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Suicide Prevention and Public Health 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 HIS IS THE SECOND OF THREE VOLUMES which together comprise Saving Lives in New York: Suicide Prevention and Public Health, a com- prehensive, data-driven report on suicide, its risks and prevention, Treleased 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 individu- als 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 vol- umes, 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 popula- tions. 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 recom- mendations 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 dis- the brain. Studies 28; 29 have identified orders, with over 90% of suicide victims or abnormalities of the serotonin system in suicide attempters having a diagnosable suicide victims, in a part of the prefrontal psychiatric illness 1-7. However, diagnosis cortex area of the brain located above the alone is not sufficient to explain suicidal eyes and called the ventromedial prefrontal behavior. Clinical studies have found a cortex 30;31. Moreover, this alteration in the range of other factors including aggres- brain has been found to be related to sui- sive/impulsive traits, hopeless ness or pes- cide independently of a history of a major simistic traits, substance abuse and alco- depressive episode 32 indicating that it is holism 5; 8-16, a history of physical or sexual involved in the predisposition to suicide in abuse during childhood 17, a history of many psychiatric disorders. head injury or neurological disorder 18-22, and cigarette smoking 23 all contribute to The ventromedial prefrontal cortex is increased risk for suicidal behavior 24-27. involved in the executive function of behavioral and cognitive inhibition 33. A stress-diathesis model attributes suicidal Injuries to this brain area can result in dis- behavior to the coincidence of stressors, inhibition 34. Such disinhibition can be such as onset of a depressive episode, with manifested by a disregard for social stric- a diathesis, or predisposition, for suicidal tures or requirements in terms of polite- behavior. Pessimism, aggression/impulsivi- ness, job performance, impulsive aggres- ty, and suicidal intent have been identified sion or suicide depending on the circum- as three elements of the diathesis for suici- stances or emotional state. Low serotoner- dal behavior 25. These diathesis factors are gic input into this part of the brain may due to both genetic and environmental contribute to impaired inhibition, and thus causes, and neurobiological studies have create a greater propensity to act on suici- identified brain-related abnormalities asso- dal or aggressive feelings. In brain imaging ciated with impulsivity and aggression. studies we, and others, have linked activity in this area and serotonin release 35 to Serotonin, an important brain neurotrans- severity of suicidal acts and impulsivity 36. mitter, has been the most fruitful object of This area of the brain is part of a universal study to date. Suicide attempters have been restraint mechanism and less behavioral found to have lower serotonin functioning, restraint can lead to aggressive or suicidal with those who complete suicide having behavior depending on the affective state the lowest levels. Importantly, this dysfunc- of the individual. tion has been linked to particular regions of Neurobiological Aspects of Suicide 1 Saving Lives in New York Volume 2: Approaches and Special Populations While serotonergic function and both cide acts46. Both twin 47;48 and adoption 49 aggressive and suicidal behavior are under studies have noted a heritability of suicidal substantial genetic control37 it is also sub- behavior independent of psychiatric disor- ject to environmental influences. Demon- ders 50. As yet, the specific genes that con- strating the interaction of genetics and tribute to suicide risk are unknown. Howev- environment, peer-reared monkeys, in er since serotonin activity is related to suici- comparison with maternally raised mon- dal behavior, and under partial genetic con- keys, develop lower serotonergic activity trol, investigators have examined the rela- that persists into adulthood and is reflected tionship between genetic variation in sero- in greater impulsivity and aggression. Thus, tonin-related genes and both suicidal effects of rearing are superimposed on behavior and impulsive aggression. To date genetic effects. Given that a history of child candidate gene association findings are abuse is associated with a greater risk for inconsistent and unlikely to bear fruit with- suicidal behavior in adult life, and extrapo- out directly sequencing candidate genes. lating from these
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