in need to seek treatment.
In the words of Charles Curie, the administrator of SAMHSA: “We need to raise (public) awareness that help is available, treatment is effective, and recovery is possible.”
References
Altan, DJ, “Follow-up care found lacking in treatment for depression,” Los Angeles Times, July 2, 2004.
Caine,E.D. M.D. and Knox, K.L., Ph.D., Preventing Suicide and
Reducing the Burden of Suicidal Behaviors, University of
Rochester: CSPS, 2003
Caine, E.D., M.D., Suicide Risks and Prevention: Presentation to
Psychiatry Grand Rounds. New York State Office of Mental
Health. September 17, 2003
Caine, E.D., M.D., Suicide Prevention in 2005 - Moving from
Identified Risk Factors to Prevention Programs, University of
Rochester Center for Study and Prevention of Suicide.
Presentation to National Council on Suicide Prevention,
New York City, January 20, 2005
Carey, B., “Study of Antidepressants Finds Little Disparity in
Suicide Risk.” The New York Times, July 21, 2004
Centers for Disease Control and Prevention (CDC),
WISQARS, 2005
Grunebaum, MF, Ellis, SP, Li, S, Oquendo, M, and Mann, JJ,
“Antidepressants and Suicide Risk in the United States,
1985-1999, “ Journal of Clinical Psychiatry, 65:11,
November 2004, 1456-1462
Gupta, S, M.D. Why Men Die Young. Time, May 4, 2003
Lewis, G., Hawton, K., and Jones, P. (1997), Strategies for
Preventing Suicide, British Journal of Psychiatry, 171, 351354
Hendin, Herbert, MD et al., Desperation and Other Affective
States in Suicidal Behavior, Suicide and Life-threatening
Behavior, 34 (4), Winter 2004, 386-394
Kessler, Ronald, MD, Results of the National Cormorbidity Study,
JAMA, 6/18/03
Mann, J.John, MD, A Current Perspective of Suicide and
Attempted Suicide. Annals of Internal Medicine. 2002; 136;
302-311
MSNBC, Men Need to Talk About Depression. October 23, 2003
(www.msnbc.com/news/893794.asp)
Munoz, SS, Cost to Treat a Depression Case Falls, The Wall
Street Journal, December 31, 2003
Neville, A. The Specter of Suicide, Buffalo News, August 26,
2003
97
Saving Lives in New York Volume 2: Approaches and Special Populations
New York State Department of Health, Resident Deaths due to
Suicide by Race/Ethnicity, Sex and Age, 2000 Vital
Statistics, Table 43. 2001
Substance Abuse and Mental Health Services Administration
News, News: National Strategy Seeks to Prevent Suicide,
Vol. X, No.4, Fall 2002News:
The New York State Health Accountability Foundation, New York
State HMO Report Card (2004)
Williams, DR The Health of Men: Structured Inequalities and
Opportunities, American Journal of Public Health, May
2003. Vol. 93, No.5, 724-731
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Men in the Middle Years
Saving Lives in New York Volume 2: Approaches and Special Populations
Appendix
Real Men. Real Depression
National Institute of Mental Health
Men and Depression
Depression is a serious but treatable medical condition that can strike anyone
regardless of age, ethnic background,
socioeconomic status, or gender. However,
depression may go unrecognized by those
who have it, their families and friends, and
even their physicians. Men, in particular,
may be unlikely to admit to depressive
symptoms and seek help. But depression in
men is not uncommon: in the United States
every year, depressive illnesses affect an
estimated seven percent of men (more
than six million men).
Depression comes in different forms, just
as is the case with other illnesses such as
heart disease. The three main depressive
disorders are: major depressive disorder,
dysthymic disorder, and bipolar disorder
(manic-depressive illness). Not everyone
with a depressive disorder experiences
every symptom. The number and severity
of symptoms may vary among individuals
and also over time.
Symptoms of depression include:
•
Persistent sad, anxious, or "empty"
mood
•
Feelings of hopelessness, pessimism
•
Feelings of guilt, worthlessness, helplessness
Men in the Middle Years (Appendix)
•
Loss of interest or pleasure in hobbies
and activities that were once enjoyed,
including sex
•
Decreased energy, fatigue, being
"slowed down"
•
Difficulty concentrating, remembering,
making decisions
•
Trouble sleeping, early-morning awakening, or oversleeping
•
Appetite and/or weight changes
•
Thoughts of death or suicide, or suicide
attempts
•
Restlessness, irritability
•
Persistent physical symptoms, such as
headaches, digestive disorders, and
chronic pain, which do not respond to
routine treatment
Research and clinical findings reveal that
while both men and women can develop the
standard symptoms of depression, they often
experience depression differently and may
have different ways of coping. Men may be
more willing to report fatigue, irritability, loss
of interest in work or hobbies, and sleep disturbances rather than feelings of sadness,
worthlessness, and excessive guilt.
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Saving Lives in New York Volume 2: Approaches and Special Populations
Some researchers question whether the
standard definition of depression and the
diagnostic tests based on it adequately capture the condition as it occurs in men.
Men are more likely than women to report
alcohol and drug abuse or dependence in
their lifetime; however, there is debate
among researchers as to whether substance use is a "symptom" of underlying
depression in men, or a co-occurring condition that more commonly develops in
men. Nevertheless, substance abuse can
mask depression, making it harder to recognize depression as a separate illness that
needs treatment.
Instead of acknowledging their feelings,
asking for help, or seeking appropriate
treatment, men may turn to alcohol or
street drugs when they are depressed, or
become frustrated, discouraged, angry, irritable and, sometimes, violently abusive.
Some men may deal with depression by
throwing themselves compulsively into
their work, attempting to hide their depression from themselves, family, and friends;
other men may respond to depression by
engaging in reckless behavior, taking risks,
and putting themselves in harm's way.
Four times as many men as women die by
suicide in the United States, even though
women make more suicide attempts during their lives. In light of research indicating that suicide is often associated with
depression, the alarming suicide rate
among men may reflect the fact that men
are less likely to seek treatment for depression. Many men with depression do not
obtain adequate diagnosis and treatment,
which may be life saving.
ing depressive symptoms in men and helping them get treatment.
Seek Help for Depression
If you are having symptoms of depression
or know someone who is, seek help. There
are several places in most communities
where people with depressive disorders
can be diagnosed and treated. Help is
available from family doctors, mental
health specialists in mental health clinics or
private clinics, and from other health professionals.
A variety of treatments, including medications and short-term psychotherapies (i.e.,
"talking" therapies), have proven effective
for depressive disorders: more than 80 percent of people with a depressive illness
improve with appropriate treatment. Not
only can treatment lessen the severity of
depression, but it may also reduce the
duration of the episode and may help prevent additional bouts of depression.
For More Information
National Institute of Mental Health
Public Inquiries
6001 Executive Boulevard
Room 8184, MSC 9663
Bethesda, MD 20892-9663
Toll-Free: 1-866-227-NIMH (6464)
FAX: 1-301-443-4279
TTY: 1-301-443-8431
E-mail: nimhinfo@nih.gov
Website: http://www.nimh.nih.gov
NIH Publication No. 03-5297
Printed March 2003
Department of Health & Human Services
National Institute of Mental Health
More research is needed to understand all
aspects of depression in men, including
how men respond to stress and feelings
associated with depression, how to make
them more comfortable acknowledging
these feelings and getting the help they
need, and how to train physicians to better
recognize and treat depression in men.
Family members, friends, and employee
assistance professionals in the workplace
also can play important roles in recogniz-
100
Men in the Middle Years (Appendix)
Saving Lives in New York Volume 2: Approaches and Special Populations
Cultural, Ethnic and Racial Groups
Janet Chassman, Bureau of Public Affairs & Community Outreach,
New York State Office of Mental Health
&
Cathy Cave, Director, Multicultural Affairs,
New York State Office of Mental Health
I. Findings
New York is arguably the most culturally
diverse state in the nation. The borough of
Queens in the City of New York is the most
ethnically diverse large county in the United States. According to the 2000 Census,
46% of Queens residents are foreign born.
Its 2.2 million residents are drawn from
more than 90 countries and speak 138 different languages. However, very little is
known about suicide rates, mental health
status, and the effectiveness of mental
health treatments in ethnic and linguistic
minorities because few studies have been
done on the subject.
While the following recommendations refer
to the four most recognized cultural minorities (African-Americans, Hispanics, Asian
American/Pacific Islanders, and Native
Americans/Alaska Natives), there is great
diversity within these groups. For example,
Asian Americans/Pacific Islanders speak
over 100 different languages; Native Americans/Alaska Natives come from over 500
tribes, Hispanic persons are from Puerto
Rico, Cuba, Mexico, or any Central or South
American country, and include a significant
number of immigrants. African-Americans
are diverse as well, with some descendants
from populations that were brought to the
U.S. more than 200 years ago, while others
recently emigrated from the Caribbean,
South America and Africa.
Cultural, Ethnic and Racial Groups
The following items summarize research
findings and expert opinion.
General information on ethnic and racial
minorities:
•
While suicide rates vary between people of different cultural backgrounds,
rates of mental illness are generally
similar across ethnic groups.
•
Evidence-based treatments have not
been sufficiently tested on individuals
from diverse cultures. Therefore, effectiveness across cultures is not known
and cannot be assumed.
•
Ethnic minorities are under-represented
among recipients of mental health services. It is well documented that these
individuals are less likely to seek mental
health treatment than whites. Asian
Americans/Pacific Islanders have the
lowest utilization rate of all minorities.
•
Studies have consistently documented
disparities in the health and mental
health treatment of minorities that
remain after controlling for income,
insurance, and clinical factors.
•
Ethnic minorities are more likely to
seek assistance from community members, natural supports, and traditional
healers. When they do seek treatment,
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Saving Lives in New York Volume 2: Approaches and Special Populations
it is more likely to be from a primary
care physician than a specialist.
•
Mood disorders and substance abuse
disorders, both highly correlated with
suicide, are very prevalent among
some ethnic/racial minorities, and are
believed to be more influenced by environmental factors than other mental illnesses. Ethnic minorities also have
higher rates of post-traumatic stress
disorder, possibly due to an elevated
exposure to violence.
•
Ethnic minorities who belong to other
at-risk populations, e.g. lesbian, gay,
bisexual or trans-gender youth, may be
at increased risk for suicide.
•
Ethnic minorities face inequality that
includes greater exposure to discrimination and poverty, which, in turn, may
contribute to mental illness.
•
Cultural minorities are over-represented among populations who are poor, in
jail, homeless, HIV/AIDS positive, and
exposed to violence/trauma.
•
Symptom presentation may be different
in various cultural groups, which may
lead to mis-diagnosis and inappropriate
treatment. There may be “culturebound syndromes” only seen in persons of particular ethnic groups.
•
Poverty and lack of health insurance
make health and mental health care less
accessible to many minority persons.
•
Other risk factors cited: lack of cultural
and spiritual development, loss of ethnic identity (especially for Native Americans), and acculturation -the adopting
of a majority culture by minorities or
the loss of ethnic culture.
•
While some cultural minorities have
expressed greater comfort in being treated by health care professionals of the
same ethnic background, there is a shortage of minority health care providers.
A. Prevalence and Patterns
•
The rate of suicide for American Indians/Alaska Natives is 1.5 times higher
than the national rate. Native American
males aged 15 to 24 have a rate two to
three times the national suicide rate.
•
The rate of suicide among African
American males aged 10-14 jumped by
233% between 1980 and 1995, compared to a 120% increase for white
males of the same age.
•
Statistics report that whites are twice
as likely to commit suicide as AfricanAmericans. However, the incidence of
“suicide by cop” has led to a mis-classification of this behavior as a homicide.
Among the elderly, African-American
women have a lower suicide rate than
their white counterparts. Possible reasons are the protective role of spirituality among them, and their extended role
as care givers to their family, especially
their grandchildren.
•
Asian American women have the highest suicide rate of all women over 65.
Of girls in grades 5-12, Asian American/Pacific Islanders show the highest
level of depressive symptoms.
•
While the reported suicide rate for Hispanics is lower than the general population, a national survey found
increased levels of suicidal ideation and
attempts among Hispanic high school
students.
B. Risk and Protective Factors
102
The greatest risks for suicide in the general
population as well as among ethnic and
racial minorities are depression and substance abuse disorders. Exposure to violence and other traumatic events creates a
suicidal risk, as does access to firearms. In
addition, risk factors that disproportionately
affect minorities include: poverty, immigration, violence, racism, and discrimination.
Protective factors for minorities include:
supportive families, strong communities,
spirituality and religion.
Cultural, Ethnic and Racial Groups
Saving Lives in New York Volume 2: Approaches and Special Populations
II. Current State Efforts
methods recommended are to form
linkages with varied communities and
to meet the language needs of the
recipients to be served.
New York’s initiatives include the following:
•
Tiered Certification – Cultural competence is one of eight stated values
underlying the certification process for
OMH-licensed mental health programs.
Certified programs are expected to
ensure that “human rights, cultural differences and the dignity of those served
are preserved.”
Following are examples of survey guidelines:
•
Program employs staff who are of the
same or similar ethnicity or culture as
the recipients served, by: screening
potential candidates for cultural competence; recruiting culturally competent
staff; and providing staff training to foster staff’s cultural competence and ethnic awareness.
•
Multi-cultural training should include
in-service training on: cultural and ethnic differences of the program recipients; culturally appropriate treatment
practices; and the program’s approach
to working with culturally diverse service recipients.
•
OMH has compiled a directory of staff
proficient in several languages that has
been disseminated to all State-operated
mental health programs.
•
OMH Core Curriculum, a mandatory
training program for all psychiatric center staff, includes a section on cultural
competence.
•
In 2001, OMH created the position of
Cultural Competence Coordinator.
•
OMH collects data on service utilization
by race/ethnicity by program type, e.g.
type of emergency, inpatient, outpatient, residential, and community support.
•
Integrating cultural competence is part
of the OMH strategy for change as stated in the agency’s 5.07 Plan. Some
Cultural, Ethnic and Racial Groups
•
Project Liberty, developed by OMH to
meet the needs of communities, families and individuals affected by the
events of 9/11, offered services, outreach and information in several languages.
•
Building Effective Relations in a Diverse
Workplace train-the-trainer program
was provided to OMH in 2000.
•
Cultural competence considerations in
treatment have been the topic of
statewide training programs.
III. Action Steps
1. Imbue cultural competence in all prevention strategies. New York is
arguably the most culturally-diverse
state. Varying cultures regard mental
illness quite differently. To engage these
populations, we need to appreciate
those differences and design programs
and services that reflect cultural understanding.
2. Develop community-based suicide prevention and mental health wellness
outreach programs that are culturally
appropriate, multi-disciplinary and
delivered by community members.
3. Increase the cultural competence of
health care and mental health care professionals and staff.
4. Implement culturally appropriate suicide screening and prevention training
for medical and mental health professionals and staff, including emergency
room staff.
5. Evidence-based treatments have not
been sufficiently tested on individuals
from diverse cultures. Therefore, their
effectiveness across cultures is not
known and cannot be assumed.
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Saving Lives in New York Volume 2: Approaches and Special Populations
6. Collect and report data on access and
utilization of health and mental health
care, including disparity measures by
race, ethnicity, primary language,
socioeconomic status, age, gender,
sexual orientation, geographic location,
housing situation, and criminal justice
involvement. Also monitor progress
toward elimination of disparities, and
increase the dissemination of strategies
proven to be effective across cultural
and linguistic groups.
7. Invest in research to identify and
overcome disparities in mental
health service utilization and treatment of minorities.
104
References
American College of Mental Health Administration, Summary of
Conference Proceedings, Santa Fe Summit (NM), August 28,
2003
Collins, KS, Hughes, DL, Doty, MM, Ives, BL, Edwards, JN,
Tenney, K, Diverse Communities, Common Concerns:
Assessing Health Care Quality for Minority American:
Findings from the Commonwealth Fund 20021 Health Care
Quality Survey, March 2002
Smedley, BD, Stith, AY, Nelson, AR, eds. Unequal Treatment:
Confronting Racial and Ethnic Disparities in Health Care,
Committee on Understanding and Eliminating Racial and
Ethnic Disparities in Health Care, Board on Health Sciences
Policy, Institute of Medicine, National Academy (of
Sciences) Press, Washington, DC
The President’s New Freedom Commission on Mental Health
Final Report: Achieving the Promise: Transforming Mental
Health Care in America. Washington, DC July 2003
US Department of Health and Human Services (1999), Mental
Health: A Report of the Surgeon General, Rockville, MD
US Department of Health and Human Services (2001), Mental
Health: Culture, Race and Ethnicity: A Supplement to
Mental Health - A Report of the Surgeon General of the
United States, Public Health Service, Office of Surgeon
General
Cultural, Ethnic and Racial Groups
Saving Lives in New York Volume 2: Approaches and Special Populations
Recipients of Mental Health Services
Laurie Flynn and Roisin O’Mara,
The Carmel Hill Center Division of Child and Adolescent Psychiatry,
Columbia University
I. Findings.
New York State’s mental health system is
working to embrace the goals of the President’s New Freedom Commission on Mental Health (2003): that mental health is
essential to overall health; mental health
care is consumer and family-driven; disparities in mental health services are eliminated; early mental health screening and treatment in multiple settings are important;
care offered is the best science can provide;
and information technology can help us
access care.
Besides preventing suicides among recipients of mental health services, we must
also work toward reducing suicide
attempts and disease morbidity. The burdens of mental illnesses, such as depression, alcohol dependence and schizophrenia have been seriously underestimated by
traditional approaches in public health that
take account only of deaths and not disability. Psychiatric conditions account for
almost 11 per cent of disease burden
worldwide. By 2020, it is estimated that the
second leading cause of disability among
the general population will be unipolar
depression; among women it will be the
first (World Health Organization, 1999).
This is the context within which we consider how to improve the improve the experiences of mental health recipients and
reduce their mortality from suicide
Specific groups of recipients have a significantly increased rate of suicide. Those
diagnosed with depression, schizophrenia
and schizoaffective disorder are at elevated
risk. Estimates of suicide rates range from
6% in broadly depressive samples to as
many as 25% among severely depressed or
bipolar patients (Tondo et al., 2001).
Approximately 50% of patients with schizophrenia or schizoaffective disorder attempt
suicide, and about 10% of them die by suicide (Meltzer, H. et al., 2003). A small proportion of those suffering from a severe
mental illness actually receive treatment,
so we must first ensure that individuals
who seek treatment are given adequate
care in hopes that their risk for suicide will
be lowered. We also need to strengthen
our outreach to those not currently receiving services who could benefit from them.
The U.S. mental health system is complex
and connects to many sectors (public -private, speciality-general health, social welfare, housing, criminal justice, and education). As a result, care may become organizationally fragmented, creating barriers to
access. The system is also financed by many
funding streams, adding to the complexity,
given sometimes competing incentives
between funding streams. (U.S. Surgeon
General, Mental Health: A Report. 1999)
One of the most compelling predictors of
suicide is a previous attempt. If a recipient
Recipients of Mental Health Services
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Saving Lives in New York Volume 2: Approaches and Special Populations
of mental health services moves from one
provider to another and their previous suicide attempt history is not shared, this puts
the recipient at risk. We need to address
the need for long-term case management
and continuous care in some cases, as in
depression. The chronic nature of depression places its suffers in a life-long elevated
risk for suicide. Our system needs to greatly improve its integration, communication
and co-operation so that consumers are
not allowed to “fall through the cracks.”
Loss of hope is also an important predictor
of suicide. Seriously ill patients, are vulnerable to homelessness and social isolation.
Over 80% are unemployed and poverty is,
for them, often the norm.
106
sion or anxiety disorders are extremely
common, yet treatable, will encourage
help-seeking behavior among those suffering from mental health problems. Education programs like NAMI’s “Family to Family” and “In Our Own Voice” for consumers,
as well as community outreach like Red
Flags, Yellow Ribbons, SOS, etc. all help
bring light to issues surrounding depression and suicide risk.
Mental health services are best delivered
using a partnership approach. Forging a
therapeutic alliance depends on mutual
respect between a client and provider and a
realistic assessment of needs and assets.
Self-help should be the first pillar of recovery. This is particularly needed when the
other pillars - family and community - are
disconnected or dysfunctional. Key to selfhelp is development and use of natural support networks - individuals and organizations from which people seek advice and
support. They provide a listening post that
people can access when they need to talk
or seek guidance and understanding. They
provide information to members of their
communities as a community service and
would likely provide assistance to recipients
living in the community. Together, they can
build “islands of resilience.” (Allen: 2003)
Individuals diagnosed with a mental illness,
particularly mood disorder, can benefit
greatly from membership in a peer-led support group. A recent article by Sheffield
(2003) discussed the benefits of referral to
peer support groups to both patients with
mood disorders and their physicians. Consumer surveys indicate that peer-led support
groups improve communication between
patients and physicians, increase medication
compliance and reduce crises. Similar
groups for family members provide relatives
with accurate information, enabling them to
participate constructively in treatment decisions and act as an early warning system at
home. The benefits to physicians include
avoiding many of the drawbacks commonly
associated with the treatment of depression,
such as poor professional education about
depression and inadequate time to evaluate
and treat depression. The author recommends that physicians should become more
active in informing patients of the benefits of
support groups; and mental health organizations that run support groups should seek
the involvement of physicians in their communities.
Education of consumers, their families and
the community will help advance the long
term goal of reducing stigma associated
with having a mental illness and receiving
services for it. Increased education will
empower consumers to become more
active partners in their own treatment. If
recipients of mental health services
become engaged in their own treatment
and receive education about their mental
illness, its management, potential side
effects of medication and alternative possibilities for intervention, they stand a better
chance of recovery. Receiving education
explaining how illnesses such as depres-
By educating, involving and supporting the
family of a person with a mental illness we
stand a much better chance for successful
outcomes. Of special importance is supporting the family of children and adolescents with mental disorders. These services
enable children with mental health problems to remain at home and in the community. Families need to be educated
specifically in suicide prevention - know
the signs of depression and suicidal
ideation, remove lethal means from the
home, restrict access to alcohol, develop
an emergency plan - should a family member attempt suicide.
Recipients of Mental Health Services
Saving Lives in New York Volume 2: Approaches and Special Populations
Increasing education in the community is
essential if we are to move forward in our
plan to prevent suicides in New York State.
New York’s citizens need to be educated
and engaged in the goal of preventing suicide and treating mental illness, especially
among our younger population, where suicide is the third leading cause of death
among 15-24 year olds (Centers for Disease
Control and Prevention, 2000). By educating and encouraging recipients of mental
health services, their families and the community, in addition to moving mental
health services into the community and
integrating mental and physical health
services, we can look forward to a future
where mental illness is as widely accepted
and treated as physical illness.
Recipients of Mental Health Services
References
Allen, John, Enhancing Outreach Efforts through Indigenous
Natural Support Networks, (Prepared for Project Liberty),
OMH, Albany, NY: 2003 (8 pp.)
Centers for Disease Control and Prevention. (2000) WISQARS
Leading Causes of Death Report. (Available at
http://webapp.cdc.gov/sasweb/ncipc/leadcaus10.html).
Edlund, MJ; Wang, PS; Berglund, PA; and Katz, SJ.,(2002).
Dropping out of mental health treatment patterns and predictors among epidemiological survey respondents in the
United States and Ontario. The American Journal of
Psychiatry, 159 (5), 845-851.
Kessler, RC, Ph.D. et al. (2005), “Trends in Suicide Ideation, Plans,
Gestures, and Attempts in the United States, 1990-92 to
2001-03, JAMA, 293 (20), 2487-2495
Meltzer, HY; Alphs, L; Green, AI; Altamura, AC; Anand, R; Bertoldi,
A; Bourgeois, M; Chouinard,G; Islam, MZ; Kane, J; Krishnan,
R; Lindenmayer, JP; and Potkin, S. Clozapine treatment for
suicidality in schizophrenia: International suicide prevention
trial (Inter SePT). Archives of General Psychiatry, 60 (1), 82-91.
New York State Office of Mental Health (2002). Statewide
Comprehensive Plan for Mental Health Services, 2002-2006.
Rickert, A. and Ro, K. (2003). Mental Health Parity: State of the
States, April 2003 Update.
Sheffield, A. (2003). Referral to a Peer-Led Support Group: An
Effective Aid for Mood Disorder Patients. Primary Psychiatry,
10 (5) 89-94.
The President’s New Freedom Commission on Mental Health
(2003). Achieving the Promise: Transforming Mental Health
Care in America. (Available at: http://www.mentalhealthcommission.gov/)
Tondo, L; Hennen,J; and Baldessarini, RJ; (2001). Lower suicide
risk with long-term treatment in major affective illness: A
meta-analysis. Acta Psychiatrica Scandinavica. 104 (3), 163172.
US Department of Health and Human Services. (1999). Mental
Health: A Report of the Surgeon General. Rockville: SAMHSA, CMHS, National Institutes of Health
Wang, PS; Demler, O; Kessler, R. (2002). Adequacy of treatment
for serious mental illness in the United States. American
Journal of Public Health, 92(1), 92-98
World Health Organization (1999). The Global Burden of Disease:
A comprehensive assessment of mortality and disability
from diseases, injuries and risk factors in 1990 and projected to 2020. (Available at
http://www.who.int/msa/mnh/ems/dalys/intro.htm.)
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Saving Lives in New York Volume 2: Approaches and Special Populations
Dually Diagnosed
(Substance Abuse and Mental Illness)
Jennifer Berryman, Ph.D.
Lisa Blackwell, Ph.D.
Connie Kinch, M.S.
Vigita Reddy, Psy.D.
Greater Binghamton Health Center
New York State Office of Mental Health
•
In any given year, approximately 10
million people in the United
States have a substance-related disorder and at least one other mental illness. (SAMHSA/NAC, 1997)
In a Veterans Administration study,
investigators found 77% of suicide completers who were diagnosed with substance abuse had an additional diagnosis, most commonly, an affective disorder (39%). Of patients who completed
suicide, 5% had a co-morbid psychosis
and substance abuse; 67% of people
with PTSD who completed suicide had
a co-morbid disorder, usually an affective disorder or substance abuse.
(Lehmann, McCormick & McCracken,
1995)
•
Psychological autopsies have found
that over 90% of all completed suicides
in all age groups are associated with
psychopathology (Shaffer et al., 1996).
Approximately two-thirds of suicide
completers suffered from either a mood
disorder or alcoholism.
B. Risk Factors
Goal 8 of the National Strategy for Suicide
Prevention is to improve access to and
community linkages with mental health
and substance abuse services. It is
designed to prevent suicide by ensuring
that individuals who are at high risk due to
mental health and substance use problems
can receive prevention and treatment services.
I. FINDINGS
A. Overall Rates and Patterns
•
•
•
Approximately one-half of those diagnosed with a psychiatric disorder also
have a substance abuse problem
(NAMI).
•
51% of suicide completers have both
substance abuse and mood
disorders (Suominen et al., 1996)
•
Suicide in alcoholics is largely dependent on the co-occurrence of a depressive episode.
Dually Diagnosed
The risk of suicide is often increased in
people with co-occurring disorders who
may present with multiple risk factors at
any given time. For example, the individual
may be non-compliant with medication, be
infected with HIV, and experiencing command hallucinations. The individual may
be at greater risk for cognitive problems
due to extensive substance abuse or lack
supportive relationships due to stigma
associated with having a psychiatric and
substance abuse disorder.
Typical risks for this population are: trauma
history, cognitive/ neurological problems,
family history of suicide, history of losses
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Saving Lives in New York Volume 2: Approaches and Special Populations
and deaths, history of medication noncompliance, impulsive behavior, history of
psychosis, chronic medical problems,
chronic pain, difficulty controlling or
expressing anger, history of self-injury, and
a criminal history.
severe substance disorder. Locus of
care: primary health care settings.
Quadrant II
More severe mental disorder/less
severe substance disorder. Locus of
care: mental health system
C. Precipitating Factors
This includes losses of many kinds, such as
physical health, vocational, financial, psychological, interpersonal (one-third had a
relationship loss within six weeks of completing suicide), access to weapons, current
medication non-compliance, substance
abuse, suicidal ideation, shame, guilt,
humiliation, command hallucinations, suicide by friend or family member, pain,
hopelessness, recent trauma or abuse,
family conflict.
Quadrant III
Less severe mental disorder/more
severe substance disorder. Locus of
care: alcohol and other drug treatment
facility
D. Protective Factors
Individuals located in Quadrant IV are
most at-risk and New York State. As
such a Quadrant IV Task Force was
jointly supported by the NYS Office of
Mental Health (OMH) and Office of
Alcohol and Substance Abuse Services
(OASAS) and it produced a report, Treatment of Co-Occurring Mental Health and
Addictive Disorders in New York State: A
Comprehensive View (May 2001). The
report contains an action plan that
addresses problems such as the need
for integrated treatment, stigma, funding issues, and staff competency.
Many factors can decrease the risk for suicide by those with a dual diagnosis. Among
them are: cognitive flexibility, good coping
skills, strong social support, hopefulness,
hobbies and interests, short-term plans,
ability to develop alternatives to self-harm,
good compliance with treatment, hobbies
and interests, sobriety, education of primary care physicians, media education,
lethal means restriction, screening of atrisk youth, and school-based skills training
for students.
Quadrant IV
More severe mental disorder/more
severe
substance disorder. Locus
of care: “No man’s land”(joint alcohol
and mental health systems).
E. The New York Model
New York State has taken great strides in
improving care and treatment for individuals with co-occurring disorders. Some of
the evidence of progress is as follows:
1. Evidence-Based Practices
The New York Model is a framework
for describing symptom severity, locus
of care, and level of service integration
needed among mental health, substance abuse, and primary health care
systems.
The Model consists of four quadrants with
the locus of care for each:
Quadrant 1
Less severe mental disorder/less
110
2. Additionally, OMH has directed its psychiatric centers to provide evidencebased treatments (EBT). A SAMHSA
Evidence Based Practice Implementation Kit for Co-Occurring Disorders is
being developed and will be distributed
to adult psychiatric centers. The Kit will
include: Fidelity scales, a user’s guide,
workbook, practice demonstration
video tapes, and recipient outcome
measures.
3. Other evidence-based practices being
implemented in New York State should
also have a positive impact:
SAMHSA’s Wellness Self-Management
EBP plan is beginning to be implemented in New York State’s psychiatric cen-
Dually Diagnosed
Saving Lives in New York Volume 2: Approaches and Special Populations
ters. Although the curriculum is not
designed specifically for the co-occurring patient, it addresses many risk factors for suicide such as relapse, stress,
medication compliance, and relationships. It can be an important part of
treatment for those with a co-occurring
disorder.
4. New York State has funded Dual
Recovery Coordinators who bring
together administrators and service
providers from substance abuse, mental health, corrections, and social service agencies to address current issues
in the treatment of co-occurring disorders. Action plans are being developed
and efforts have already begun to
improve services. Issues being
addressed include: housing, standardized assessment instruments, funding,
training and competencies for both
agencies (OMH, OASAS).
5. Improve training and assessment to
increase identification of mood disorders and suicide risk factors.
II. ACTION STEPS
1. Promote access to mental health and
substance abuse treatment. Treatments
for mental disorders and substance
abuse are increasingly effective. The
New York Model is a proven approach
to improving care and treatment for
individuals with co-occurring disorders.
Early interventions that are evidencebased also reduce the need for emergency health care services and costs.
Avoided costs could also be expected in
law enforcement, corrections, and
social services. Most importantly,
access to early interventions could prevent pain and suffering among those
affected by mental disorders and substance addiction.
2. Promote greater awareness of cooccurring psychiatric and addictive disorders, and the consequent risk of suicide to this population among
providers, law enforcement, corrections, and homeless shelter personnel,
Dually Diagnosed
general public, emergency room physicians, and family members.
3. Increased integration and co-operation
between substance abuse and mental
health services, and between public
and private care systems. Poorly coordinated treatment among multiple
providers is a real barrier to recovery.
Long-term case management is one
way to ensure continuity of care involving chronic illnesses like depression
and addiction.
4. Dual recovery coordinators and interagency workgroups can provide integrated treatment that decreases both
homelessness and hospitalization for
those diagnosed with mental illness
and addiction disorders. This involves
treatment of both disorders in one setting at the same time. Treatment can
consist of outreach, pharmacological
treatment, mental health and substance abuse counseling, group treatment, family psycho-education and
community-based self-help. Train more
individuals in the New York Model and
other evidence-based practices; provide
more appropriate housing for those not
yet abstinent; and assist with transportation and medical needs of the
dually diagnosed.
5. Share the results of the Seeking Safety
program developed by Dr. Lisa Najavits
at Harvard Medical School/McLean
Hospital. It is the first integrated program for persons who, in addition to
being dually diagnosed, also suffer
from Post-Traumatic Stress Disorder.
6. Screen chemical dependency patients
for depression or mood changes, and
violence toward an intimate partner or
spouse.
7. Educate and train family members and
community gatekeepers to detect
changes in those at suicidal risk outside
the clinical care systems. Signs include
reduced performance in the workplace
and unexplained absences from work or
school. Knowing how and where to
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Saving Lives in New York Volume 2: Approaches and Special Populations
respond and refer individuals for treatment should be part of the training.
Gatekeepers would include health, mental health, substance abuse, social work
and human service professionals and
lay people including clergy, teachers,
correctional workers, coaches, youth
workers, nurses’ aides, and faith leaders.
8. Substance abuse is a significant risk
factor for suicidal behavior, especially
among older adolescent males. Strategies to tighten teenage access to alcohol have successfully decreased youth
suicidal behavior. Besides raising the
legal drinking age to 21, stricter
enforcement of such laws can deter
risky behavior, as can increased surveillance.
2511-2518.
Rich, C.L., Fowler, R.C., Fogarty, L.A. & Young, D. (1988). San
Diego suicide study: III Relationships between diagnoses
and stressors. Archives of General Psychiatry, 45, 589-592.
Shaffer, D.A., Gould, M.S., Fisher, P. et al. (1966). Psychiatric
Diagnosis in Child and Adolescent Suicide. Archives of
General Psychiatry, 53, 339-348.
Suominen, K., Henriksson, M.M., Suokas, J. et al., (1996). Mental
Disorders and co-morbidity in attempted suicide. Acta
Psychiatrica Scandinavica, 94, 234-240.
Weiss, R.D., & Hufford, M.R. Substance abuse and suicide. In
D.G. Jacobs (ed.) The Harvard Medical School Guide to
Suicide Assessment and Intervention. (pp. 300-310). San
Francisco: Jossey-Bass, Pfeiffer.
REFERENCES
Clark, D.C. & Goebel-Fabbri, A.E. (1999). Lifetime risk of suicide in
major affective disorders. In D.G. Jacobs (ed.), The Harvard
Medical School Guide to Suicide Assessment and
Intervention, pp.300-310, San Francisco: JosseyBass/Pfeiffer.
Dalton, E.J., Cate-Carter, T.D., Mundo, E., Parikh, S.V. & Kennedy,
J.L. (2003). Suicide risk in bipolar patients: The role of comorbid substance abuse disorders. Bipolar Disorders, 5, pp.
58-61.
Drake, R.E. & Mueser, K.T. (2001). Co-occurring alcohol use disorder and schizophrenia. Retrieved on 6/16/03 from
http://www.niaaa.nih.gov/publications/arh 262/99/102/text.htm.
Jamison, K.R. (1999). Suicide and manic depressive illness: An
overview and personal accounts. In D.G. Jacobs (ed.), The
Harvard Medical School Guide to Suicide Assessment and
Intervention (pp.251-269), San Francisco:
Jossey/Bass/Pfeiffer.
Lehmann, L., McCormick, R.A., & McCracken, L. (1995). Suicidal
behavior among patients in the VA health care system.
Psychiatric Services, 47(10), 1069-1071.
Marzuk, P.M. & Mann, J.John. (1988). Suicide and substance
abuse. Psychiatric Annals, 18, 639-645.
McHugh, G.J., Mueser, K.T., & Drake, R.E. (2001). Treatment of
substance abuse in persons with severe mental illness. In
H.D. Brenner, W. Boewker, et al. (eds.) The Treatment of
Schizophrenia: Status and Emerging Trends, (pp. 137-152).
Kirkland, WA, Hogrefe and Huber Publishers.
Mueser, G.J., Drake, R.E., & Noordsy, D.L. (1998). Integrated mental health and substance abuse treatment for severe psychiatric disorders. Journal of Practical Psychology and
Behavioral Health, May, 129-139.
Murphy, G.E., Armstrong, J.W., Jr., Hermele, S.L. et al., (1979).
Suicide and Alcoholism: Interpersonal loss confirmed as a
predictor. Archives of General Psychiatry, 36, 65-69.
Najavits, L.M. (2002). Seeking Safety: A Treatment Manual for
PTSD and Substance Abuse. New York: Guilford Press.
Pirkis, J. & Burgess, P. (1998). Suicide and recency of health care
contacts: A systematic review. British Journal of Psychiatry,
173, 462-474.
Regier, D.A., Farmer, M.E., Rae, D.S. et al., (1990). Co-morbidity of
mental disorder with alcohol and other drug abuse: Results
from the Epidemiologic Catchment Area (ECA) study.
Journal of the American Medical Association, (JAMA),
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Saving Lives in New York Volume 2: Approaches and Special Populations
Elders*
Yeates Conwell, M.D.
Professor of Psychiatry & Associate Chair for Academic Affairs
University of Rochester School of Medicine
&
Co-Director, Center for the Study and Prevention of Suicide
Suicide among older people is a major
public health problem here in New York
and across the United States. In 2002, the
suicide rate for elders (age 55 and up) was
24 % higher than the rate for New Yorkers
under the age of 55.* * In coming decades
it is likely to take an even greater toll on
senior citizens and their families. The
determined and aggressive nature of selfdestructive behaviors in late life makes suicide an especially challenging problem to
address. The challenge must be taken up
on a variety of fronts simultaneously.
Key Trends
The Office of Mental Health’s (OMH) analysis of population projections prepared from
2000 U.S. Census data identifies five major
trends that will have a major impact on the
mental health needs of New York elders in
the next ten years. (NYSOMH: 2002)
1. Increased Racial and Ethnic Diversity.
While New York’s projected population
growth of 4.2% between 2000 and
2015, is expected to be among the lowest in the nation, significant changes
will occur in the composition: the
group of older New Yorkers will
increase faster, up 19%, and be more
diverse than any preceding old age
group in terms of ethnicity, income
level, education, family configurations,
living arrangements and health. Minority elderly populations will increase the
fastest: black, non-Hispanic (up 27%);
Hispanic (up 76%); and Asian/Pacific
(up over 110%).
2. Weakened Family Support Structures.
The large cohort of baby boomers moving into the older population will be
more likely than the preceding cohort
to enter old age without spouses, and
more will be childless or parents of
only children. Still, more grandparents
will be involved in the raising of their
grandchildren, and the most significant
mental health problem for this group is
depression, with one in four grandparent care givers nationally experiencing
a significant level of depression.
3. Major Growth in Two Important
Groups. Rapid population growth of
younger and older minority populations, as well as major growth in the
older worker and pre-retirement populations as the baby boomers age out is
expected. Cultural factors, immigration,
socioeconomic status, language and literacy will need to be considered in
designing responses to the mental
health needs of the elderly in the future.
* Adapted from Yeates Conwell, M.D. Suicide in later life: a review and recommendations for prevention. Centers for Disease Control
and Prevention. Suicide Prevention Now: Linking Research to Practice. CD-ROM. Atlanta, GA: 2001, 79-99
** CDC, NCIPC, Wisqars Injury Mortality Report, 2002, New York (2005)
Elders
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Saving Lives in New York Volume 2: Approaches and Special Populations
4. Dramatic Increases in Dementia. One of
the fastest rising age groups will be those
85 and older. By 2010, the number of
cases of Alzheimer’s disease and other
dementias will have increased by at least
25 percent. Alzheimer’s disease poses an
enormous burden to health service and
public health resources. Also, improvements in general health and health care
techniques will lengthen the survival of
patients with dementia, increasing the
number of severely affected patients and
raising the level of morbidity among
patients with dementia.
5. More Demand for Care, Less supply of
Care Givers. New York’s dependency
ratio is changing: there are fewer care
givers available for more older persons
needing care. Therefore, the family,
which currently provides 80% of the
long-term care services, will be providing less and the “systems of care” must
provide more. At the same time, we
should recognize that many senior citizens are reluctant to utilize traditional
mental health services which will
require OMH to work with county mental health departments to increase the
accessibility of mental health services
in locations where the elderly reside
and spend their time, especially home
and congregate living situations.
Accomplishing this goal will require
review of regulations and reimbursement methodologies, as well as
focused training of providers in such
issues as the risk/treatment of suicide.(Project 2015:: OMH: 2000)
I. Conclusions
A great deal of pre-intervention research
remains to be done before we have an
adequate understanding of suicide’s pathogenesis in older people. Biological, psychological, and social factors all warrant rigorous study. Even as pre-intervention
research continues, however, the ongoing
loss of senior citizens to suicide demands
that preventive interventions be designed
and implemented. Indeed, major advances
in the identification of modifiable risk factors are being made, and major initiatives
to test the effectiveness of specific preven-
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tive interventions are underway. The recognition and optimal treatment of clinical
depressive illnesses in older people, particularly in primary care settings, must remain
an area of special emphasis.
Outreach to those elders at risk in the community who avoid, or lack access to, medical care is a second important element in
any comprehensive plan for late life suicide
prevention. The cost-effectiveness and
reproducibility of these and other strategies
informed by pre-intervention research must
be tested in rigorously designed randomized, controlled trials. The relatively small
scale of many programs precludes their use
of attempted or completed suicide as outcome measures.
Empirically established risk factors for late life
suicide should be used in those circumstances as the benchmarks against which to
measure success. Opportunities should be
encouraged for programs to collaborate,
sharing methodology and procedures, to
increase the likelihood of observing a significant impact on suicide outcomes. To facilitate
that effort, a national database for suicide
prevention strategies should be established to
serve as a clearinghouse for information
regarding program design and evaluation.
Finally, biased attitudes towards aging,
deficits in knowledge about depression and
suicide on the parts of health care
providers and their older patients, and systemic barriers to mental health care access
make suicide prevention more difficult in
this population than in younger age groups.
A comprehensive approach to suicide prevention in late life, therefore, must include
the creative input of health policy makers
with regard to the financial, medicolegal,
and organizational barriers to effective suicide prevention. It also should include education programs aimed both at health care
providers as well as elderly consumers and
their families. The objectives of the education programs should be to foster an appreciation of healthy aging, improve understanding of signs and symptoms of clinical
depression, and to teach older people and
their support systems about the risks,
warning signs, and treatment responsive-
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Saving Lives in New York Volume 2: Approaches and Special Populations
ness of suicidal ideation and behavior in
late life.
Reduction of late life suicides is a realistic
goal. Creative partnerships of primary care
providers, the mental health care sector,
aging services, and other agencies and
insurers will be needed to achieve it.
cide among elders. Death of a spouse,
loss of companions and socialisolation
are also contributing risk factors.
7. Greater emphasis should be placed in
medical, nursing and social service
training on recognizing and treating
depressive disorders and suicidal states
in elders.
II. Action Steps
1. State policy should reflect the fact that
the suicide rate for elderly (>65)males is
the highest for any sub-population in
New York.
2. Depression is more prevalent among
elders than the general population.
However, it is not a normal part of the
aging process and should be treated
appropriately. Validated, self-administered voluntary screening tools for
depression should be routinely used
with elderly patients in primary care
health offices. Diagnosis and treatment
of depression in elders should be
aggressively pursued in the primary
care practitioner’s office.
3. Gatekeeper programs and telephone
support (warm lines) systems should be
implemented and evaluated as “indicated” preventive interventions for isolated,
high-risk elders. These services should
be part of a comprehensive network of
offerings, including case-finding, acute
response, multi-disciplinary assessments, and other support services.
4. Elders tend to employ more lethal
means of self-harm in the act of suicide. Restricting access to such means
of self-harm as firearms and household
poisons could save lives.
5. Since the vast majority of elders who
die by suicide have seen their health
care provider within 30 days of their
death, it is essential that such visits
include an assessment of suicidal
thoughts, intent and plans they may
have.
6. Chronic pain and debilitating physical
illnesses are frequent precursors to sui-
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8. Research should seek to determine
whether treatments designed to mitigate hopelessness and related effects in
older people are effective in lowering
suicide risk.
9. Include high-risk suicidal elders in controlled clinical trials of preventive interventions, while guaranteeing the ethical conduct of the research and the
rights of the subjects themselves.
III. Prevalence
Older people in the United States have a
higher suicide rate than any other segment
of the population. While the elderly constitute 12.7% of the population in 1998, they
accounted for 19.0% of completed suicides
(Murphy, 2000). The suicide rate for the
general population was 11.3/100,000.
Combined rates for men and women of all
races rose through young adulthood to a
high of 15.5/100,000 in the 40-44 year age
group, plateaued through mid-life, and rose
to a peak of 22.9/100,000 in 80-84 year
olds. The increased suicide risk with aging
is accounted for in large part by the strikingly high rates for white males in later life.
In 1998, the group at highest risk was
white males aged 85 and older, whose rate
of 62.7/100,000 was almost six times the
nation’s age-adjusted average (National
Center for Health Statistics, 2001).
In contrast, rates for women peak in midlife and remain stable, or decline slightly,
thereafter. This pattern is unlike patterns in
most other countries of the world where,
according to statistics reported by the
World Health Organization, later life is the
highest risk for both men and women
(Pearson and Conwell, 1995). Suicide rates
for the general population have remained
relatively stable throughout the second half
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Saving Lives in New York Volume 2: Approaches and Special Populations
of the 20th century. However, rates among
older people declined by up to 50%
between 1930 and 1980 (McIntosh et al;
1994). Optimistic explanations offered for
this decline include increased economic
security for older people resulting from the
implementation of Social Security and
Medicare legislation (Busse, 1994) and the
more widespread and effective use of antidepressant medications (Conwell, 1994).
Others ascribe such variation to generational or cohort effects, a propensity to suicide that is characteristic of a group born
within a specific time frame (Blazer et al.,
1986; Manton et al., 1987). For example,
people who entered old age before 1930
had higher rates of suicide at all points in
the life course than did birth cohorts that
entered late life from 1930 to 1980. If
cohort effects do influence suicide rates,
then the trend for lower suicide risk among
older people would be expected to reverse.
At all ages, the large postwar “baby boom”
cohort has had substantially higher suicide
rates than preceding generations (McIntosh, 1992). As more of these people enter
later life, their suicide rates are likely to rise
above those of the current elderly cohort.
Perhaps presaging this trend, a recent
report by the Centers for Disease Control
and Prevention (CDC) found that the suicide rate for the population aged 65 and
over rose 9% between 1980 and 1992
(MMWR, 1996). Rates among men and
women aged 80-84 showed rises of 35%
and 36% respectively. Some authors have
argued that the size of the baby boom generation may work to the benefit of that
cohort in later life through greater political
influence and accumulated resources
(McIntosh, 1992). Nonetheless, older people are the fastest growing segment of the
population. Haas and Hendin (1983) projected that the number of suicides committed in later life would double by the year
2030 as a function of this demographic
shift alone. There is, therefore, an urgent
need for efficient and effective measures to
prevent suicide in older people.
Havens (1965) characterized suicide as “the
final common pathway of diverse circumstances, of an independent network rather
116
than an isolated cause, a knot of circumstances tightening around a single time and
place.” General understanding of suicide
among older people is often oversimplified,
ascribed to a single factor such as severe
physical illness or depression. The reality is
far more complex. There is no single cause
for any suicide, and no two can be understood to result from exactly the same constellation of factors. As no single factor is
universally causal, no single intervention
will prevent all suicide deaths. The multidetermination of suicide present great challenges but also has important implications
for prevention (O’Carroll, 1993).
IV. Preventive Interventions
Two general approaches to suicide prevention in late life have been identified: public
health or population based strategies, and
high-risk models (Lewis et al., 1997). The
public health model advocates universal
prevention through interventions that have
a potential impact on large segments of a
society. Examples include gun control legislation (Kellerman et al., 1992), detoxification of a domestic gas (Charlton et al.,
1992), or restrictions on access to drugs
with a low therapeutic index (Gunnell &
Frankel, 1994). The high-risk model targets
more highly selected populations. Among
the elderly, two approaches to selective
interventions in high-risk samples have
been proposed: interventions in primary
care settings designed to improve recognition and treatment of depressed and suicidal older patients, and community outreach to isolated elders at risk.
Interventions in Primary Care
The majority of older people at greatest risk
for suicide already have access to health
care services in which preventative intervention should be feasible. At least six
studies conducted in Great Britain and the
United States have demonstrated that from
43% to 76% of older people who committed
suicide saw a primary care provider (PCP)
within 30 days of death (Barraclough, 1971;
Clark, 1991; Carney et al., 1994; Cattell &
Jolley, 1995; Conwell, 1994; Miller, 1976).
From 19% to 49% saw a physician within
one week of their suicide. This observation
is critical for prevention as it suggests a
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Saving Lives in New York Volume 2: Approaches and Special Populations
means for providing access for elders in, or
immediately preceding, the development of
the suicidal state.
Depression is the most common psychopathology associated with suicide in
late life, and the most prevalent mental disorder seen among older patients in primary
care settings. Yet many studies in the medical and psychiatric literature have demonstrated that PCP’s have difficulty recognizing treatable depression in their patients.
Screening tools for depression have been
validated for use in elderly primary care
patients. Such measures should be used
routinely in primary care offices. In addition, greater emphasis should be placed in
undergraduate, graduate, and continuing
medical education on recognition and
effective treatment of depressive disorders
and suicidal states in older people. Since
older people rarely utilize mental health
services, active collaborations between
psychiatry and primary care in medical settings may yield optimal outcomes.
Suicidal people are frequently excluded
from treatment research because of liability
concerns (Linehan, 1997). Without their
participation, we lack the evidence with
which to judge the interventions’ efficacy
and effectiveness at reducing suicidal outcomes. The ethical and medicolegal implications are profound. Nonetheless, it is
important that regulatory mechanisms be
devised that shield investigators from
unjustified liability claims, enabling the
inclusion of individuals at high risk, while
at the same time guaranteeing the ethical
conduct of the research and the rights of
the subjects themselves.
Community Outreach
Although initiatives in primary care settings
promise to provide access for prevention to
the majority of older people at risk for suicide, a substantial minority would slip
through the cracks: those without
resources to pay for care, those who are
homebound and physically unable to
access care, and those who, out of fear and
misunderstanding, choose not to seek help.
For these elders, who may indeed be the
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most vulnerable segment of the population,
outreach is required.
Although older adults are reluctant to use
crisis or “hot” lines, telephone support systems should be tested further as indicated
preventive interventions for the most isolated segments of the elderly population.
However, they must be embedded in a
more comprehensive network that includes
means for case finding, acute response,
multi-disciplinary in-home assessment, and
other support services. Although telephone
services offer a promising means of support to isolated elders, their effectiveness
as a suicide prevention measure hinges on
the availability of other services.
Coupled with education of health care
providers, a public campaign should be
mounted to educate older Americans and
their families about the signs and symptoms of clinical depression and the risks
and warning signs of suicide in late life.
They should be informed of the benefits of
available treatments, and dispelled of the
myths that depression and suicidal ideation
are a “normal” aspect of aging. This campaign should be coupled with the development of gatekeeper programs. These networks of lay people trained to recognize
and refer elders who may be at risk for suicide cannot operate effectively in isolation.
They must be linked to systems capable of
providing a full range of social, medical,
and psychiatric services.
Benefits of Prevention
Prevention of late-life suicide can be
expected to have benefits of reduced morbidity and mortality among the surviving
spouse and other loved ones. There is a
great deal of evidence to suggest that prevention of suicide in older people by
improved recognition and treatment of its
most potent risk factor, depression, will
result in a host of other “ancillary” benefits.
In addition to being at greater risk of suicide, older people with depression have
higher mortality from all causes. Their
functioning is significantly more impaired,
their quality of life is diminished, and utilization of health care resources is greatly
increased.
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A range of studies have confirmed an association between depression and increased
morbidity due to stroke, acute myocardial
infarction, chronic obstructive pulmonary,
hip fracture, Parkinson’s disease, and
arthritis (see review by Katz, 1996). Moreover, depression has been shown to significantly predict mortality at six month and 18
month follow-up of patients with acute
myocardial infarction (Frasure-Smith et al.,
1993, 1995), and to be associated with
increased all-cause mortality in both the
general population (Bruce et al., 1994) as
well as among older people in nursing
homes (Rovner et al., 1991).
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