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 comprehensive, 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 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 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 monkey studies, one can hypothesize that adverse rearing such as Non-genetic familial factors that may con- child abuse, resets serotonergic function at tribute to diathesis for suicidal behavior a lower level, an effect that persists into include the impact of parenting . Adults adulthood, contributing to the increased reporting childhood abuse experiences risk for suicidal behavior. have a higher rate of suicidal behavior and greater impulsivity in adulthood, consistent Other neurobiological systems are also with findings in peer-reared monkeys. We implicated in the diathesis for suicidal have observed familial transmission of behavior, though their role is less clear than impulsivity where greater parental impul- the sertonergic system. Abnormal function sivity and/or greater provocation from an of the dopamine neurotransmitter system impulsive child may increase the probabili- has been associated with major depression ty of physical or sexual abuse 51. Overly and while the influence of dopamine on sui- sensitive stress response systems in the cidal behavior is unclear 38-39, it may be brain and body are reported in abused pop- related to impulsivity and decision making. ulations and may be the neurobiological Studies have also found evidence of nora- consequences of abuse and neglect, as drenergic neurotransmitter system dysfunc- demonstrated in animal studies of mater- tion in suicide victims 40;41. The noradrener- nal separation 52. Thus adverse rearing gic system mediates acute stress responses might contribute to the neurobiological to circumstances such as a psychiatric ill- anomalies associated with components, ness or severe suicidal ideation and overac- such as impulsivity and aggression, in the tivity of that system has been associated diathesis for suicidal behavior in adulthood. with both severe anxiety or agitation and higher suicide risk 42. The hypothalamic- Treatment and prevention pituitary-adrenal (HPA) axis is another If suicidal behavior occurs as the outcome major stress response system. Major of stress-diathesis, management of suicidal depression is often associated with hyper- patients necessitates addressing both activity of the HPA axis 43, and suicide vic- aspects; diagnosis and treatment of psychi- tims exhibit HPA axis abnormalities 44;45. atric disorders which act as stressors, and Studies of both the HPA axis and noradren- treatment to reduce the diathesis, or ergic activity indicate biological responses propensity, to attempt suicide. As we have to stress that may reflect the risk for suicide. seen, diathesis, or predisposition, has an element of biological determination. Genetic and Familial Influences Diathesis includes more hopelessness or There is an important genetic contribution pessimism perhaps related to the to the propensity for suicidal behavior as noradregergic system, and more lifetime shown by several lines of researchers. Indi- impulsivity partly related to impaired sero- viduals who commit suicide or make suicide tonergic input into ventromedial prefrontal attempts have a higher rate of familial sui- cortex region of the brain. Because it is

2 Neurobiological Aspects of Suicide Saving Lives in New York Volume 2: Approaches and Special Populations related to these biological systems, the 1995;310:1366-1367. 8. Roy, A., Linnoila, M. Alcoholism and suicide. Suicide Life diathesis or propensity for suicidal behavior Threat Behav. 1986;16:244-273. is a potential therapeutic target, and a 9. Roy, A., Lamparski, D., DeJong, J., Moore, V., Linnoila, M. reduction of the diathesis for suicidal Characteristics of alcoholics who attempt suicide. Am J Psychiatry. 1990;147:761-765. behavior has been observed in the clinical 10. Roy, A., Lamparski, D., DeJong, J., Adinoff, B., Ravitz, B., effects of lithium, clozapine and psy- George, D.T., Nutt, D., Linnoila, M. Cerebrospinal ﬂuid chotherapy called dialectical behavior ther- monoamine metabolites in alcoholic patients who attempt suicide. Acta Psychiatr Scand. 1990;81:58-61. apy, which have been shown to reduce sui- 11. Murphy, G.E., Wetzel, R.D. The lifetime risk of suicide in cidal behavior 53-57. Both lithium and cloza- alcoholism. Arch Gen Psychiatry. 1990;47:383-392. pine act on the serotonergic system and 12. Murphy, G.E., Wetzel, R.D., Robins, E., McEvoy, L. Multiple risk factors predict suicide in alcoholism. Arch Gen raising serotonergic activity may reduce Psychiatry. 1992;49:459-463. risk of serious suicidal behavior by decreas- 13. Murphy, G.E. Suicide and substance abuse. Arch Gen ing aggressive behavior and impulsivity 58. Psychiatry. 1988;45:593-594. 14. Dulit, R.A., Fyer, M.R., Haas, G.L., Sullivan T., Frances, A.J. Substance use in borderline personality disorder. Am J There are many promising areas for future Psychiatry. 1990;147:1002-1007. neurobiological research into reducing the 15. Marzuk, P.M., Mann, J.J. Suicide and substance abuse. Psychiatric Annals. 1988;18:639-645. diathesis for suicidal behavior. These 16. Pezawas, L., Stamenkovic, M., Jagsch, R., Ackerl, S., Putz, include genetic and neurochemical studies, C., Stelzer, B., Moffat, R.R., Schindler, S., Aschauer, H., efforts to identify a genetic haplotype indi- Kasper, S. A longitudinal view of triggers and thresholds of suicidal behavior in depression. J Clin Psychiatry. cating risk for suicidal behavior, develop- 2002;63:866-873. ment of brain imaging and neuropsycho- 17. Brodsky, B.S., Malone, K.M., Ellis, S.P., Dulit, R.A., Mann, logical tests of decision making to measure J.J. Characteristics of borderline personality disorder associated with suicidal behavior. Am J Psychiatry. risk of attempting suicide when depressed, 1997;154:1715-1719. and the development of treatments to ame- 18. Brent, D.A. Overrepresentation of epileptics in a consecutive liorate the risk of suicidal acts while wait- series of suicide attempters seen at a Children’s Hospital, 1978-1983. J Am Acad Child Psychiatry. 1986;25(2):242-246. ing for antidepressants and antipsychotic 19. Breslau, N., Davis, G.C., Andreski, P. Migraine, psychiatric medications to work. Another promising disorders, and suicide attempts: An epidemiologic study of direction is use of animal models of impul- young adults. Psychiatry Res. 1991;37:11-23. 20. Schoenfeld, M., Myers, R.H., Cupples, L.A., Berkman, B., sive and aggressive behaviors in the identi- Sax, D.S., Clark, E. Increased rate of suicide among patients ﬁcation of candidate genes, investigation of with Huntington’s disease. J Neurol Neurosurg Psychiatry. genetic and rearing effects, and testing 1984;47:1283-1287. 21. Farrer, L.A. Suicide and attempted suicide in Huntington dis- pharmacological treatments to ameliorate ease: Implications for preclinical testing of persons at risk. aggressive/impulsive behavior that extrap- Am J Med Genet. 1986;24:305-311. olation may reduce probability of suicidal 22. Breslau, N. Migraine, suicidal ideation, and suicide attempts. Neurology. 1992;42:392-395. behavior. 23. Breslau, N., Kilbey, M.M., Andreski, P. Nicotine dependence, major depression, and anxiety in young adults. Arch Gen References Psychiatry. 1991;48:1069-1074. 1. Barraclough, B., Bunch, J., Nelson, B., Sainsbury, P. One 24. Breslau, N., Kilbey, N.M., Andreski, P. Nicotine dependence hundred cases of suicide. Clinical aspects. Br J Psychiatry. and major depression: New evidence from a prospective 1974; 125:355-373. investigation. Arch Gen Psychiatry. 1993;50:31-35. 2. Beautrais, A.L., Joyce, P.R., Mulder, R.T., Fergusson, D.M., 25. Mann, J.J., Waternaux, C., Haas, G.L., Malone, K.M. Deavoll, B.J., Nightingale, S.K. Prevalence and comorbidity Towards a clinical model of suicidal behavior in psychiatric of mental disorders in persosn making serious suicide patients. Am J Psychiatry. 1999;156:181-189. attempts: A case-control study. Am J Psychiatry. 1996; 26. Glassman, A.H., Helzer, J.E., Covey, L.S., Cottler, L.B., 153:1009-1014 Stetner, F., Tipp, J.E., Johnson, J. Smoking, smoking cessa- 3. Shaffer, D., Gould, M.S., Fisher, P., Trautman, P., Moreau, D., tion, and major depression. J Am Med Assoc. Kleinman, M., Flory, M. Psychiatric diagnosis in child and 1990;254:1546-1549. adolescent suicide. Arch Gen Psychiatry. 1996;53:339-348. 27. Glassman, A.H. Cigarette smoking: Implications for psychi- 4. Robins, E., Murphy, G.E., Wilkinson, R.H., Jr., Gassner, S., atric illness. Am J Psychiatry. 1993;150:546-553. Kayes, J. Some clinical considerations in the prevention of 28. Stanley, M., Virgilio, J., Gershon, S. Tritiated imipramine suicide based on a study of 134 successful suicides. Am J binding sites are decreased in the frontal cortex of suicide. Public Health. 1959;49:888-899. Sci. 1982;216:1337-1339. 5. Rich, C.L., Fowler, R.C., Fogarty, L.A., Young, D. San Diego 29. Stanley, M., Mann, J.J. Increased serotonin-2 binding sites suicide study. III. Relationships between diagnoses and in frontal cortex of suicide victims. Lancet. 1983;i:214-216. stressors. Arch Gen Psychiatry. 1988;45:589-592. 30. Arango, V., Underwood, M.D., Gubbi, A.V., Mann, J.J. 6. Dorpat, T.L., Ripley, H.S. A study of suicide in the Seattle Localized alterations in pre-and postsynaptic serotonin bind- area. Compr Psychiatry. 1960;1:349-359. ing sites in the ventrolateral prefrontal cortex of suicide vic- 7. Isometsa, E., Henriksson, M., Marttunen, M., Heikkinen, M., tims. Brain Res. 1995;688:121-133. Aro, H., Kuoppasalmi, K., Lonnqvist, J. Mental disorders in 31. Ono, H., Shirakawa, O., Kitamura, N., Hashimoto, T., young and middle aged men who commit suicide. BMJ. Nishiguchi, N., Nishimura, A., Nushida, H., Ueno, Y., Maeda,

Neurobiological Aspects of Suicide 3 Saving Lives in New York Volume 2: Approaches and Special Populations

K. Tryptophan hydroxylase immunoreactivity is altered by 44. Bunney, W.E., Jr., Fawcett, J.A., Davis, J.M., Gifford, S. the genetic variation in postmortem brain samples of both Further evaluation of urinary 17-Hydrocorticosteroids in sui- suicide victims and controls. Mol Psychiatry. 2002;7:1127- cidal patients. Arch Gen Psychiatry. 1969;21:138-150. 1132. 45. Nemeroff, C.B., Owens, M.J., Bissette, G., Andorn, A.C., 32. Mann, J.J., Huang, Y., Underwood, M.D., Kassir, S.A., Stanley, M. Reduced corticotropin releasing factor binding Oppenheim, S., Kelley, T.M., Dwork, A.J., Arango, V. A sero- sites in the front cortex of suicidal victims. Arch Gen tonin transporter gene promoter polymorphism (5-HTTLPR) Psychiatry. 1988;45:577-579. and prefrontal cortical binding in major depression and sui- 46. Roy, A. Family history of suicide. Arch Gen Psychiatry. cide. Arch Gen Psychiatry. 2000;57:729-738. 1983;40:971-974. 33. Shallice, T., Burgess, P. The domain of supervisory processes 47. Roy, A., Segal, N.L., Centerwall, B.S., Robinette, C.D. and temporal organization of behavior. Phil Trans R Soc Suicide in twins. Arch Gen Psychiatry. 1991;48:29-32. Lond. 1996;351:1405-1412. 48. Roy, A., Segal, L.N., Sarchiapone, M. Attempted suicide 34. Damasio, H., Grabowski, T., Frank, R., Galaburda, A.M., among living co-twins of twin suicide victims. Am J Damasio, A.R. The return of Phineas Gage: Clues about the Psychiatry. 1995;152:1075-1076. brain from the skull of a famous patient. Sci. 49. Schulsinger, F., Kety, S.S., Rosenthal, D., Wender, P.H. A 1994;264:1102-1105. Family study of Suicide. In: Schou M, Stromgren, E, eds. 35. Mann, J.J., Malone, K.M., Diehl, D.J., Perel, J., Cooper, T.B., Origin, Prevention and Treatment of Affective Disorders. Mintun, M.A. Demonstration in vivo of reduced serotonin New York: Academic Press; 1979:277-287. responsivity in the brain of untreated depressed patients. 50. Brent, D.A., Bridge, J., Johnson, B.A., Connolly, J. Suicidal Am J Psychiatry. 1996;153:174-182. behavior runs in families. A controlled family study of ado- 36. Oquendo, M.A., Placidi, G.P., Malone, K.M., Campbell, C., lescents suicide victims. Arch Gen Psychiatry. 1996;53:1145- Keilp, J., Brodsky, B., Kegeles, L.S., Cooper, T.B., Parsey, R.V., 1152. Van Heertum, R.L., Mann, J.J. Positron emission tomogra- 51. Brent, D.A., Oquendo, M., Birmaher, B., Greenhill, L., Kolko, phy for regional brain metabolic responses to a serotonergic D., Stanley, B., Zelazny, J., Brodsky, B., Bridge, J., Ellis, S., challenge and lethality of suicide attempts in major depres- Salazar, J.O., Mann, J.J. Familial pathways to early-onset sion. Arch Gen Psychiatry. 2003;60:14-22. suicide attempt: risk for suicidal behavior in offspring of 37. Higley, J.D., Thompson, W.W., Champoux, M., Goldman, D., mood-disordered suicide attempters. Arch Gen Psychiatry. Hasert, M.F., Kraemer, G.W., Scanlan, J.M., Suomi, S.J., 2002;59:801-807. Linnoila, M. Paternal and maternal genetic and environmen- 52. Viau, V., Sharma, S., Meaney, M.J. Changes in plasma tal contributions to cerebrospinal fluid monoamine metabo- adrenocorticotropin, corticosterone, corticosteroid-binding lites in Rhesus monkeys (Macaca mulatta). Arch Gen globulin, and hippocampal glucocorticoid receptor occupan- Psychiatry. 1993;50:615-623. cy/translocation in rat pups in response to stress. J. 38. Traskman, L., Asberg, M., Bertilsson, L., Sjostrand, L. Neuroendocrinology. 1996;8:1-8. Monoamine metabolites in CSF and suicidal behavior. Arch 53. Baldessarini, R.J., Tondo, L., Hennen, J. Effects of lithium Gen Psychiatry. 1981;38:631-636. treatment and its discontinuation on suicidal behavior in 39. Pitchot, W., Reggers, J., Pinto, E., Hansenne, M., Fuchs, S., bipolar manic-depressive disorders. J Clin Psychiatry. Pirard, S., Ansseau, M. Reduced dopaminergic activity in 1999;60(suppl 2):77-84. depressed suicides. Psychoneuroendocrinology. 54. Nilsson, A. Lithium therapy and suicide risk. J Clin 2001;26:331-335. Psychiatry. 1999;60(suppl2):85-88. 40. Arango, V., Underwood, M.D., Mann, J.J. Fewer pigmented 55. Meltzer, H.Y., Okayli, G. Reducation of suicidality during locus coeruleus neurons in suicide victims: Preliminary clozapine treatment of neuroleptic-resistant schizophrenia: results. Biol Psychiatry. 1996;39:112-120. Impact on risk-benefit assessment. Am J Psychiatry. 41. Arango, V., Ernsberger, P., Sved, A.G., Mann, J.J. 1995;152:183-190. Quantitative autoradiography of a1 B a2-adrenergic recep- 56. Walker, A.M., Lanza, L.L., Arellano, F., Rothman, K.J. Mortality tors in the cerebral cortex of controls and suicide victims. in current and former users of clozapine. Epidemiology. Brain Res. 1993;630:271-282. 1997;8:671-677. 42. Fawcett, J., Busch, K.A., Jacobs, D., Kravitz, H.M., Fogg, L. 57. Reid, W.H., Mason, M., Hogan, T. Suicide prevention effects Suicide. A four-pathway clinical-biochemical model. Ann associated with clozapine therapy in schizophrenia and NY Acad Sci. 1997;836;288-301. schizoaffective disorder. Psychiatric Services. 1998;49:1029- 43. Carroll, B.J., Feinberg, M., Greden, J.F., Tarika, J., Albala, 1033. A.A., Haskett, R.F., James, N.M., Kronfol, Z., Lohr, N., Steiner, 58. Mann, J.J. Violence and Aggression In Bloom FE, Kupfer DJ, M., deVigne, J.P., Young, E. A specific laboratory test for the eds. Psychopharmacology: The Fourth Generation of diagnosis of melancholia. Standardization, validation, and Progress. New York: Raven Press; 1995:1919-1928. clinical utility. Arch Gen Psychiatry. 1981; 38:15-22.

4 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 appropriate professionals to pose the ques- by suicide than from homicide in the United tion? What is an effective way to pose it? States – and New York – each year. Though What is the appropriate next step, if the not all suicides are preventable, most who answer is positive? die from suicide have made previous attempts, and a substantial number have Generalist and specialist physicians of all consulted physicians in the weeks leading types, in their role as public health agents, up to the event; thus, many may be pre- make up the "front line" on this. The rou- ventable, if appropriate attention is devoted tine initial or follow-up visit is the appropri- to identifying and intervening with those at ate setting for a physician to inquire about immediate risk. (Note: Since the under-lying suicide. There need be no more index of biological and psychosocial causes of suici- suspicion than for any other general health dal behavior are addressed in the OMH sui- issue, such as changes in diet, activity, cide prevention plan, this document will sleep, discomfort, or somatic concern. focus only on the role of physicians in early identiﬁcation and referral). Broaching the subject can be as general and unexceptional as that to any other A commonly held misconception, even organ system. Individual styles vary, but the among many physicians, is that it is some- question may take the form of, for exam- how embarrassing to a patient to be asked ple, "Since your last visit, would you say about suicidal thoughts or plans – or worse, that, for the most part, you have been insulting; the patient will respond, "What do happy with your life?" The follow-up ques- you think I am, crazy?" An extension of this tion is simply, "Are you saying then, that misconception, also mistaken, is that you have or have not had any thoughts of patients will therefore deny or conceal their suicide?" A negative response is sufficient suicidal thoughts. In fact, the overwhelming to end the line of inquiry. If the response is majority of patients experience considerable positive, it is imperative to ask: "And have relief at being asked: there is ﬁnally an you made any plans to do something to opportunity to express their terrifying con- carry them out?" cerns to the person they consider responsible and and most capable of providing for Positive responses to inquiries about suici- their overall health. Therefore, they are dal thoughts or plans should trigger a refer- forth-coming in response to being asked. ral to a psychiatrist, just as positive indica- tions should be reffered to other systemic Within this framework, three questions pathology outside the realm of the physi- immediately arise: Who are the most cians'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 There is no question but that inquiring is no more responsible for effecting the about suicidal thoughts in the course of patient's acceptance of such a referral than routine visits represents a signiﬁcant depar- that of any other referral to a specialist. ture from current practice. Therefore, some resources must be dedicated to making it Given that there are approximately 150,000 possible. The most direct is the provision of suicide attempts by teenagers in New York at least annual lectures to residents and to State each year (though only 70 completed departmental physicians. suicides), the pediatricians would face a signiﬁcant work load increase in accor- In the context of the national awareness of dance with such a practice of inquiry; other suicide, inaugurated three years ago in the primary-care physicians might not be simi- Surgeon General's Report on Mental Health larly affected. 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.

6 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 opment will depend on individual, genetic of the public health strategy to reduce the and environmental forces Resilience is pro- Number of incidents of suicide in New moted by external support – access to care, York. Resilience is the human capacity to aids to autonomy – as well as internally, deal with, overcome, learn from or even be through pride, self-respect and the ability to transformed by adversity (Grotberg: 1999). empathize. Role models are important in In the words of a leading neuroscientist: the development of resilience at all ages, from early childhood onward. “People don’t come preassembled, but are glued together by life.” (LeDoux: 1996). According to the American Psychological Association (2003), resilience is ordinary, “Like the immune system, the emotional not extraordinary. People commonly system evolves continuously, taking experi- demonstrate resilience and bounce back ences and situations and attaching emo- from adversity. The response of many New tional value to them in subtle gradations of Yorkers to the September 2001 terrorist risk and reward. Moderate stress enhances attack and individual efforts to rebuild their learning. Risk is an integral part of life and lives is more typical than atypical. Many learning.” (Gonzales: 2003) people react to traumatic events with a ﬂood of strong emotions and a sense of I. Findings. uncertainty and anxiety. Yet in the face of Human Nature and Nurture. adversity, most people adapt well over time Human nature is a powerful source of an to even life-altering situations. What individual’s ability to cope with challenges enables them to do so? It involves and threats. Parents provide their children resilience. Being “resilient” does not mean with genes as well as a home environment, that a person doesn’t experience difficulty but infants’ minds come equipped with cer- or distress. Emotional pain and sadness are tain perceptual and behavioral biases. common in people who have suffered (Restak: 1988) Discoveries in the sciences major adversity or trauma in their lives. In of mind, brain, genes and evolution chal- fact, the road to resilience is likely to lenge the notion that human nature is irrel- involve considerable emotional distress. evant to how we think, feel and behave. Resilience involves behaviors, thoughts and Human nature is central to all three, as is actions that can be learned and developed human nurture. (Pinker: 2002) in anyone. For this reason, promoting resilience is an essential element in New Resilience can be developed through prac- York’s suicide prevention strategy. tice, but the extent and depth of its devel- (APA/DHC: 2003)

Resilience 7 Saving Lives in New York Volume 2: Approaches and Special Populations

B. Factors Promoting Resilience I Am Multiple factors contribute to an individ- (Inner strengths) ual’s resilience. Many studies have shown 1. A person most people like that a prime factor is having caring and supportive primary relationships within and 2. Generally calm and good-natured outside the family. Relationships that create love and trust, provide role models, and 3. An achiever who plans for the future offer encouragement, reassurance and hope help to bolster a person’s resilience. 4. A person who respects myself Resilience is also enhanced by the capacity and others to make realistic plans and take steps to carry them out and having a positive view 5. Empathic and caring of others of one’s own journey. 6. Responsible for my own behavior and People react differently to various traumatic accepting of the consequences and stressful life events. They also use different approaches and strategies. Cultural 7. A conﬁdent, optimistic, hopeful person, differences also produce variations and with faith preferences in how individuals communicate and deal with adversity. Growing cul- I Can tural diversity provides the public with (Interpersonal and problem-solving skills) additional approaches to building 1. Generate new ideas or new ways to do resilience. (APA/DHC: 2003) things

C. Origins of Resilience 2. Stay with a task until it is ﬁnished According to Grotberg (2002), resilience comes from three sources: external sup- 3. See the humor in life and use it to ports that promote resilience; inner reduce tensions strengths that develop over time and sustain those who are dealing with adversities; 4. Express thoughts and feelings in com- and interpersonal, problem-solving skills munication with others that deal with the actual adversity. Speciﬁ- cally, these are: 5. Solve problems in various settings – academic, job-related, personal and I Have social (External Supports) 1. One or more persons within my family 6. Manage my behavior – feelings, I can trust and who love me without impulses, acting-out reservation. 7. Reach out for help when I need it. 2. One or more persons outside my family (Grotberg: 2002) I can trust without reservation. D. Approaches to Teaching Resilience 3. Limits to my behavior 1. Penn Resiliency Project (Positive Psy- chology for Youth Project) 4. People who encourage me to be independent. This Project seeks to prevent depression by giving children the tools to deal with chal- 5. Good role models lenges faced in high school and life. It uses psychology, to optimize human potential. 6. Access to health, education, and the Research shows that children who are social and security services I need resilient – who bounce back from problems because they are good at seeing them 7. A stable family and community from multiple perspectives – and who

8 Resilience Saving Lives in New York Volume 2: Approaches and Special Populations accurately understand their role in the situ- is our openness with ourselves that allows ation fare better after trauma. us to enjoy life fully. “Peace of mind comes with self-acceptance. It is not conferred by The curriculum flows from an Adversity achievement, it is the gift you give to your- Belief s and Consequencees model (ABC self.” (Viscott: 1996) model). Step A: Identify “push-button adversities,” challenges in the important 3. Enhancing Natural Support Networks areas of an adolescent’s life: school, friend- Local communities of neighborhoods have ships and family. Step B: Capture what it is individuals, organizations and institutions you say to yourself in the heat of the where people go to seek advice, informa- moment. This is an internal radio station, tion and support. These are the resources often a litany of negative thoughts about that influence and enhance community life the adversity. “I’m not good enough to get by providing numerous support mecha- the grade.” Step C: Examine how inaccu- nisms. Some of the informal community rate beliefs shape the quality of your feel- sources of support that regularly dispense ings and behavior – the consequences. Did advice and support – such as barbers, hair- you get the low grade because you were dressers and taxi drivers – are not usually too busy to study during the semester? Will recognized for providing this service, but your negative reaction keep you from pur- they constitute part of a natural support suing a genuine interest? What are the network for people around them. Besides facts surrounding the adversity? Does your providing information, they serve as listen- reaction reflect them? ing posts that are in themselves a valuable form of natural support. The key to the exercise is connecting Steps B and C and separating fact from interpre- These networks are valuable for both indi- tation. “It’s your beliefs that drive viduals and groups affected by a common you...They will determine how you threat, such as a terrorist attack or natural respond.” If the Project can help children disaster. While these lay persons typically “evaluate themselves more realistically and lack formal training as counselors or less harshly, that’s important. It can loosen providers, they do come in contact with them from the grip of pressures they face.” large numbers of the public. As such, they As one of the students put it: “People have can be a valuable adjunct to a community’s the idea that being happy means skipping crisis-response. Properly trained,they could through the flowers...But happy is being help local communities heal themselves. happy with who you are.” (Simon: 2004) Such a proposal was made to sustain and broaden the community response to the 2. Natural Therapy World Trade Center terrorist attack and cre- Another prominent model promoting ate what is termed an island of resilience in resilience involves Natural Therapy. Based a sea of uncertainty. In the future, they on the premise that most of life’s difficulties could be trained and deployed to help indi- require telling or hearing the truth, this viduals become more resilient and able to approach teaches that living in a lie fend off future disasters and attacks. (Allen: eclipses the joy of the world and lowers a 2003) person’s self-esteem. Concealing lies drain people’s energy so they don’t have enough 4. Extreme Resilience strength to do their best. Lies complicate. What makes a difference in determining The truth simplifies. The truth has the whether someone succumbs to a threat or power to heal, to protect, to guide. Living survives? Who lives and who dies? A in the truth is living free and at one’s best. recent analysis of “deep survival” examined Moreover, the greatest pleasures come the attitudes and behaviors exhibited by only when you are aware of yourself and individuals caught in life and death situa- know your strengths and limitations. Our tions in a range of adverse environments. capacity to enjoy pleasure is limited by our (Gonzales: 2003) The study revealed 12 les- self-acceptance. More than anything else, it sons for prevailing against extreme odds.

Resilience 9 Saving Lives in New York Volume 2: Approaches and Special Populations

Such conditions can produce what could also lead to a novel solution to the be termed “extreme resilience,” the ability problem at hand. to think and behave successfully in the clutch of mortal danger. 8. See the beauty (remember: it’s a vision quest). The appreciation of beauty can 1. Perceive, believe (look, see, believe). relieve stress and create strong motiva- Extreme survivors rapidly grasp the tions, as well as help to take in new reality of their situation and acknowl- information more effectively. edge that everything – good or bad – emanates from within. Their life is ulti- 9. Believe that you will succeed (develop a mately in their grasp. They move quick- deep conviction that you will live.) Sur- ly through denial, anger, bargaining, vivors consolidate their personalities depression and acceptance very quick- and ﬁx their determination; they ly. admonish themselves to make no more mistakes, to be very careful and to do 2. Stay calm (use humor, use fear to focus). their very best. They become convinced Survivors use fear, turn it into anger, that they will prevail if they do these and it motivates them. They under- things. stand at a deep level about being cool and are ever on guard against the 10. Surrender (let go of your fear of dying). mutiny of too much emotion. They Survivors manage pain well. They keep their sense of humor and keep practice resignation without giving up. calm. It is survival by surrender.

3. Think/analyze/plan. Survivors quickly 11. Do whatever is necessary (be determined: organize, set up routines, and institute have the will and the skill). Survivors discipline. They push away thoughts have meta-knowledge: they know their that their situation is hopeless. They act abilities and do not over or under-esti- with the expectation of success. mate them.

4. Take correct, decisive action. Survivors 12. Never give up (let nothing break your are able to transform thought into support). Survivors have a clear reason action: take risks to save themselves for going on. They are not discouraged and others and break down large jobs by setbacks. They come to embrace the into small, manageable tasks. world in which they ﬁnd themselves and see opportunity in adversity. (Gon- 5. Celebrate your successes (take joy in zales: 2003, 270-274) completing tasks). Survivors take great joy from even the smallest successes. II. Action Steps Important to sustain motivation, this To build resilience, the following steps are attitude also prevents the descent into recommended by the American Psycholog- hopelessness. ical Association:

6. Count your successes (take joy in com- 1. Make Connections. Good relationships pleting tasks). This is how survivors with other family members, friends, or become rescuers instead of victims. others are important. Accepting help There is always someone else they are and support from those who care about helping more than themselves, even if you and will listen to you strengthens that someone is not present. resilience. Some people ﬁnd that being active in civic groups, faith-based 7. Play (wing, play mind games, recite poet- organizations, or other local groups ry, count anything). Using deeper pow- provides social support and can help ers of intellect can help to stimulate, with reclaiming hope. Assisting others calm, and entertain the mind. It can

10 Resilience Saving Lives in New York Volume 2: Approaches and Special Populations

in their time of need also can benefit 7. Nurture a Positive View of Yourself. the helper. Developing confidence in your ability to solve problems and trusting your 2. Avoid Seeing Crises as Insurmountable instincts helps build resilience. Problems. While you can’t change the fact that highly stressful events do hap- 8. Keep Things in Perspective. Even when pen, you can change how you interpret facing very painful events, try to con- and respond to these events. Look sider the stressful situation in a broader beyond the present for how future cir- context and keep a long-term perspec- cumstances may be a little better. tive. Avoid blowing the event out of proportion. 3. Accept that Change is a Part of Living. Certain goals may no longer be attain- 9. Maintain a Hopeful Outlook. An opti- able as a result of adverse situations. mistic outlook enables you to expect Accepting circumstances that cannot that good things will happen in your life. be changed can help you focus on cir- Try visualizing what you want, rather cumstances that you can alter. As one than worrying about what you fear. sage observer noted, “freedom is the recognition of necessity.” 10. Take Care of Yourself. Pay attention to your own needs and feelings. Engage 4. Move Toward Your Goals. Develop some in activities that you enjoy and find realistic goals and do something regu- relaxing. Exercise regularly. Taking care larly that enables you to move towards of yourself helps to keep your mind and your goals, even if it seems like a small body primed to deal with situations that accomplishment. Instead of focusing require resilience. on tasks that seems unachievable, ask yourself, “What’s one thing I know I 11. Learn From Experience. Focusing on can accomplish today that helps me past experiences and sources of per- move in the direction I want to go?” sonal strength can help you learn about One step does not make a big differ- what strategies for building resilience ence, but one step taken regularly can. might work for you.

5. Take Decisive Action. Act on adverse sit- 12. Stay Flexible. Resilience involves main- uations as much as you can. Take deci- taining ﬂexibility and balance in your sive action, rather than detaching com- life as you deal with stressful circum- pletely from problems and stresses and stances and traumatic events. wishing they would just go away. Chances are they won’t, but decisive 13. Complete Your Journey. Developing action may do just that. resilience is similar to taking a raft trip down a river. “Perseverance and trust 6. Look for Opportunities for Self-Discovery. in your ability to work your way around People often learn something about boulders and other obstacles are themselves and may ﬁnd that they have important. You can gain courage and grown in some respect as a result of insight by successfully navigating your their struggle with loss. Many people way through white water... You can who have experienced tragedies and climb out to rest alongside the river. hardship have reported better relation- But to get to the end of your journey, ships, greater sense of personal you need to get back in the raft and strength, even while feeling vulnerable, continue.” (APA/DHC: 2003) an increased sense of self-worth, a more developed spirituality, and heightened appreciation for life.

Resilience 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 1- 800-964-2000 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 those who lose their lives to suicide. Fortu- Today’s media play a major role in inﬂu- nately, the potency of the media means encing peoples’ images and ideas about they must be part of the solution as well. mental illness and suicide. Negative stereo- types are too often the only image the pub- Research shows that media alone do not lic receives about these subjects and, in cause suicide – healthy people, even effect, become the only sources of their teenagers – don’t normally “up and kill knowledge about them. Many New Yorkers themselves” due to what they see or read. continue to associate mental illness with But media are unhelpful when they present people who are dangerous and pose a an inaccurate, overly dramatized image of threat to public safety and welfare. The mental illness and its treatment, thereby stigma that accompanies mental illness is a discouraging help-seeking. Moreover, major barrier for people who are struggling media can also play a real role in prevent- to manage their illness through medication ing suicide – compassionate reporting and and therapy. accurate representation can both educate and reduce stigma, leading to treatment Despite advances in treatment that enable and eventually, healthy people. people to live and work successfully in the community, mental illness continues to be A. The Annenberg Report (2001) regarded as a social disease rather than a 1. Four years ago, the Annenberg Public neurobiological disorder. This lag in the Policy Center at the University of Penn- public mind does a profound disservice to sylvania, in collaboration with the thousands of New York citizens who suffer American Association of Suicidology from a mental illness. Feelings of internal- and the American Foundation for Sui- ized shame and low self-esteem continue cide Prevention, issued a report, Report- to plague these individuals, compounding ing on Suicide: Recommendations for the the effects of the illness. Media.

It contributes to the reality that only 1 per- Highlights of the Report are these: son in 5 will seek professional help for an • The media can play a powerful role in emotional disorder and choose instead to educating the public about suicide pre- suffer silently, but not painlessly. The media vention. Stories about suicide can must take responsibility for the misinfor- inform readers, viewers, and listeners mation and stereotyping projected daily about the likely causes of suicide, its about people with mental illness, including warning signs, trends in suicide rates, and recent treatment advances. They

Media 13 Saving Lives in New York Volume 2: Approaches and Special Populations

can also highlight opportunities to pre- 7. Research has shown that when open vent suicide. Media stories about indi- aggression, anxiety or agitation is pres- vidual deaths by suicide may be news- ent in individuals who are depressed, worthy and need to be covered, but the risk for suicide increases signiﬁ- they also have the potential to do harm. cantly.

Implementation of recommendations for 8. The cause of an individual suicide is media coverage of suicides has been typically more complicated than a shown to decrease suicide rates. Unfortu- recent painful event, such as a break- nately, many media practices can have up of a relationship or the loss of a job. negative effects on the public: Social conditions alone do not explain a suicide. 1. Certain ways of describing suicide in the news contribute to what is called 9. People who appear to become suicidal “suicide contagion” or “copycat sui- in response to such events, or in cides.” This is especially potent within response to a physical illness, generally the adolescent population. (See Chap- have significant mental problems, ter on Adolescents for more informa- though they may be well-hidden. tion) II. Action Steps for Working 2. Research suggests that inadvertently with the Media romanticizing suicide or idealizing 1. If you don’t know what good and bad those who take their own lives by por- examples of how the media reports on traying suicide as a heroic or romantic suicide are, educate yourself. Read the act may encourage others to identify Annenberg Report and go to the Ameri- with the victim. can Foundation for Suicide Prevention’s web site for current examples 3. Exposure to suicide method through (www.afsp.org). media reports can encourage vulnerable individuals to imitate it. Clinicians 2. Once you understand the issues and warn the danger is even greater if there have some examples to back yourself is a detailed description of the method. up, tell others. Helping the media Research indicates that pictures or understand the issue and educating other detailed information of the site of them about how they might do a better a suicide also encourages imitation. job is a concrete way that you can bring about change. 4. Presenting suicide as the inexplicable act of an otherwise healthy or high- 3. Reach out to the news and health edi- achieving person may encourage iden- tors at your local newspapers – big or tification with the victim, and engender small – and at your local broadcast a “copycat behavior.” newsrooms. Often a suicide in a specific neighborhood or borough is reported 5. The media should know that 90% of in the neighborhood paper and not the suicide victims have a significant psy- major paper. If you live in a college chiatric illness at their time of death. town, get in touch with the editor of the These are often undiagnosed, untreat- student newspaper or student-run ed, or both. Mood disorders and sub- radio and television station: young stance abuse are the two most com- adults need this information as well. mon diagnoses. 4. Get phone, fax and e-mail contact 6. When both mood disorders and sub- information for these individuals, but stance abuse are present, the risk for open your communication with some- suicide is much greater, especially for thing written: a letter, fax or e-mail that adolescents and young adults. explains who you are and why you

14 Media Saving Lives in New York Volume 2: Approaches and Special Populations

care about suicide prevention (and its mental health in the press and fictional coverage). If you can help your reader media. If it’s very good, nominate it for understand why you are writing and an award. that you are truly invested in suicide prevention, they will take you more 10. Use the media to educate your local seriously. Include a copy of Reporting community by asking local health edi- on Suicide with your letter. tors to assign stories about depression and mental illness at any time of the 5. Offer to meet with editors, reporters year, but specifically when a suicide and copy editors at your local media occurs in your community. Stories outlets. Each of these groups plays a about warning signs for suicide, stories key role in how the media represents that profile local organizations or indi- suicide: the editor by assigning the viduals who work in suicide preven- story to a reporter, a reporter by telling tion, and stories about mental health that story and a copy editor by writing and suicide related legislation can all the headline and photo captions for be effective uses of media to de-stig- that story. matize mental health, educate the public and, ultimately, combat suicide. If 6. Maintain ongoing communication and information about warning signs and dialogue with your local news agen- prevention is presented along side a cies. Let them know you are available story about a local suicide your com- to consult as an “expert” or that you munity will learn something from the can help them get the information they tragedy. need when reporting on a suicide. Keep them abreast of mental health and sui- 11. If a local mental health organization is cide related legislative news at the state having a rally or educational event, and federal levels. invite the media. This is a great opportunity to educate them and to provide 7. In addition to working with your local them with “content” for a story. media outlets, get in touch with profes- sors at the local university or commu- 12. If a television program or (fictional) film nity college. Offer to speak to journal- misrepresents suicide or mental illness, ism classes or at schools of communi- media watchers can do several things: cations. We need to educate today’s students before they begin working as • Write a letter to the production com- professional journalists. pany that created the program and the distribution outlet. Most films are 8. If you find examples of “bad” reporting produced and distributed by studios in your local news outlets, let them but some are produced by one com- know in a calm, intelligent, educational pany and then distributed by a studio manner. Refer them to the Annenberg or distribution company. All of this Report. Help them to understand where information is found in the opening they went wrong and how they could credits of the film...take notes. To have done better without alienating comment on a television program, them. Provide examples of how they look for the production company’s could have done better and make your- credit at the end of the show and self available for ongoing communica- write to the broadcast outlet (the tel- tion about the issue. evision channel).

9. If you find examples of “good” report- • Write a letter to the editor of your ing....praise them. Many mental health local newspaper about the program associations, including the National or film, ask a local columnist to do Mental Health Association, offer media an opinion piece, or find out if your awards for positive representations of 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 one’s death by suicide inexplicable or stations do program commentary by they may deny that there were warning local residents. signs. Accounts based on these initial reactions are often unreliable. • Hold an awareness event and invite local media to cover the event. 5. Thorough investigations generally reveal underlying problems unrecognized even 13. Deliver the message yourself. Give pre- by close friends and family members. sentations to local houses of worship, Most victims do, however, give warning community centers and libraries. Col- signs of their risk for suicide. laborate with institutions in the community, and ask them to help spread 6. Some informants are likely to suggest the word about suicide and mental ill- that a particular individual – a family ness...Talk helps to spread information member, school employee, health serv- and de-stigmatize the issues. If you live ice provider – played a role in the vic- in a college or university town, volun- tim’s death by suicide. Thorough investi- teer to coordinate a public awareness gation almost always finds multiple campaign on campus. If your commu- causes for suicide and fails to corrobo- nity has a web site, ask for a link to the rate a simple attribution of responsibility. local suicide prevention council. Better yet, ask the webmaster to include infor- 7. A concern exists about dramatizing the mation about suicide and mental ill- impact of suicide through descriptions ness. and pictures of grieving relatives, teachers or classmates. This may III. Guidelines for Media Coverage encourage potential victims to see sui- of Suicides * cide as a way of getting attention or as 1. In covering a story about suicide, find a means of retaliation against others. out if the victim ever received treatment for depression or any other men- 8. Using adolescents on TV or in print tal illness. Did the victim have a sub- media to tell the stories of their suicide stance abuse problem? Conveying the attempts may be harmful to the adoles- message that effective treatments for cents themselves or may encourage most of these conditions are available – other vulnerable young people to seek but underutilized – may encourage attention this way. those with such problems to seek help. IV. The Significance of Language. 2. Acknowledging the deceased person’s 1. A cautionary note on language: refer- problems and struggles as well as the ring to a “rise” in suicide rates is usually positive aspects of his/her life or char- more accurate than calling such a rise acter contributes to a more balanced an “epidemic,” which implies a more picture. dramatic and sudden increase than what we generally find in suicide rates. 3. During the period immediately follow- Similarly, research has shown that the ing a suicide death, grieving family use of the word “suicide” in headlines members or friends may have difficulty and reference to the cause of death as understanding what happened. “self-inflicted” increases the likelihood Responses may be extreme, problems of contagion. may be minimized, and motives may be complicated. Notes: * From the American Foundation for Suicide 4. Studies of suicide based on in-depth Prevention and the interviews with those close to the victim Annenberg School of indicate that, in their first, shocked reac- Communications and Public Policy (2001) tion friends and family may find a loved

16 Media Saving Lives in New York Volume 2: Approaches and Special Populations

2. Unless the death took place in public, VI. Stories To Consider Covering. the cause of death should be reported 1. Trends in suicide rates in the body of the story, not in the headline. 2. Recent treatment advances

3. In deaths that will be covered national- 3. Individual stories of how treatment was ly, such as celebrities, or those apt to be life-saving covered locally, such as persons living in small towns, consider phrasing 4. Stories of people who overcame headlines such as “Marilyn Monroe despair without attempting suicide dead at 36” or “John Smith dead at 48.” How they died could be reported in the 5. Myths about suicide body of the article. 6. Warning signs of suicide 4. In the body of the story, it is preferable to describe the deceased as “having 7. Actions that individuals can take to died by suicide” rather than as “a sui- prevent suicide by others cide,” or having “committed suicide.” The latter two expressions reduce the person to the mode of death, or con- References note criminal or sinful behavior. For reporting on Suicide – Recommendations for the Media: American Foundation for Suicide Prevention www.afsp.org or 1-888-333-AFSP 5. Contrasting “suicide deaths” with “non- The Annenberg Public Policy Center of the University of fatal attempts” is preferable to using Pennsylvania www.appcpenn.org or (215) 898-7041 American Association of Suicidology www.suicidology.org or terms such as “successful,” “unsuccess- (202) 237-2280 ful” or “failed.” Articles and Papers: Goldsmith, SK; Pellmar, TC; Kleinman AM; Bunney, WE; Reducing Suicide: A National Imperative (Washington: The National Academies Press, 2002) V. Special Situations. www.nap.edu 1. Celebrity deaths by suicide (e.g. Marilyn Gould, M.; Jamieson, P.; Romer, D., Media Contagion and Suicide Monroe, Kurt Cobain) are more likely Among the Young American Behavioral Scientist, Vol.46, No.9, May 2003, 1269-1284 than non-celebrity deaths to produce Mann, J.John, MD, A Current Perspective of Suicide and imitations. While suicides by celebrities Attempted Suicide, Annals of Internal Medicine, 2002; 136: will receive prominent coverage, it is 302-311 Web Site: The Advertising Council provides advice to not-for-prof- important not to let the glamour of the its that want to work with the media on their web site. individual obscure any mental health www.adcouncil.org problems or use of drugs. 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 sepa- rated (e.g. Romeo and Juliet). Research shows that most pacts involve an individual who is coercive and another who is extremely dependent.

Media 17

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 In any other area of medicine, if we knew have reached crisis proportions in the Unit- what caused 90% of mortality associated ed States and throughout the world. Mental with a particular illness, we would certainly illness is now the leading cause of disability implement widespread screening for the worldwide, accounting for nearly 25% of all associated risk factors. Since the risk factors disability across major industrialized coun- for suicide are both identifiable and treat- tries. Suicide claims more than 30,000 lives able, screening for untreated mental health in the United States every year. disorders should be an important component of any suicide prevention program Findings (Shaffer: 1994). Advances in the area of More Americans suffer from depression efforts to prevent suicide should promote than coronary heart disease (7 million), voluntary mental health screening for all cancer (6 million) and AIDS (200,000) com- ages in order to find those most at risk for bined. About 15 percent of the population suicide and link them to further evaluation will suffer from clinical depression at some and services. time during their lifetime. Depression is a very serious disease and is one of the lead- The President’s New Freedom Commission ing causes of suicide. Thirty percent of all for Mental Health (2003) called special clinically depressed patients attempt sui- attention to the need for mental health cide, and half of them ultimately succeed. screening in schools and primary health However, depression is one of the most care. Accordingly, these two areas will be of treatable of psychiatric illnesses. Some esti- special focus in this chapter as they relate to mates suggest that between 80 and 90 per- mental health screening across the lifespan. cent of people with depression respond Voluntary mental health screening is impor- positively to treatment, and almost all tant at any age, starting with adolescence patients gain some relief from their symp- and continuing through old age. Undetected toms. But first, depression has to be recog- mental illness and suicide is a tragedy that nized (AFSP). Other mental health disor- we all need to work towards preventing in ders such as schizophrenia, anxiety and every stage of life. alcohol and substance abuse also carry an increased risk for suicide. Mental Health Screening for Adolescents Psychological autopsy studies have reliably It is estimated that one in ten youth suffer shown that 90% of people who die by sui- from a mental health problem serious cide have a diagnosable mental illness at enough to cause impairment, yet only one the time of their death. (Shaffer, D.: 1996)as in five of these receive any treatment. Sui-

Voluntary Mental Health Screening as a Means to Prevent Suicide 19 Saving Lives in New York Volume 2: Approaches and Special Populations

cide is the third leading cause of death second stage where they are interviewed by among young people aged 13-19 years, a mental health professional to determine if and more teens die from suicide than all an outside referral for further evaluation natural causes combined. Each year an would be beneficial. If this is recommended, additional 600,000 youth require medical the youth and his/her family are then pro- services as a result of suicide attempts vided assistance with the referral process. (CDC: 2002). Mental health screening rep- Follow up contact with the family continues resents a way to find these youth early and through the first clinical appointment. link them to treatment long before suicide seems like their only solution. Signs of Suicide (SOS) is another national school-based suicide prevention program The President’s New Freedom Commission that incorporates two prominent suicide on Mental Health (2003) sent a strong mes- prevention strategies into a single program, sage to schools and parents about the combining a curriculum that aims to raise importance of mental health in academic awareness of suicide and its related issues achievement, stating: “The mission of public with a briefing screening for depression schools is to educate all students. However, and other risk factors. The educational children with serious emotional distur- component is expected to reduce suicidali- bances have the highest rate of school fail- ty by increasing students understanding of ure. While schools are primarily concerned and promoting more adaptive attitudes with education, mental health is essential to toward depression and suicidal behavior. learning as well as to social and emotional The self-screening component enables stu- development. Because of this important dents to recognize depression and suicidal interplay between emotional health and thoughts and behaviors in themselves and school success, schools must be partners in prompts them to seek assistance. the mental health care of our children.” The program’s main educational materials The President’s Commission named the are a video (featuring dramatizations Columbia University TeenScreen Program as depicting the signs of suicidality and a model screening and early intervention depression, recommended ways to react to program. The Columbia University Teen- someone who is depressed and suicidal, as Screen Program works by creating partner- well as interviews with real people whose ships with schools and communities across lives have been touched by suicide) and a the nation to implement their evidence- discussion guide. There are additional based mental health screening program. materials included for training of school The Columbia TeenScreen Program provides personnel, including videos and step-by- consultation, training, screening tools, soft- step instructions for implementation. The ware and technical assistance free of charge screening tool is optional but recommend- to schools and communities who want to ed and is included in the training packet. implement mental health screening. The screening tool used by SOS is the seven-item Brief Screen for Adolescent The Columbia University TeenScreen Pro- Depression (BSAD). The BSAD includes a gram uses a two-stage process to identify scoring system that allows the student to at-risk youth. First, all youth who have score his or her own questionnaire and to parental consent, and who themselves determine personally whether to seek help assent to participation, complete a brief based on the results. The SOS Program has mental health check-up. Ther are several been shown in a randomized, controlled screening instruments available through the study to significantly reduce the suicide TeenScreen program, both computerized attempt rate among those who participated and paper/pencil, which screen for mental in their program in the three months fol- health problems and suicide risk. Teens lowing the intervention by 40%. (Aseltine & who “screen negative” are debriefed and DeMartino, 2004) dismissed from the screening, and youth who “screen positive” are advanced to the

20 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 safe- tested at The University of North Carolina ty of asking about suicide ideation and at Chapel Hill (UNC/CH). The college attempt has shown that there is no evi- screening project uses a screening instru- dence of iatrogenic effects of suicide ment known as the Depression Screening screening. Neither distress nor suicidality Questionnaire. Students responding to the increased among the general student group online questionnaire identify themselves by or among the high school students – in fact a self-assigned User ID. the findings suggested that asking about suicidal ideation or behavior may have Based on their responses to specific ques- been beneficial for students with depres- tions, a computer program places each stu- sion symptoms or previous suicide dent in one of three tiers, according to the attempts (Gould, M. et al.: 2005) level of their psychological problems, and sends an email with this information to a Mental Health Screening counselor affiliated with the university’s for College Students mental health services. The counselor then Suicide is the second leading cause of accesses and reviews each questionnaire death among college-age students. Among and provides an assessment. An individual- college students, 7.5 of every 100,000 take ly tailored counselor’s assessment is then their own lives and the National College sent back to the student’s User ID on the Health Risk Behavior Study (1995) found secure website. In this assessment, the that 11.4% of students seriously consider counselor will recommend students whose attempting suicide. To tackle this problem, questionnaire responses suggest psycho- the Jed Foundation and the American logical difficulties to come in for a face-to- Foundation for Suicide Prevention (AFSP) face evaluation by a counselor. The ques- have been actively working to develop and tionnaires of students identified as experi- implement effective suicide prevention encing the most significant problems are screening programs for college students. assessed within 24 hours of receipt. Stu- dents then access their personalized To leverage the anonymity of the Internet assessment and are given the option of and its popularity among young adults, the communicating anonymously with a coun- Jed Foundation has created Ulifeline.org. selor online. Ulifeling is an anonymous, web-based resource that provides students with a non- Voluntary Mental Health Screening threatening and supportive link to their col- for Adults lege mental health or counseling center. Screening for Mental Health, Inc. is a non- Ulifeline was created to give students more profit organization developed to coordinate knowledge about mental health and the nationwide mental health screening pro- signs and symptoms of emotional prob- grams and to ensure cooperation, profes- lems. The website includes a library of sionalism, and accountability in mental mental health information and an interac- health screenings. tive screening tool to help students uncov- er whether they, or a friend, are at risk. National Depression Screening Day, held Currently, more than 160 universities are every October during Mental Illness Aware- participating in the Ulifeline network, ness Week, is designed to call attention to including Columbia, Harvard, MIT, North- the illnesses of depression, bipolar disor- western and the University of Arizona. der, PTSD, and anxiety on a national level, to educate the public about their symptoms The American Foundation for Suicide Pre- and effective treatments, to offer individu- vention is implementing a college screen- als the opportunity to be screened for the ing project designed to identify and refer disorders, and to connect those in need of for treatment students at risk for suicide. To treatment to the mental health system. Fol- date, the project has targeted students in low-up studies of the National Depression five successive semesters at Emory Univer- Screening Day are demonstrating that the sity in Atlanta, and is currently being pilot- program is effective in motivating those

Voluntary Mental Health Screening as a Means to Prevent Suicide 21 Saving Lives in New York Volume 2: Approaches and Special Populations

who screen positive for the illness to seek Action Steps treatment. Recent data indicates that as 1. Endorse the report of the President’s many as 65% of those who score positive New Freedom Commission for Mental and are referred for a full evaluation follow Health (2003) call for screening in through on the recommendation. schools and primary health care and linkages to appropriate treatment. Voluntary Mental Health Screening for Older Adults 2. Support the efforts of the Columbia Suicide disproportionately impacts the elder- University TeenScreen Program in New ly, with the highest suicide rates of any age York schools, SOS, the Jed Foundation group occurring among persons aged 65 and the American Foundation for Sui- years and older. According to the American cide Prevention with college students, Association of Geriatric Psychiatry, depres- Screening for Mental Health, Inc. in sion affects 15 percent of adults older than their National Depression Day efforts 65 in the United States. Depression is not for adults, and Older Adult Outreach in just a condition that occurs when people get their work with the elderly. older, but rather, it is a medical illness that is treatable. There are over 40 million Ameri- 3. Validated, self-administered screening cans over the age of 65, and more than 6 tools for depression should be routinely million are affected by depression. used in primary care offices with elderly patients. Risk factors for suicide among the elderly include the presence of a mental illness 4. Screen chemical dependency patients (especially depression and alcohol abuse); for depression or mood changes, and the presence of a physical illness; social iso- violence toward an intimate partner or lation (especially being widowed in males); spouse. and the availability of ﬁrearms in the home (AFSP). 5. Screening programs are an important strategy in a campus suicide prevention It is estimated that 20% of elderly over 65 program. Voluntary screening for spe- years who die by suicide visited a physician ciﬁc conditions associated with suicide, within 24 hours of the act; 41% visited with- especially depression and substance in a week of their suicide; and 75% have abuse, can identify students at risk and been seen by a physician within one month facilitate referral to appropriate treat- of their suicide (National Strategy for Sui- ment services. The Internet provides an cide Prevention: 2001). excellent mechanism for reaching college students because of high access Regular mental health screening of this and usage. Voluntary screening pro- population in primary care would allow grams that allow for anonymity until he physicians the opportunity to quickly and or she is ready to self-identify, and that reliably screen for depression among this provide a personalized response from a age group and offer treatment. One current trained clinician, appear to be the most mental health screening program for the successful. elderly is run in association with National Depression Screening Day. “Older Adult 6. Support research on mental health Outreach” is a part of National Depression screening to improve the capacity to Screening Day and brings the depression identify mental illness in its early and anxiety screening to places where eld- stages, and to promote adoption of erly people can participate, including retire- mental health checkups. ment communities, assisted living facilities, social clubs and nursing homes.

22 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 23

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 • Life Line: A Program of DePaul Prevention Lifeline came into existence. It (Rochester) is a national, 24-hour, 7-day a week, toll- free suicide prevention service available to Approximately 30,000 lives are lost to sui- all those in suicidal crisis who are seeking cide each year in the United States. About help. Individuals seeking help can dial 1- 1,300 lives (or 1 in 25 deaths by suicide 800-273-TALK (8255). Callers to the Lifeline nationally) are lost in New York annually. will receive suicide prevention counseling “The purpose and promise of this national from staff at the closest available certiﬁed suicide hotline is to be there for people in crisis center in the network. It is adminis- their time of need,” said Lifeline Director, tered through the Mental Health Associa- Dr. John Draper “Working with our federal, tion of New York City, an organization with state and local partners, we will be able to experience in crisis, information, and refer- build on our strength and expand this ral help management. More than 109 crisis national hotline to reach suffering individu- centers in 42 states currently participate in als in ways that each of us could not do the National Suicide Prevention Lifeline alone.”

In New York State, the list of participating “For many people, crisis hotlines serve as crisis centers includes: an entry point into the mental health system,” said Dr. Robert Glover, Executive • Long Island Crisis Center (Bellmore) Director of NASMHPD. “By expanding the National Suicide Prevention Lifeline into • Crisis Services (Buffalo) underserved regions and by linking crisis centers to a national database of mental • Covenant House Nineline (New York health resources, we can get people the City) help they need and reduce suicide in this country.” • 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 25 Saving Lives in New York Volume 2: Approaches and Special Populations

Suicide Hotlines And Public Access inquiries from New Yorkers from all walks Alan Ross, Executive Director of life, ranging from simply having a bad The Samaritans of New York day, to feeling overwhelmed by some The recognition that suicide poses a major “reversal” in their life including a major health threat that demands a proven trauma, personal loss, chronic physical and means of prevention came to the public’s mental illnesses. These hotlines provide: attention almost simultaneously in the United States and England a little over 50 1. Free of charge an immediately avail- years ago. While in California psychologist able, caring, professionally trained vol- Edward Schneidman was pouring over unteer or staff member who will talk hundreds of “suicide notes” at a county about what callers are feeling and, coroner’s office, Schneidman came to the most importantly, listen to what they conclusion that suicides could and should are going through 24 hours a day be prevented. Soon thereafter, the first recognized crisis hotline in the United States 2. An ongoing “bridging service,” i.e., a was set up as the Los Angeles Suicide Pre- place callers can turn 24 hours a day, vention Center. The same initiative led to while they are seeking other forms of the establishment of the field of “suicidolo- professional care or personal support, gy,” and the American Association of Suici- and as a transition service as they are dology (AAS) moving from one form of treatment to another In London, an Anglican minister, Chad Varah, who was trained in psychotherapy, 3. An immediately accessible individual was making some remarkable discoveries who will talk to callers and assist them of his own. He had set up a walk-in site for in “calming down,” stabilizing their sit- those in his parish who were experiencing uation (whether the result of anxiety, some form of emotional or spiritual crisis. panic attack, waiting for their medica- He discovered that many of the people who tion to take effect, or a care giver to came to see him would sit in the waiting arrive) without requiring them to seek room, have a cup of tea with one of the out more formal and/or dramatic pro- “church ladies” (community volunteers fessional attention who oversaw much of the church’s daily operations), and, after talking to them and 4. Emotional support, information and, pouring out their hearts about their trou- when appropriate, professional refer- bles, trials and tribulations, would experi- rals, including immediate emergency ence a sense of catharsis, and leave his medical attention, as the extent of a office feeling no further need to see the caller’s problems, suicidal behavior, “professional” counselor/minister. And so and degree of risk is assessed and the non-religious Samaritans volunteer determined hotline movement was born. Today, there are 350 such centers in 32 countries B Community Benefits 1. A majority of callers to suicide preven- Findings tion hotlines come from the chronically Today, suicide prevention hotlines tend to sick, elderly, homebound, disabled and fall into one of four categories: 1. All-volun- isolated. Many are MICA clients (See teer lay “humanistic” emotional support 2. Chapter on Co-Occurring Disorders), or Combination volunteer/lay emotional sup- those who suffer from alcohol and/or port and clinical service 3. Completely clini- substance misuse. Others are those cal “professional help” service 4. Informa- who suffer from alcohol and/or sub- tion and referral service stance misuse. Others are dealing with issues tied to violence, child and sexual A Characteristics And Functions abuse. Frequently, callers are suffering At their best, 24-hour suicide prevention from grief following a recent loss, trau- hotlines respond to a wide range of matic event or personal tragedy. Hot-

26 National Suicide Prevention Lifeline Saving Lives in New York Volume 2: Approaches and Special Populations

lines are often an outlet for those in the 3. Increase access to and community link- lesbian, gay, bisexual and trans-gen- ages with mental health and substance dered communities (LGBT), as well as abuse services “at risk” youth and those with AIDS Suicide hotlines and crisis centers’ role in 2. On a community level, suicide preven- furthering the National Strategy is supported tion hotlines and crisis centers provide by the finding in the President’s New Free- mental and public health consumers dom Commission on Mental Health report with a safety net: a place they can turn that a key goal is to “increase and improve a to when they are afraid to go some- diverse mental health workforce across the place else, or feel they have no place country through public-private partnerships else, whether it is 2 o’clock in the based on multi- disciplinary training models.” morning, after attending a counseling This goal builds on the research and findings session, while seeking professional of the Institute of Medicine report which calls help or after exhausting those clinical for “collaborative and cooperative efforts” to or professional services that have spec- implement effective suicide prevention initia- ified limits. That net extends as well to tives and the evaluation of the US Air Force lay and professional mental health highly successful program which found that service providers, in that 24-hour hot- a key component of its effectiveness was in lines offer an additional level of support “creating competent communities,” utilizing and care that is available as a “back leadership, professionals, peers and caring up” to other care and services they are members of the community in addressing providing to consumers the needs of those at risk and providing them with a myriad of services 3. At a practical level, suicide prevention hotlines and crisis centers save mil- The two national organizations that have lions of dollars by providing callers with received federal appropriations for certifying, an immediate, personal response that evaluating and “linking” suicide prevention acts as a pressure release valve, often hotlines: the AAS and the Kristin Brooks diffusing individuals’ crisis events and Hope Center have estimated that there are stabilizing their situation, thereby, pre- 600 suicide-related crisis hotlines through- venting the potentially unnecessary – out the country, but the exact number and and costly – dispatching of ambulances, quality of such services offered in any one use of hospital emergency rooms, uti- state remains a matter of speculation lization of hospital medical staff ,etc. Finally, hotline services reduce the This is due in part to the absence of a des- demand for and drain on other social ignating authority overseeing hotlines (sui- service, mental health, emergency cide prevention included), the ease with response and medical staff, facilities which any individual or organization can and agencies set up a hotline and the lack of coordination and networking of hotlines Role In The National Strategy for Suicide Prevention II. Action Steps Three objectives of the National Strategy for 1. Ensure availability of “suicide hotlines” Suicide Prevention (NSSP) bear directly on and “warm lines” statewide. Such servic- the significant role played by suicide preven- es are heavily used by certain risk groups, tion hotlines and crisis centers in addressing from female adolescents and middle- this serious public health problem aged men to elders. Ensure statewide access to them is a matter of equity. 1. Develop broad-based support for suicide prevention 2. Enhance the quality of suicide prevention hotlines and warm lines statewide 2. Develop and implement community- by establishing minimal operating stan- based suicide prevention programs dards and formal risk-assessment pro-

National Suicide Prevention Lifeline 27 Saving Lives in New York Volume 2: Approaches and Special Populations

tocols, providing comprehensive quali- tative 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 self- The value of means restriction also per- harm is an effective strategy to prevent tains to adolescent behavior. “When vul- self-destructive behavior, including suicide. nerable kids crack, the weapons that are at Some suicidal acts are impulsive, resulting hand make the consequences of that vul- from a combination of psychological pain nerability more serious.” (JJ Mann in Goode: or despair coupled with easy availability of 1999) According to the Centers for Disease the means to inflict self-injury: firearms, Control and Prevention (CDC), the rate of carbon monoxide, medications, sharp firearm death in the United States of chil- objects, tall structures. By limiting the indi- dren ages 0 to 14 is nearly 12 times higher vidual’s accessibility to the means of self- than in the 25 other industrialized nations harm, a suicidal act may be prevented. The combined. More than 800 Americans, goal is to separate in time and space the young and old, die each year from guns individual experiencing an acute suicidal shot by children under the age of 19. crisis from easy access to lethal means of self-injury and personal harm. The hope is In New York, firearms were used in 33% of by making it harder for those intent on self- all suicides in 2002, and in approximately harm to act on that impulse, one can buy 28% of those between 15-24 years of age. time for the crisis to pass and for healing (CDC: 2005) A 2004 study examined the and recovery to occur. association between youth-focused firearm laws and suicides among youth in 18 A study by Dr. Richard Seiden of 515 peo- states. The study’s author concluded that ple who were prevented from jumping as many as 300 lives have been saved as a from the Golden Gate Bridge to a near-cer- result of laws that require guns to be safely tain death found that 26 years later, 94% of stored away from children. Laws that the would-be suicides were either still raised the required age of gun buyers and alive or had died of natural causes. The owners, however, did not significantly study, Where Are They Now? (1978) “con- reduce suicide rates. (Webster et al.: 2004) firmed previous observations that suicidal behavior is crisis-oriented and acute in Firearms are the most common method of nature. It concluded that if a suicidal per- completed suicides nationwide (54%), fol- son can be helped through his/her crises, lowed by suffocation (20%), poisoning one at a time, chances are extremely good (17.5%), falls (2.3%), cut/pierce (1.8%), and that he/she won’t die by suicide later.” drowning (1.2%) (CDC: 2005). This is true for (Friend: 2003) men, women and adolescents who complete suicide. In New York, firearms are also the predominant means of suicide, but by a

Means Restriction 29 Saving Lives in New York Volume 2: Approaches and Special Populations

much slimmer margin. Suicide by firearms cides (-25%) and suicides (-23%). New York seems to be associated with their availability City has one of the most stringent handgun in the home and with victim intoxication. control laws of any jurisdiction in the coun- Many homes contain guns and nearly half try. It also has one of the lowest suicide (43%) of all homicides and suicides occur in rates as well. a home. Most victims are shot: 67% of the homicides and 54% of the suicides in 2002 To further reduce the rate of suicide by (CDC: WISQARS, 2005). In some studies, firearm, the American Academy of Pediatrics handguns pose the greatest risk. recommends that parents and others who possess firearms should be educated to: Several studies have shown that the mere presence of a firearm in a home significant- • keep the gun unloaded and locked up; ly increases the risk of completed suicide. This holds true for the population as a • lock and store bullets in a separate whole and for every age group.(Miller, location; Hemenway and Azrael: 2004) A recent national study (2003) found that having a • make sure children don’t have access gun at home is a risk factor for adults to be to keys; fatally shot (gun homicide) and to die by one’s own hand (gun suicide). The adjusted • ask police for advice on safe storage odds ratio for suicide by gun increased by a and gun locks; factor of 16 compared to homes with no guns. (Wiebe: 2003) Another study con- • remove all firearms from the homes of cluded that the purchase of a handgun adolescents and others judged by a from a licensed dealer was associated with physician to be at suicidal risk. becoming a suicide victim (Miller, Hemen- way and Azrael: 2004). Those who don’t own a gun should be educated to: Most children older than age 7 have the strength to pull the trigger of a firearm, • talk with children about the risks of gun especially a handgun, so that restricting injury outside the home; access to a loaded weapon would also decrease the chances of an accidental • tell children to stay clear of guns when shooting leading to death or injury. Finally, they are in the homes of friends; “methods used in fatal suicide attempts dif- fered from those commonly used in • ask parents of children’s friends if they attempts overall.” (Miller, Hemenway and keep a gun at home; Azrael: 2004) When it comes to surviving a suicide attempt, the choice of means • if they do, urge them to empty it out employed is critical. Most victims who use and lock it up. a firearm do not survive. Other means are more forgiving. Regardless of the means Parents and/or guardians of children and employed, two routes to means restriction adolescents experiencing substance abuse are: education and technology. or emotional disturbance problems should be informed that these individuals may use Educational Initiatives lethal firearms or another means of self- Educating the public is an important strate- injury if these means are not safely gy for shaping behavior. The impact of secured. To reduce the threat of ingesting stricter gun control laws on suicide rates poison, parents should be made aware of has been evaluated in a small number of safe methods for storing and dispensing studies. A gun control law in Ontario was common pediatric medications, as well as followed by a decrease in firearm suicides. household toxics. Physicians should be A District of Columbia handgun control law encouraged to prescribe medications that was followed by a decrease both in homi- are efficacious but not lethal for those that

30 Means Restriction Saving Lives in New York Volume 2: Approaches and Special Populations are lethal, e.g. desipramine and other tri- grounds of aesthetics, obstructed views, cyclic antidepressants, when treating an at- and cost. Even though they are decidedly risk suicidal patient. low-tech, barriers have worked on other high structures. “The Empire State Building, Safety Technologies the Duomo, St. Peter’s Basilica, and Sydney “Every two weeks, on average, someone Harbor Bridge were all suicide magnets jumps off the Golden Gate Bridge” into the before barriers were erected on them. At all 55-degree water of San Francisco Bay some of these places, after the barriers were in two hundred and twenty feet below. “ It is place the number of jumpers declined to a the world’s leading suicide location.” Since handful, or to zero.” (Friend: 2003) the 1950’s, the idea of building a barrier to prevent would-be jumpers from completing The current system for preventing suicide their suicide has been hotly debated. Dr. on the Golden Gate is what officials call the Lanny Berman, the executive director of the “non-physical barrier.” This includes American Association of Suicidology, says, “numerous security cameras, thirteen tele- “Suicidal people have transformational fan- phones, which potential suicides or tasies and are prone to magical thinking, alarmed passers-by can use to reach the like children and psychotics...Jumpers are bridge’s control tower. The most important drawn to the Golden Gate because they element is randomly scheduled patrols by believe it’s a gateway to another place. the California Highway Patrolmen and They think that life will slow down in those Golden Gate Bridge personnel in squad final seconds, and then they’ll hit the water cars and on foot, bicycle, and motorcycle.” cleanly, like a high diver.” (Friend: 2003). (Friend: 2003) Despite these countermea- They rarely do. Most die by multiple blunt- sures, the jumpers continue to plunge at force trauma. Others drown in the three the rate of one suicide every two weeks. hundred and fifty feet of water beneath the More recently, The Board of Directors of bridge. Only 2 in 100 jumpers survive. the Bridge has voted to explore installing a barrier and is seeking $2 million for studies “Survivors often regret their decision in and preliminary designs of a barrier. (Blum: midair, if not before. Ken Baldwin and March 20, 2005) Kevin Hines both say they hurdled over the railing, afraid that if they stood on the While New York does not have the Golden chord they might lose their courage. Bald- Gate, it does have at least two bridges like win was twenty-eight and severely it: the George Washington and Verrazano depressed on the August day of 1985 when Narrows. Neither attract would-be suicides he told his wife not to expect him home the way that the Golden Gate does. In fact, until later. “I wanted to disappear,” he said. the suicide rate in New York City, where “So the Golden Gate was the spot. I’d heard both bridges are located, is below the that the water just sweeps you under.” On statewide average. Within the New York the bridge, Baldwin counted to ten and City rate, however, is an interesting con- stayed frozen. He counted to ten again, trast: suicides by jumping were highest in then vaulted over. “I still see my hands Manhattan, site of the tallest buildings in coming off the railing,” he said. As he the world, and lowest in Staten Island, crossed the chord in flight, Baldwin recalls, largely devoid of buildings over 7 stories “I instantly realized that everything in my high. (Marzuk et al.: 1992) In another study life that I’d thought was unfixable was in New York, 81 percent of all suicides totally fixable – except for having just jumped from their own residences (Fischer jumped.” (Friend: 2003) et al.: 1993)

Through the years, efforts to thwart would- Following ﬁve student suicides, New York be jumpers have been made, but no physi- University has turned to physical barriers to cal barrier exists today to do so. Objections deny access to jumping-off sites on cam- have been raised to installing a barrier pus. More than 179 balconies will now above the four-foot high railing on the have restricted access. NYU’s safety con-

Means Restriction 31 Saving Lives in New York Volume 2: Approaches and Special Populations

sultant called the move “a rational step.” are killed by guns than die in car crashes – “What you have is a systems approach that and that must change. This new law will makes it less easy for someone to take help.” (Pataki: 2000) Recent statistics on the impulsive action. It is no different from put- use of firearms in suicides show this ting up fences to prevent suicide on the change is occurring. Golden Gate Bridge.” (Arenson: March 30, 2005) The move to restricted access is not A recent study, published in the Journal of without controversy: the student newspa- the American Medical Association on Febru- per at NYU described the installation of ary 9, 2005 found that locked guns appear barriers as “a face-saving way for NYU to to offer the most protection against acci- ensure that students don’t end their lives dental death and injury or during a suicide on NYU’s campus, rather than a way to attempt. Any one of the four storage meth- reach out to suicidal students and offer ods, including keeping guns and ammuni- them help and guidance.” (Arenson: March tion in different locations, cuts the risk of 30, 2005) Meanwhile, the University has death and injury by between 55 and 73 per- also expanded counseling services, pro- cent. (Grossman et al: February 9, 2005) moted mental health literacy, and The study found that when guns are stored increased access to information on depres- unloaded, locked and separate from ammu- sion and related disorders for its students. nition, this practice offers the most protection against accidental or suicidal use. Another example of technology successful- “Doctors who treated suicidal teens should ly reducing suicide deaths is the conversion use the study to reinforce the effectiveness in England in 1963 from deadly coke gas to of keeping guns securely locked and inac- a less lethal natural gas for home use. cessible,” said Jerry Reed, executive director There was little substitution to more avail- of the Suicide Prevention Action Network. able means such as hanging or drowning “It just seems appropriate we would look at and within a few years, the overall suicide this just like we would storing poison under rate was reduced by one-third. (Seiden: the sink.” Finally, we should recognize the 1978) To make a major impact on our own limits of means restriction. In New Jersey, suicide rate, safety technologies that make there has been a rash of ‘suicides by loco- discharge of firearms less likely should be motive’, where people deliberately place made more widely available. A law signed themselves in front of moving commuter by Governor Pataki in 2000 has helped to trains traveling at high speeds. Because rail achieve this goal. It requires firearms retail- lines are so extensive, fences are not a real ers to include a child safety locking device deterrent to someone who is determined to with all purchases; post notices regarding gain access to the railroad tracks. Death on safe storage of guns in their place of busi- the tracks – at a rate of about 25 a year – ness; and include gun safety information has become a regular occurrence. The New with the purchase of any gun. Failure to Jersey Transit Authority has responded by comply with this law is punishable as a providing a regular counseling program for class A misdemeanor. train crews who respond to these grisly suicidal incidents. (Smothers: 2003) This law also places a ban on assault weapons; raises the minimum age to As noted, a possible outcome of restricting obtain a permit to purchase a handgun to one specific means of self-harm is the substi- 21 years old; implements a DNA for Hand- tution of another means in its place. This has guns program; establishes a gun trafficking apparently been the case for American ado- interdiction; and directs a study to be con- lescents, ages 10-14, between 1992-2001 ducted on “smart gun” technology. In sign- (CDC: 2004). Over this period, rates of suicide ing this law, Governor Pataki said: “While using firearms and poisoning decreased, New York State leads the nation with a 39 whereas suicides by suffocation increased. percent drop in violent crime since 1994, By 2001, suffocation (asphyxia/hanging) had we still have too much gun violence in our surpassed firearms to become the most com- communities. Each year more New Yorkers mon method of suicide death for this age

32 Means Restriction Saving Lives in New York Volume 2: Approaches and Special Populations group. The reasons for this change in suicide “Governor Pataki Signs Legislation to Combat Gun Violence,” Executive Chamber, Albany, NY: August 9, 2000 methods are not fully understood. However, Grossman, David, MD et al.: (Safely Storing Firearms Saves tougher handgun laws, the private nature of Young Lives,) JAMA, February 9, 2005 suffocation, its widespread availability, and Group for the Advancement of Psychiatry, Committee on Preventive Psychiatry, Violent Behavior in Children and its high lethality suggest that population- Youth: Preventive Intervention from a Psychiatric based prevention efforts must address the Perspective, J. American Academy of Child & Adolescent underlying reasons for suicidality to avoid Psychiatry, 38:3, March 1999, 235-241 Kaufman, AS and Doty, CS, Esqs. Prosecution and Defense of the potential for method substitution. (CDC: Suicide Claims, New York Law Journal, 228: 117, pp.4-5, 2004) In 2002, suicide was the 3rd leading July 26, 2002 cause of death for persons age 15-19 in New Marzuk PM, Leon AC, Tardiff K, Morgan EB, Stajic M, Mann JJ. 1992. The effect of access to lethal methods of injury on sui- York. (CDC: 2005) cide rates. Archives of General Psychiatry, 49 (6); 451-458. Miller, M; Hemenway, D; Azrael, D, Firearms and Suicide in the Given the many means of ending one’s life, Northeast, Trauma, September 2004, 57, 626-632 National Center for Injury Prevention and Control, CDC, NCHS restricting access by conﬁning those at sui- Vital Statistics System, 2003 cidal risk to institutional settings has been Pataki, George E. Governor, New York State 2004-05 Executive considered. In most cases, this is a difficult Budget Overview, (Albany: The Executive Chamber, January 20, 2004) proposition to justify. While many people Seiden, RH, “Where Are They Now ? A Follow-Up Study of who die by suicide possess multiple risk Suicide Attempters From the Golden Gate Bridge,” Suicide factors, many more will not die by suicide. and Life-Threatening Behavior, 8 (4), Winter 1978 Smothers, Ronald, Death Shares Commuter Tracks: New Jersey Conﬁnement in a safe and secure facility Suicides Illustrate Morbid Lure of the Rails, The New York for the vast majority of these at-risk indi- Times, October 15, 2003 viduals would be counterproductive. “ The U.S. Dept. of Health and Human Services, Multiple Causes of Death for ICD-9 1998 Data: Washington, DC, 1999 great number of false positives would Webster, DW, Vernick,JS, Zeoli, AM, Manganello, JA, result in commitment of large numbers of Association Between Youth-Focused Firearms Laws and patients not in need of such treatment (and Youth Suicides, JAMA, (2004), 292: 594-601 Wiebe, DJ, Ph.D. Homicide and Suicide Risks Associated with control). This inability to predict the out- Firearms in the Home: A National Case-Control Study, come would probably be the result of any Annals of Emergency Medicine, 41:6, 771-782, June 2003 attempt to predict a rare occurrence.” (Kaufman and Doty: 2002) 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, 1992- 2001, 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 65+ All Ages

Homicide Homicide Homicide Homicide Homicide Homicide Homicide Homicide Suicide Homicide Suicide Other Spec., Transportati Transportati Transportati Transportati Transportati 1 Suffocation Firearm Suffocation Firearm Firearm classiﬁable on Related on Related onRelated onRelated onRelated 5 4 8 253 82 8 551 614 365 146 1,774

Homicide Homicide Homicide Homicide Homicide Homicide Homicide Suicide Suicide Suicide Homicide Other Spec., Transportati 2 Unspeciﬁed Unspeciﬁed Firearm Firearm Firearm Firearm Firearm Suffocation Firearm NECN onRelated 4 4 4 189 89 79 65 46 583 2 78

Homicide Homicide Homicide Homicide Suicide Suicide Suicide Suicide Suicide Suicide Suicide 3 Drowning Fire/burn Fire/burn Drowning Firearm Firearm Poisoning Suffocation Poisoning Firearm Firearm 69 2 3 1 1 69 88 49 36 38 453

Homicide Homicide Homicide Homicide Suicide Suicide Suicide Suicide Suicide Suicide Other Spec., Other Spec., Other Spec., Other Spec., Suicide Fall 4 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 Homicide Suicide Homicide Homicide Suicide Transportati 5 Cut/pierce Suffocation Unspecified Suffocation Cut/pierce Cut/pierce Poisoning Unspecified Unspecified Poisoning on Related 1 2 1 1 46 46 63 29 14 213 20

Rank Homicide Homicide Homicide Homicide Suicide Homicide Homicide Homicide Homicide Homicide Other Spec., 6 Cut/pierce Unspecified Unspecified Poisoning Cut/pierce Firearm Cut/pierce Unspecified Cut/pierce classifiable 1 1 16 24 44 28 10 16 183 1

Homicide Suicide Homicide Homicide Homicide Suicide Fall Suicide Fall Suicide Fall Suicide Fall 7 Drowning Poisoning Cut/pierce Cut/pierce Unspeciﬁed 1 22 23 10 1 14 23 12 124

Suicide Suicide Homicide Homicide Homicide Suicide Fall Homicide Suicide Fall 8 Firearm Drowning Unspeciﬁed Unspeciﬁed Firearm 19 Firearm 8 108 1 8 19 18 8

Homicide Homicide Homicide Suicide Homicide Suicide Homicide Suicide Fall Other Spec., Other Spec., Other Spec., Other Spec., Other Spec., 9 Unspeciﬁed Suffocation 8 NECN NECN NECN NECN NECN 1 6 16 11 16 8 65

Homicide Homicide Suicide Homicide Homicide Suicide Homicide Other Spec., Other Spec., 10 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 Means Restriction 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 sui- Over the past two decades, research on cide do not receive treatment for their youth suicide has yielded invaluable infor- psychiatric disorder. This is particularly mation on who is at risk for suicide, shap- distressing because dialectical behavior ing our prevention strategies. The key ﬁnd- therapy, cognitive- behavior therapy, ings are: and treatment with antidepressants have been identiﬁed as promising treat- A. Overall Rates and Secular Patterns ments of youth suicide. in New York State • Over 150,000 New York State teenagers • A prior suicide attempt is one attempt suicide each year, and approxi- of the strongest predictors of mately 70 die by suicide. completed suicide.

• More than 1 out of 10 tenth graders in • Although suicidal ideation and New York State will attempt suicide this attempts are more common among year. girls, five times more teenage boys than girls commit suicide. This may partly • New York State ranks fourth in the reflect a sex-related method preference: nation on the number of suicide deaths methods favored by girls and women, among 10 to 24 year olds (See Table 1). such as overdoses, tend to be less lethal in the U.S. Boys are apt to use • During the past decade, there has been more lethal means, such as firearms. little change in the youth suicide death rates in New York State. However, • The most common diagnoses in young there has been a slight tapering off people who die by suicide are mood among boys and whites since 1994, disorder, alcohol or drug abuse (in paralleling the decrease in national boys), and conduct disorder. rates (See Tables 3 and 4). • Most suicide deaths are triggered by B. Risk Factors getting into trouble – leading to a legal • 90% of adolescents who die by suicide or disciplinary problem – or breaking have a mental disorder at the time of up with a girlfriend or boyfriend. their death. • Many suicidal teens have parents and other family members who have been

Adolescents 37 Saving Lives in New York Volume 2: Approaches and Special Populations

grappling with their own suicidality and independent of maternal bonding, mental health problems. social functioning, implying that maternal religiosity might protect against sui- • A disproportionate number of teen suicide also. cides are either school dropouts or youngsters who have had difficulties at II. Action Steps school. These recommended action steps are based on the key risk factors for youth sui- • Same-sex sexual orientation is a risk cide, which provide a set of identified, mod- factor for suicidal behavior. However, ifiable risk factors to target, and the recog- most gay and lesbian youth report no nition that vulnerable youth are often not suicidality at all. identified nor referred for appropriate mental health services. Those action steps that • Sexual and physical abuse are associat- are supported by the largest body of empir- ed with an increased risk of suicidal ical evidence have been selected. The behavior, but other social and psycho- action steps include a range of options for logical factors may account for much of implementation by either health or mental the increased risk. health departments, hospital and emergency rooms, schools, community organi- • Teenagers are more susceptible to sui- zations and advocacy groups, schools, cide contagion/imitation than adults. and/or parent groups. An illustrative, but not exhaustive, set of resources follow C. Protective Factors each action step, to guide those interested Protective factors are influences that buffer in implementing a particular recommenda- the impact of risk factors. They are not tion in their clinical or community setting. merely the opposite or low end of risk factors, but different factors that actively pro- A. Enhance Support Systems mote positive behavior that insulates for Vulnerable Youth against the consequence of risk factors. (1). Parent Education Programs Despite the burgeoning research literature Stakeholder: Parents and Other Adults during the past two decades on risk factors Psychoeducational programs are critical for for youth suicide, there remains a paucity parents of youth who have declared their of empirical information on protective fac- risk vis-a-vis a suicide attempt or by tors. Promising protective factors identified engaging in risky behaviors, such as alco- from recent research include: hol or drug use. An emergency room contact provides a prime opportunity to target • Family cohesion: Increasing family these parents. Parents should be trained to cohesion appears protective for suicide be key support persons by educating them attempts. Teenagers who describe fam- about adolescent psychopathology, treat- ily life in terms of a high degree of ment, signs of risk, availability of profes- mutual involvement, shared interests, sional resources and emergency services, and emotional support were several and communication/support strategies. times less likely to be suicidal than are Such psychoeducational programs would adolescents from less cohesive fami- supplement usual mental health services. lies, even those with the same levels of depression or life stress. Resource: Youth-Nominated Support Team (YST), Cheryl King, Ph.D (Kingca@med. Umich.edu). • Religiosity: The protective value of religiosity against suicide, suicidal (2) School Re-entry Guidelines ideation, and perceived acceptability of and Training suicide among adolescents has recently Stakeholder: Schoold been reported. Furthermore, maternal A teenager’s re-entry into school after a sui- religiosity appears to be a protective cide attempt and/or psychiatric hospitaliza- factor against offspring depression, tion is a particular stressful time for the ado-

38 Adolescents Saving Lives in New York Volume 2: Approaches and Special Populations lescent. Rumors among the study body often Resource: The American Foundation for Suicide Prevention (AFSP website: www.afsp.org) has developed educational posters arise in the aftermath of such an event, highlighting suicide risk factors and management guidelines making re-entry a time of potential humilia- for staff in Emergency Departments and E.R.s. tion and increased stigmatization. School guidance personnel are often at a loss as to B. Implement Case-Finding with how best to meet the needs of the returning Accompanying Referral and Treatment student. Enhanced liaison between the (1.) Screening Programs treatment provider/team and a designated Stakeholder: Service Providers case manager at the school would be essen- One valuable case-finding strategy to tial components of the guidelines. increase the recognition and referral of suicidal youth involves direct screening of Resource: Intensive Day Treatment (IDT) Program, Rockland Children’s Psychiatric Center (Dr. Barry Kutok, RCCSBLK@ children and teens in various settings (e.g., omh.state.ny.us;www.sharingsuccess.org/code/eptw/ schools, pediatricians’ offices). A question- pdf_profiles/idt.pdf). naire or other screening instrument, whch targets depression, substance abuse, and (3) Peer-Helper Programs suicidal ideation and behavior, can be used Stakeholder: Schoold as a universal prevention tool to identify Although empirical evaluations of peer- high-risk adolescents and young adults helper programs are quite limited, they from among a general population of stu- could potentially provide a source of sup- dent/patients, or can be used as targeted port for a vulnerable youth. For example, prevention strategy by providing an assess- peer-helper procedures incorporated into a ment to youngsters already thought to be school- reentry program could enhance the at possible risk by school guidance coun- levels of support provided to the returning selors or pediatricians. Two vulnerable student. The responsibilities of the peer populations of teenagers, often neglected helper are best limited to listening and in suicide prevention efforts, include reporting and possibly warning signs, youngsters who have dropped out of rather than counseling. It is imperative that school or are at risk for dropping out and peer helpers be carefully supervised by those youth who are in county level proba- school guidance personnel who have tion, detention, and correctional programs undergone extensive suicide prevention and facilities. Recognition and identification training to determine the level of risk, and of heightened suicide risk in these to make referrals. teenagers, with accompanying treatment plans, is critical. Resource: Youth-Nominated Support Team (YST) (Cheryl King, Ph.D.) ([email protected]). Resources: Teen Screen (Leslie McGuire, MSW, www.teen screen.org); Signs of Suicide (SOS) Prevention Program (4) Post-Attempt Treatment Program (Douglas Jacobs, MD [email protected]) Stakeholder: Rarents and Other Adults Following a suicide attempt, it is essential (2.) Gatekeeper/Caregiver that clinicians and staff in Emergency Training Programs Departments/E.R.s are adequately trained Stakeholder: Service Providers to assess continued risk. In addition, these The inability of potential gatekeepers/care- staff have a critical role in immediately givers to be “first-aid” resources to youth at linking the teen and family to mental risk of suicide has been an impetus for the health resources for follow-up and contin- development of training programs for com- ued treatment. They must be knowledge- munity-based caregivers, including school able about the availability of and access to personnel, clergy, police, and community specific resources in their particular com- volunteers. Such programs aim to develop munity. Community mental health treat- the knowledge, attitudes and skills to iden- ment providers must also have systems in tify individuals at risk, determine the levels place to prioritize follow-up appointments of risk, and to make referrals. for teens who have made a suicide Resources: Applied Suicide Intervention Skills Training (ASSIST), attempt. “Living Works Education” (www.livingworks.net)

Adolescents 39 Saving Lives in New York Volume 2: Approaches and Special Populations

(3.) Professional Education Programs dle school aged children are targeted for Stakeholder: Service Providers this prevention strategy. Training primary care physicians and pediatricians about suicide risk, assessment and Resource: Penn Resiliency Project (PRP) 3815 Walnut Street, Philadelphia, PA 19104 (215) 573-4128 treatment is an essential suicide prevention strategy. Despite the frequent prescription of (2). Firearms Restriction Procedures SSRIs by primary care physicians and pedi- Stakeholder: Parents and Other Adults atricians, they admit to inadequate training in the treatment of childhood depression. Firearms used in youth suicides are often Training medical professionals in the appro- obtained from the home environment. priate use of antidepressant and mood-sta- Firearm safety counseling to parents of bilizing drugs has been found to reduce the high-risk youth is one essential strategy for suicide rate, at least among female adults. youth suicide prevention. Such programs The demonstrated effectiveness of such emphasize safe storage and/or removal of educational programs should encourage ﬁrearms from the home. Injury prevention their dissemination. education in emergnecy rooms can lead parents to take new action to limit access Resources: American Foundation for Suicide Prevention (2003). to lethal means. The adult male in the The Suicidal Patient: Assessment and Care. A ﬁlm available household or the actual gun owner has at AFSP.org/index-1.htm; American Academy of Child and Adolescent Psychiatry Workgroup on Quality Issues. been found to be the most appropriate per- Practice parameters for the assessment and treatment of son to counsel. children and adolescents with suicidal behavior. Journal of the American Academy of Adolescent and Child Psychiatry, Resource: Love Our Kids, Lock Your Guns (LOK) 40 (7), 24s-51s, (2001) ([email protected])

(4.) Postvention/Crisis Intervention (3). Alcohol Restriction Policies in Schools Stakeholder: Government Stakeholder: Schools Substance abuse is a signiﬁcant risk factor A timely response to a suicide is likely to for suicidal behavior, particularly among reduce subsequent depression and suicidal older adolescent males. Strategies to “tight- ideation and behavior in fellow students. en” teenage access to alcohol have suc- The major goals of postvention/crisis inter- cessfully decreased youth suicidal behavior. vention programs is to assist survivors in Such efforts have included increasing the the grief process, identify and refer those minimum drinking age from 18 to 21 years, individuals who may be at risk following which resulted in a substantial decrease in the suicide, provide accurate information youth suicide deaths. Additional efforts to about suicide while attempting to minimize make drinking more difficult among suicide contagion, and implement a struc- teenagers include stricter enforcement of ture for ongoing prevention efforts. such laws in bars, liquor stores, and other establishments selling beer. Increased sur- Resource: Services for Teens at Risk (STAR) Center Postvention. Standards Guidelines (Mary Margaret Kerr, Ed.D. Director, veillance of cases of drinking while intoxi- STAR- Center Outreach ([email protected]) cated may also enhance case ﬁnding of at- risk teens. C. Develop Risk Reduction Plans Resource: Reducing Underage Drinking: A Collective (1). School-Based Risk Reduction Plans Responsibility. Richard Bonnie and Mary Ellen O’Connell, Stakeholder: Schools Editors, Committee on Developing a Strategy to Reduce and Teaching cognitive and social problem- Prevent Underage Drinking, National Research Council, Institute of Medicine. (www.nap.edu/catalog/10729.html) solving techniques to children as they enter puberty can yield a “psychological immu- (4). Media Education nization” against depressive symptoms. Stakeholder: Youth/Peers Cognitive interventions begun in late childhood may prevent depressive symptoms Given the substantial evidence for suicide from developing in early adolescence. Mid- contagion and imitative behavior among teenagers, recommended prevention strategies involve educating media profes-

40 Adolescents Saving Lives in New York Volume 2: Approaches and Special Populations sionals. Such action steps are described • Opportunities to make a contribution to elsewhere in the Media section of the New one’s community and develop a sense York State Suicide Prevention Plan. of mattering.

D. Enhance Protective Factors • Strong links between families, schools (1) Promoting Youth Development and broader community resources. Stakeholder: Schools Experience and research have shown that Resources: New York State Office of Children and Family Services, New York Youth: The Key to Our Economic and young people need a set of personal and Social Future. Blueprint for State and Local Action, Albany, social assets that will increase their healthy NY. National Research Council and Institute of Medicine development and well-being, and facilitate (2002), Community Programs to Promote Youth Development, National Academy Press, Washington, DC. a successful transition from childhood through adolescence into adulthood. These Resource essential assets have been grouped into Comprehensive reviews of research on youth suicide risks and four broad categories: physical, intellectual, preventive interventions, which provide an empirical base psychological and social development for the ﬁndings and action steps for this portion of the New (Community Programs to Promote Youth York State Suicide Prevention Plan include the following: Development, 2002). Continued exposure Gould, M.S. Greenberg, T., Velting, D.W., Shaffer, D., Youth sui- to positive experiences, settings, and peo- cide risk and preventive interventions: A review of the past ple as well as opportunities to gain and 10 years. Journal of the American Academy of Child and reﬁne life skills support youth in the acqui- Adolescent Psychiatry, 2003, 42 (4) 386-405. (See the Appendix to this section) sition of these assets. In addition, it helps them gain strategies to deal with the many Gould, M.S. & Kramer, R.A. Youth suicide prevention. Suicide and challenges they will be confronted with in Life-Threatening Behavior, 31 (supplement), Spring: 6-31. life. Examples of opportunities that can assist youth in acquiring and building these Shaffer, D., Gould, M.S., Greenberg, T., Fisher, P., Hicks, R., assets include: McGuire, L., Mufson, L. Teen Suicide Fact Sheet. (2003) Department of Child Psychiatry, New York State Psychiatric Institute, Columbia College of Physicians & Surgeons. • Clear expectations for behavior (http://childpsych.columbia.edu/Disorders/Suicide/suicide. as well as opportunities to make html. 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 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 ously considers suicide (Grunbaum et al., 2002); 5% to is at risk for suicide and how to prevent and treat suicide 8% of adolescents attempt suicide, representing approx- will be critically evaluated. A comprehensive understanding imately 1 million teenagers, of whom nearly 700,000 of this information is critical to clinicians who deal with receive medical attention for their attempt (Grunbaum the mental health problems of children and adolescents. et al., 2002); and approximately 1,600 teenagers die by Each year, one in ﬁve teenagers in the United States seri- suicide (Anderson, 2002). Only by recognizing who is at risk for suicide, and knowing how to prevent suicidal Accepted December 3, 2002. behavior and provide treatment for suicidal individuals, Dr. Gould is a Professor at Columbia University in the Division of Child and will mental health practitioners and those designing edu- Adolescent Psychiatry (College of Physicians & Surgeons) and Department of Epidemiology (School of Public Health) and a Research Scientist at the New York cational and public health prevention programs have suf- State Psychiatric Institute (NYSPI). Mr. Greenberg is with the Division of Child ﬁcient armamentaria to combat this major public health and Adolescent Psychiatry, Columbia University, NYSPI. Dr. Velting is an Assistant and clinical problem in youths. The current review is Professor at Columbia University in the Division of Child and Adolescent Psychiatry (College of Physicians & Surgeons), and Dr. Shaffer is Irving Philips Professor based on a comprehensive, but not exhaustive, review of of Child Psychiatry and Pediatrics at the College of Physicians & Surgeons at the research on youth suicide conducted in the past decade. Columbia University. Preference was given to population-based epidemiolog- The expert assistance of Margaret Lamm in the preparation of this manu- ical and longitudinal investigations and controlled pre- script is gratefully acknowledged. Reprint requests to Dr. Gould, Division of Child and Adolescent Psychiatry, vention/intervention studies. NYSPI, 1051 Riverside Drive, Unit 72, New York, NY 10032; e-mail: [email protected]. OVERALL RATES AND SECULAR PATTERNS 0890-8567/03/4204–0386᭧2003 by the American Academy of Child and Adolescent Psychiatry. Suicide was the third leading cause of death among DOI: 10.1097/01.CHI.0000046821.95464.CF 10- to 14-year-olds and 15- to 19-year-olds in the United

386 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 42:4, APRIL 2003

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YOUTH SUICIDE RISK AND INTERVENTIONS

States in 2000 (Anderson, 2002). While the rates of com- Like completed suicides, suicide attempts are relatively pleted suicide are low (1.5 per 100,000 among 10- to 14- rare among prepubertal children and increase in frequency year-olds and 8.2 per 100,000 among 15- to 19-year-olds), through adolescence (Andrus et al., 1991; Velez and when nonlethal suicidal behavior and ideation are taken Cohen, 1988). However, unlike completed suicides, into account, the magnitude of the problem becomes obvi- attempts peak between 16 and 18 years of age, after which ous. The surge of general population studies of suicide there is a marked decline in frequency (Kessler et al., attempts and ideation has yielded reliable estimates of 1999), particularly for young women (Lewinsohn et al., their rates (e.g., Andrews and Lewinsohn, 1992; Fergusson 2001). and Lynskey, 1995; Fergusson et al., 2000; Garrison et al., 1993; Gould et al., 1998; Grunbaum et al., 2002; Gender Lewinsohn et al., 1996; Roberts and Chen, 1995; Sourander Paradoxically, although suicidal ideation and attempts et al., 2001; Swanson et al., 1992; Wichstrom, 2000; are more common among females (Garrison et al., 1993; Windle et al., 1992). Of these studies, the largest and the Gould et al., 1998; Grunbaum et al., 2002; Lewinsohn most representative is the Youth Risk Behavior Survey et al., 1996) in the United States, completed suicide is (YRBS) (Grunbaum et al., 2002), conducted by the more common among males. Five times more 15- to 19- Centers for Disease Control and Prevention (CDC). The year-old boys than girls commit suicide (Anderson, 2002). YRBS indicated that during the past year, 19% of high The same pattern of sex differences does not exist in all school students “seriously considered attempting suicide,” countries (World Health Organization, 2002). While nearly 15% made a specific plan to attempt suicide, 8.8% completed suicide is more common in 15- to 24-year old reported any suicide attempt, and 2.6% made a medically males than females in North America, Western Europe, serious suicide attempt that required medical attention. Australia, and New Zealand, sex rates are equal in some These results are consistent with those cited in the epi- countries in Asia (e.g., Singapore), and in China, the demiological literature. majority of suicides are committed by females. Age The YRBS (Grunbaum et al., 2002) indicated that girls were significantly more likely to have seriously con- Suicide is uncommon in childhood and early adoles- sidered attempting suicide (23.6%), made a specific plan cence. Within the 10- to 14-year-old group, most suicides occur between ages 12 and 14. Suicide incidence (17.7%), and attempted suicide (11.2%) than were boys increases markedly in the late teens and continues to rise (14.2%, 11.8%, 6.2%, respectively); however, no signif- until the early twenties, reaching a level that is maintained icant difference by gender in the prevalence of medically throughout adulthood until the sixth decade, when the serious attempts (3.1% females, 2.1% males) was found. rates increase markedly among men (Anderson, 2002). Both psychopathological factors and sex-related method In 2000, the suicide mortality rate for 10- to 14-year- preferences are considered to contribute to the pattern of olds in the United States was 1.5 per 100,000. Although sex differences (Shaffer and Hicks, 1994). Completed sui- 10- to 14-year-olds represented 7.2% of the U.S. popu- cide is often associated with aggressive behavior and sub- lation, the 300 children who committed suicide repre- stance abuse (see discussion below), and both are more sented only 1.0% of all suicides. The suicide mortality common in males. Methods favored by women, such as rate for 15- to 19-year-olds was 8.2 per 100,000, five times overdoses, which account for 30% of all female suicides the rate of the younger age group. yet only 6.7% of all male suicides (CDC, 2002), tend to The rarity of completed suicide before puberty is a be less lethal in the United States. However, in societies universal phenomenon (World Health Organization, where treatment resources are not readily available or 2002). Shaffer et al. (1996) suggested that the most likely when the chosen ingestant is untreatable, overdoses are reason underlying the age of onset of suicide is that depres- more likely to be lethal. Whereas in the United States, sion and exposure to drugs and alcohol, two significant only 11% of completed suicides in 1999 resulted from risk factors for suicide in adults (e.g., Barraclough et al., an ingestion, in some South Asian and South Pacific coun- 1974; Robins et al., 1959) and adolescents (e.g., Brent tries, the majority of suicides are due to ingestions of her- et al., 1993a; Shaffer et al., 1996), are rare in very young bicides, such as paraquat, for which no effective treatment children and become prevalent only in later adolescence. is available (Haynes, 1987; Shaffer and Hicks, 1994).

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Ethnicity At that time the decline gathered pace and included both Youth suicide is more common among whites than white and African-American males and females. The rate African Americans in the United States (Anderson, 2002), among white males, nearly 20/100,000 in 1988, had fallen although the rates are highest among Native Americans to approximately 14/100,000 by the year 2000 (Fig. 1). and generally the lowest among Asian/Pacific Islanders The reasons for the decline are by no means clear. One (Anderson, 2002; Shiang et al., 1997; Wallace et al., 1996). of the more plausible reasons for the earlier increase had Latinos are not overrepresented among completed sui- been the effects of greater exposure of the youth popu- cides in the United States (Demetriades et al., 1998; Gould lation to drugs and alcohol. Alcohol use had been noted et al., 1996; Smith et al., 1985). The historically higher to be a significant risk factor for suicide since the first suicide rate among Native Americans is not fully under- psychological autopsy study (Robins et al., 1959), and at stood, but proposed risk factors include low social inte- least in some studies (Shaffer et al., 1996) it has been a gration, access to firearms, and alcohol or drug use significantly more important risk factor for males, the (Borowsky et al., 1999; Middlebrook et al., 2001). The group that had showed the dramatic increase. However, historically lower suicide rate among African Americans repeat benchmark studies that use similar measures and has been attributed to greater religiosity and differences sampling methods such as the YRBS (CDC, 1995, 1996, in “outwardly” rather “inwardly” directed aggression 1998, 2000; Grunbaum et al., 2002) give no indication (Gibbs, 1997; Shaffer et al., 1994). However, the differ- of a decline in alcohol or cocaine use during this time. ence in suicide rates between whites and African Americans Another reason posited for the earlier increase was an has decreased during the past 15 years because of a marked increased availability of firearms (Brent et al., 1991). increase in the suicide rate among African-American males Legislation restricting access to firearms was passed in between 1986 and 1994. 1994 (Ludwig and Cook, 2000), at the time that the The YRBS (Grunbaum et al., 2002) found that African- decrease became more marked and the rate of handling American students were significantly less likely (13.3%) firearms among high school students declined (CDC, than white or Latino students (19.7% and 19.4%, respec- 1995, 1996, 1998, 2000; Grunbaum et al., 2002). However, tively) to have considered suicide or to have made a spe- the proportion of suicides by firearms, a plausible proxy cific plan (African-Americans: 10.3%; whites: 15.3%; for method availability (Cutright and Fernquist, 2000), Latinos: 14.1%). Latino students (12.1%) were signifi- did not change between 1988 and 1999. There has been cantly more likely than either African-American or white a decline ranging from 20% to 30% in the youth suicide students to have made a suicide attempt (8.8% and 7.9%, rates in England, Finland, Germany, and Sweden, where respectively); however, there was no preponderance of firearms account for very few suicides (Krug et al., 1998), medically serious attempts among Latinos (3.4%) com- and a systematic examination of the proportion of sui- pared with whites (2.3%) or African Americans (3.4%). cides committed with firearms over a long period of time Although some studies have found higher rates of sui- has shown that the proportion is only weakly related to cidal ideation and attempts among Latino youths overall changes in the rate (Cutright and Fernquist, 2000). (Roberts et al., 1997; Roberts and Chen, 1995), Grunbaum Another plausible cause of the reduction has been the et al. (1998) and Walter et al. (1995) did not find a higher extraordinary increase in antidepressants being prescribed prevalence of either among Latinos. These equivocal find- for adolescents during this period. Olfson et al. (2002b) ings highlight the need for further research in this area. showed that between 1987 and 1996 the annual rate of antidepressant use increased from approximately 0.3% Secular Trends to 1.0% of those aged 6 to 19 years in the United States. Secular changes in the incidence of a disease are impor- Selective serotonin reuptake inhibitors (SSRIs) affect not tant because they may give an indication of causal and/or only depression (see “Psychopharmacological Interventions” preventive factors. Following a nearly threefold increase below), but also aggressive outbursts, and have been shown in the adolescent male suicide rate between 1964 and in adults to reduce suicidal thinking. It is unlikely that 1988, the consistent increase in the white male suicide the increase in the prescription of antidepressants is an rate ceased and in the mid 1990s started to decline. Rates indication of a more general increase in access or use of in African-American males, while still lower than among mental health services. During the period from 1987 to whites, showed no sign of a plateau or decrease until 1995. 1997, the number of adolescents who received psycho-

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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 prevalent disorders among adolescent suicide victims, in the onset of the decline in African-American suicides ranging from 49% to 64% (Brent et al., 1993a; Marttunen is compatible with a treatment effect because of African et al., 1991; Shaffer et al., 1996). The increased risk of Americans’ greater difficulty in accessing treatment resources suicide (odds ratios) for those with an affective disorder (Goodwin et al., 2001). Another indication that antide- ranges from 11 to 27 (Brent et al., 1988, 1993a; Groholt pressant treatment may be a factor in the recent decline et al., 1998; Shaffer et al., 1996; Shafii et al., 1988). Female is the finding in Sweden that the proportion of suicide victims are more likely than males to have had an affec- victims who received antidepressant treatment is lower tive disorder (Brent et al., 1999; Shaffer et al., 1996). than the rest of the depressed population (Isacsson, 2000). Substance abuse is another significant risk factor, espe- Firm conclusions, however, are not possible given the cially among older adolescent male suicide victims ecological nature of the supporting data. Randomized (Marttunen et al., 1991; Shaffer et al., 1996). A high clinical trials will be necessary before the decline in rates prevalence of comorbidity between affective and sub- can be confidently attributed to treatment with antide- stance abuse disorder has consistently been found pressants. (Brent et al., 1993a; Shaffer et al., 1996). Disruptive disorders are also common in male teenage suicide victims RISK FACTORS (Brent et al., 1993a; Shaffer et al., 1996). Approximately one third of male suicides have had a conduct disorder, Personal Characteristics often comorbid with a mood, anxiety, or substance abuse Psychopathology. More than 90% of youth suicides have disorder. Discrepant results have been reported for bipo- had at least one major psychiatric disorder, although lar disorder: Brent et al. (1988, 1993a) reported relatively younger adolescent suicide victims have lower rates of high rates, whereas others reported no or few bipolar cases psychopathology, averaging around 60% (Beautrais, 2001; (Apter et al., 1993a; Marttunen et al., 1991; Rich et al., Brent et al., 1999; Groholt et al., 1998; Shaffer et al., 1990; Runeson, 1989; Shaffer et al., 1994). Despite the 1996). Depressive disorders are consistently the most generally high risk of suicide among people with schizo-

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phrenia, schizophrenia accounts for very few of all youth Marcenko et al., 1999; Overholser et al., 1995; Ruben- suicides (Brent et al., 1993a; Shaffer et al., 1996). stein et al., 1989; Russell and Joyner, 2001; Shaffer et al., The psychiatric problems and gender-specific diag- 1996); however, it has not consistently proven to be an nostic profiles of youth suicide attempters are quite sim- independent predictor, once depression is taken into ilar to the profiles of those who complete suicide (e.g., account (Cole, 1988; Howard-Pitney et al., 1992; Lewinsohn Andrews and Lewinsohn, 1992; Beautrais et al., 1996, et al., 1994; Reifman and Windle, 1995; Rotheram-Borus 1998; Gould et al., 1998). However, despite the overlap and Trautman, 1988). Poor interpersonal problem-solv- between suicidal attempts and ideation (Andrews and ing ability has also been reported to differentiate suicidal Lewinsohn, 1992; Reinherz et al., 1995) and the signif- from nonsuicidal youths (Asarnow et al., 1987; Rotheram- icant prediction of future attempts from ideation (Lewin- Borus et al., 1990), even after adjusting for depression sohn et al., 1994; McKeown et al., 1998; Reinherz et al., (Rotheram-Borus et al., 1990). Social problem-solving 1995), the diagnostic profiles of attempters and ideators has been found to partially mediate the influence of life are somewhat distinct (Gould et al., 1998). Substance stress on suicide, although life stress was a stronger pre- abuse/dependence is more strongly associated with sui- dictor than social problem-solving (Chang, 2002). Aggressive- cide attempts than with ideation (Garrison et al., 1993; impulsive behavior has also been linked with an increased Gould et al., 1998; Kandel, 1988). Recent studies have risk of suicidal behavior (Apter et al., 1993b; McKeown found an association between posttraumatic stress disor- et al., 1998; Sourander et al., 2001). In a Finnish school der and suicidal behavior among adolescents (Giaconia study (Sourander et al., 2001), aggressive 8-year-olds were et al., 1995; Mazza, 2000; Wunderlich et al., 1998), but more than twice as likely to think about or attempt sui- in the largest and most representative of the studies cide at age 16. (Wunderlich et al., 1998), the association was not main- Sexual Orientation. Recent cross-sectional and longi- tained after adjusting for comorbid psychiatric problems. tudinal epidemiological studies found a significant two- Panic attacks have also been reported to be associated to sixfold increased risk of nonlethal suicidal behavior for with an increased risk of suicidal behavior in adolescents, homosexual and bisexual youths (Blake et al., 2001; Faulkner even after adjusting for comorbid psychiatric disorders and Cranston, 1998; Garofalo et al., 1998; Remafedi et al., and demographic factors (Gould et al., 1996; Pilowsky 1998; Russell and Joyner, 2001; see McDaniel et al., 2001, et al., 1999). The negative finding by Andrews and for a recent review). In a study of a nationally represen- Lewinsohn (1992) may be due to a gender specificity of tative sample of nearly 12,000 adolescents, those who the association: panic attacks may increase suicide risk reported same-sex sexual orientation also exhibited sig- for girls only (Gould et al., 1996). Inconsistent findings nificantly higher rates of other suicide risk factors (Russell have been reported in the adult literature (Johnson et al., and Joyner, 2001). After adjusting for these risks, the 1990; Warshaw et al., 2000; Weissman et al., 1989) effects of same-sex sexual orientation on suicidal behav- Prior Suicide Attempts. A history of a prior suicide ior remained, but were substantially mediated by depres- attempt is one of the strongest predictors of completed sion, alcohol abuse, family history of attempts, and suicide, conferring a particularly high risk for boys (30- victimization. Notably, most youths who reported same- fold increase) and a less elevated risk for girls (3-fold sex sexual orientation reported no suicidality at all: 84.6% increase) (Shaffer et al., 1996). Between one quarter to of males and 71.7% of females. one third of youth suicide victims have made a prior sui- Biological Factors. Over the past 25 years, a substantial cide attempt (see Groholt et al., 1997). Similarly strong body of knowledge has accrued, indicating abnormali- associations between a history of suicidal behavior and ties of serotonin function in suicidal and in impulsive, future attempts have been reported in general popula- aggressive individuals, regardless of psychiatric diagno- tion surveys and longitudinal studies (Lewinsohn et al.,1994; sis. Earlier studies focused on simple indices of seroto- McKeown et al., 1998; Reinherz et al., 1995; Wichstrom, nin activity, such as the reduced concentration of serotonin 2000) and clinical samples (Hulten et al., 2001; Pfeffer metabolites in the brain and cerebrospinal fluid (CSF) in et al., 1991), with risk for an attempt increasing between suicide victims or among suicide attempters compared 3 and 17 times for those with prior suicidal behavior. with age- and gender-matched controls (see Oquendo Cognitive and Personality Factors. Hopelessness has been and Mann, 2000). More recently, neuroanatomical stud- linked with suicidality (Howard-Pitney et al., 1992; ies have shown a reduction in the overall density of sero-

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tonin 1A receptors and serotonin transporter receptors complexity of the suicide phenotype; that the genetic (which regulate serotonin uptake) in the prefrontal cor- effect is small and requires examination of large samples; tex. Most recently, Arango and her colleagues (2001) or because a single genetic variant is less important than found significant reductions in the number and binding patterns of variance (Marshall et al., 1999). Support for capacity of serotonin 1A receptors in the dorsal raphe this is offered by haplotype analyses (haplotypes are clus- nucleus, from which serotonin innervation of the pre- ters of genes that are usually found together) that have frontal cortex arises (Arango et al., 2001). shown a distinctive profile among both suicide completers To explain the often-replicated finding that serotonin (Turecki et al., 2001) and attempters (Rotondo et al., dysregulation is associated with suicidality regardless of 1999) in samples in which single-gene polymorphisms diagnosis, Mann et al. (1999) suggested that the dysreg- did not differ significantly from those of controls. ulation is a biological trait that predisposes to suicide— The other two candidate genes that have been studied a stress-diathesis model. Thus a mentally ill person with are the serotonin transporter (SERT ) gene and the sero- the diathesis is more likely to respond to a stressful expe- tonin A receptor gene. Polymorphisms in these genes have rience in an impulsive fashion that may include a deci- been reported in completed and attempted suicide sion to commit suicide. (Arango et al., 2001; Courtet et al., 2001; Du et al., 2001; Despite the great volume of work, unanswered ques- Neumeister et al., 2002). tions remain. The behavioral correlates of low-serotonin While biological findings currently have little impact states are assumed to include irritability, impulsivity, and on clinical practice, Nordstrom and colleagues’ (1994) emotional volatility, but most studies address diagnosis finding that suicide attempters with low levels of CSF 5- rather than specific symptoms and the correlation has yet hydroxyindoleacetic acid have a significantly higher like- to be explored in the general population. An absence of lihood of making further suicide attempts and/or committing representative studies has meant that neither the relative suicide, coupled with the promising research on candi- risk of serotonin dysfunction nor the fraction of suicides date genes, may eventually take suicide prediction and attributable to serotonin underfunctioning is yet known. prevention to new, more precise levels and/or may lead to Finally, the examination of the association of serotonin specific interventions that will reduce the impact of the metabolism with suicide has largely been limited to stud- predisposing trait. ies of adults. Family Characteristics The documented suicide risk associated with family history (see “Family History of Suicidal Behavior” below) Family History of Suicidal Behavior. A family history has led to an active investigation of candidate genes, of suicidal behavior greatly increases the risk of com- attempting to identify what suicidogenic factor might be pleted suicide (Agerbo et al., 2002; Brent et al., 1988, inherited. Given the substantial body of data that point 1994a, 1996; Gould et al., 1996; Shaffer, 1974; Shafii to reduced serotonin neurotransmission in suicide (see et al., 1985) and attempted suicide (Bridge et al., 1997; above), the target of most recent association studies has Glowinski et al., 2001; Johnson et al., 1998). Because been polymorphisms in three genes that play important suicide and psychiatric illness almost always co-occur, roles in the regulation of serotonin. One gene is trypto- account has to be taken of whether apparent familiality phan hydroxylase (TPH), the rate-limiting enzyme for reflects suicide specifically or instead an association with the biosynthesis of serotonin. Early studies (Mann and parental psychiatric illness (Brent et al., 1996). Most Stoff, 1997; Nielsen et al., 1994, 1998) reported a rela- recently, the Danish Registry study (Agerbo et al., 2002) tionship between attempted suicide and a polymorphism found youth suicide to be nearly five times more likely on intron 7 of the TPH gene. Since then, a large num- in the offspring of mothers who have completed suicide ber of studies with inconsistent findings have been car- and twice as common in the offspring of fathers, adjust- ried out on suicidal patients with various diagnoses with ing for parental psychiatric history. and without suicidality. The Utah Youth Suicide Study The Missouri Adolescent Twin Study (Heath et al., has been the main study to have examined adolescents 2002) addressed the question of inheritance versus envi- (Bennet et al., 2000), and it has failed to find an associ- ronment among teenage suicide attempters. One hun- ation. There are several possible reasons for the inconsis- dred thirty twin pairs had been affected by a suicide tent findings, including the probable heterogeneity and attempt within the total representative sample of 3,416

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female adolescent twins. After controlling for other psy- Brent et al., 1994a, 1999; Fergusson and Lynskey, 1995; chiatric risk factors, the twin/cotwin odds ratio was 5.6 Fergusson et al., 2000; Gould et al., 1996; Lewinsohn (95% confidence interval [CI] 1.75–17.8) for monozy- et al., 1993, 1994; McKeown et al., 1998; Tousignant gotes and 4.0 (95% CI 1.1–14.7) for dizygotes, suggest- et al., 1993). However, because an underlying psychiat- ing a degree of inheritance for suicidality (Glowinski ric problem in the youth may precipitate impaired par- et al., 2001). The heritability of youth suicide gains fur- ent–child relationships, it is necessary to disentangle these ther support from a meta-analysis by McGuffin et al. factors. While Gould et al. (1996) found that suicide vic- (2001), who reexamined a large body of published twin tims still had significantly less frequent and less satisfy- data (all ages). They concluded that first-degree relatives ing communication with their mothers and fathers than of suicides have more than twice the risk of the general community controls, even after adjusting for their psy- population, with the relative risk increasing among iden- chiatric disorders, others have found that the associations tical cotwins of suicides to about 11. The estimated her- between nonlethal suicidal behavior and poor attachment itability for completed suicide was 43% (95% CIs 25–60). and family cohesion are not independent of the youth’s Parental Psychopathology. High rates of parental psy- psychological problems (Fergusson et al., 2000; McKeown chopathology, particularly depression and substance abuse, et al., 1998). Similarly, parent–child conflict has been have been found to be associated with completed suicide found to be no longer associated with completed suicide (Brent et al., 1988, 1994a; Gould et al., 1996) and with (Brent et al., 1994a) or attempts (Lewinsohn et al., 1993) suicidal ideation and attempts in adolescence (e.g., once the youth’s psychopathology is taken into account. Fergusson and Lynskey, 1995; Joffe et al., 1988; Kashani Adverse Life Circumstances et al., 1989). Brent and his colleagues (1994a) reported that a family history of depression and substance abuse Stressful Life Events. Life stressors, such as interpersonal significantly increased the risk of completed suicide, even losses (e.g., breaking up with a girlfriend or boyfriend) after controlling for the victim’s psychopathology. They and legal or disciplinary problems, are associated with concluded that familial psychopathology adds to suicide completed suicide (Beautrais, 2001; Brent et al., 1993c; risk by mechanisms other than merely increasing the lia- Gould et al., 1996; Marttunen et al., 1993; Rich et al., bility for similar psychopathology in an adolescent. In 1988; Runeson, 1990) and suicide attempts (Beautrais contrast, Gould and her colleagues (1996) found that the et al., 1997; Fergusson et al., 2000; Lewinsohn et al., impact of parental psychopathology no longer contributed 1996), even after adjusting for psychopathology (Brent to the youth’s suicide risk after the study controlled for et al., 1993c; Gould et al., 1996) and antecedent social, the youth’s psychopathology. To date, it is unclear pre- family, and personality factors (Beautrais et al., 1997). cisely how familial psychopathology increases the risk for The prevalence of specific stressors among suicide vic- completed suicide. tims varies by age: parent–child conflict is a more com- Parental Divorce. Suicide victims are more likely to come mon precipitant for younger adolescent victims, whereas from nonintact families of origin (Beautrais, 2001; Brent romantic difficulties are more common in older adoles- et al., 1993a, 1994a; Gould et al., 1996; Groholt et al., cents (Brent et al., 1999; Groholt et al., 1998). Stressors 1998; Sauvola et al., 2001). However, the association also vary by psychiatric disorder: interpersonal losses are between separation/divorce and suicide decreases when more common among suicide victims with substance accounting for parental psychopathology (Brent et al., abuse disorders (Brent et al., 1993c; Gould et al., 1996; 1994a; Gould et al., 1996). Similarly, although many Marttunen et al., 1994; Rich et al., 1988), and legal or population-based studies have found significant univari- disciplinary crises are more common in victims with dis- ate associations (e.g., Andrews and Lewinsohn, 1992; ruptive disorders (Brent et al., 1993c; Gould et al., 1996) Fergusson and Lynskey, 1995), these associations are no or substance abuse disorders (Brent et al., 1993c). Bullying, longer evident or are markedly attenuated once psychosocial whether as victim or perpetrator, has also recently been risk factors are taken into account (e.g., Beautrais et al., demonstrated to increase the risk for suicidal ideation 1996; Fergusson et al., 2000; Groholt et al., 2000). (Kaltiala-Heino et al., 1999). Parent–Child Relationships. Impaired parent–child rela- Physical Abuse. The association between physical abuse tionships are associated with increased risk of suicide and and suicide reported in case-control psychological autopsy suicide attempts among youths (Beautrais et al., 1996; studies (Brent et al., 1994a, 1999) has been replicated in

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prospective longitudinal community studies (Brown et al., been found to have higher rates of sociodemographic dis- 1999; Johnson et al., 2002; Silverman et al., 1996), the advantage, even after controlling for other social and psy- most methodologically rigorous design to examine this chiatric risk factors (Beautrais et al., 1996; Fergusson issue. Childhood physical abuse has been found to be et al., 2000; Wunderlich et al., 1998). associated with an increased risk of suicide attempts in School and Work Problems. Difficulties in school, nei- late adolescence or early adulthood, even after adjusting ther working nor being in school, and not going to col- for demographic characteristics, psychiatric symptoms lege pose significant risks for completed suicide (Gould during childhood and early adolescence, and parental et al., 1996). Beautrais et al. (1996) reported that serious psychiatric disorders (Johnson et al., 2002). Interpersonal suicide attempters were also more likely to drop out of difficulties during middle adolescence, such as frequent high school or not attend college, and Wunderlich and arguments with adults and peers and having no close colleagues (1998) reported that German school dropouts friends, were found to mediate the association between were 37 times more likely to attempt suicide, even after child abuse and later suicide attempts (Johnson et al., adjusting for diagnostic and social risk factors. 2002). Johnson and his colleagues (2002) suggested that Contagion/Imitation. Evidence continues to amass from children who are physically abused may have difficulty studies of suicide clusters and the impact of the media, developing the social skills necessary for healthy rela- supporting the existence of suicide contagion. Several tionships, which leads to social isolation and/or antago- studies have reported significant clustering of suicides, nistic interactions with others, which in turn puts them defined by temporal-spatial factors, among teenagers and at increased risk for suicidal behavior. young adults (Brent et al., 1989; Gould et al., 1990a,b, Sexual Abuse. Longitudinal community studies are also 1994), with only minimal effects beyond 24 years of age the most methodologically rigorous design to examine (Gould et al., 1990a,b). Similar age-specific patterns have the association between child sexual abuse (CSA) and been reported for clusters of attempted suicides (Gould subsequent suicidality due to the serious problems of ret- et al., 1994). Since 1990, the effect of the media on sui- rospective recall in this area. Two such studies have found cide rates has been documented in many other countries self-reported CSA to be significantly associated with an besides the United States, including Australia (e.g., Hassan, increased risk of suicidal behavior in adolescence 1995), Austria (e.g., Etzersdorfer et al., 1992), Germany (Fergusson et al., 1996; Silverman et al., 1996). Because (e.g., Jonas, 1992), Hungary (e.g., Fekete and Macsai, CSA may be associated with reported risk factors for sui- 1990), and Japan (Ishii, 1991; Stack, 1996), adding to cide (e.g., parental substance abuse), it is necessary to the extensive work prior to 1990 in the United States on control for such factors. Fergusson et al. (1996) found newspaper articles, television news reports, and fictional that the association between CSA and suicidality was dramatizations. Overall, the magnitude of the suicide greatly reduced but was not eliminated, after controlling increase is proportional to the amount, duration, and for a wide range of potentially confounding factors. This prominence of media coverage, and the impact of sui- suggests that the increased risk of suicide from CSA may cide stories on subsequent completed suicides appears to be partly, but not entirely, accounted for by other factors. be greatest for teenagers (see Gould, 2001; Schmidtke and Schaller, 2000; Stack, 2000). Socioenvironmental and Contextual Factors Stack’s (2000) review of 293 findings from 42 studies Socioeconomic Status. Studies of suicide victims gener- indicates that methodological differences among studies are ally have found no or small effects of socioeconomic dis- strong predictors of differences in their findings. For exam- advantage (Agerbo et al., 2002; Brent et al., 1988). ple, although a highly publicized recent study (Mercy et al., Specifically, Agerbo et al. (2002) noted that the effect of 2001) found that exposure to media accounts of suicidal socioeconomic disadvantage decreased after adjustment behavior and exposure to suicidal behavior in friends or for family history of mental illness or suicide. Gould et al. acquaintances were associated with a lower risk of youth (1996) also found no effect of socioeconomic status for suicide attempts, the interpretability of the findings is lim- white or Latino victims, but African-American victims ited because (1) the media exposure factor was a conglom- had a significantly higher socioeconomic status than their erate of different types of media stories; (2) attempters may general population counterparts. Youth suicide attempters, have had less exposure to media generally (e.g., read fewer compared with community controls, have consistently books, fewer newspapers, etc.); (3) attempters had signifi-

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cantly more proximal stressors, possibly overshadowing their nity, and health-care systems—and generally have one of recollection of media exposure; (4) the timing of exposure two general goals: case finding with accompanying refer- was a 30-day interval, in contrast to most other studies, ral and treatment or risk factor reduction (CDC, 1994; which examined a shorter interval following the exposure; Gould and Kramer, 2001). and (5) nearly half of the sample was between 25 and 34 years of age, a group not particularly sensitive to imitation. School-Based Suicide Prevention Programs Another study finding—no effect of parental suicide—was Suicide Awareness Curriculum. These programs seek to also inconsistent with the prevailing research literature. A increase awareness of suicidal behavior in order to facil- summary of interactive factors that may moderate the impact itate self-disclosure and prepare teenagers to identify at- of media stories, including characteristics of the stories, risk peers and take responsible action (Kalafat and Elias, individual reader/viewer attributes, and social context of 1994). The underlying rationale of these programs is that the stories, is presented by Gould (2001). teenagers are more likely to turn to peers than adults for support in dealing with suicidal thoughts (Hazell and PROTECTIVE FACTORS King, 1996; Kalafat and Elias, 1994; Ross, 1985). Family Cohesion Several studies evaluated school-based suicide awareness programs in the past decade (Ciffone, 1993; Kalafat and Family cohesion has been reported as a protective fac- Elias, 1994; Kalafat and Gagliano, 1996; Shaffer et al., tor for suicidal behavior among adolescents in a longitu- 1991; Silbert and Berry, 1991; Vieland et al., 1991). While dinal study of middle school students (McKeown et al., improvements in knowledge (Kalafat and Elias, 1994; 1998) and cross-sectional community studies of high Silbert and Berry, 1991), attitudes (Ciffone, 1993; Kalafat school (Rubenstein et al., 1989, 1998) and college stu- and Elias, 1994; Kalafat and Gagliano, 1996), and help- dents (Zhang and Jin, 1996). Students who described fam- seeking behavior (Ciffone, 1993) have been found, other ily life in terms of a high degree of mutual involvement, studies reported either no benefits (Shaffer et al., 1990, shared interests, and emotional support were 3.5 to 5.5 1991; Vieland et al., 1991) or detrimental effects of sui- times less likely to be suicidal than were adolescents from cide prevention education programs (Overholser et al., less cohesive families who had the same levels of depres- 1989; Shaffer et al., 1991). Detrimental effects included a sion or life stress (Rubenstein et al., 1989, 1998). decrease in desirable attitudes (Shaffer et al., 1991); a reduc- Religiosity tion in the likelihood of recommending mental health evaluations to a suicidal friend (Kalafat and Elias, 1994); more Since Durkheim’s (1966) formulation of a social inte- hopelessness and maladaptive coping responses among gration model, the protective role of religiosity on sui- boys after exposure to the curriculum (Overholser et al., cide has been a focus of scientific investigation (e.g., 1989); and negative reactions among students with a his- Hovey, 1999; Lester, 1992; Neeleman, 1998; Neeleman tory of suicidal behavior, including their not recommending and Lewis, 1999; Sorri et al., 1996; Stack, 1998; Stack the programs to other students and feeling that talking and Lester, 1991). As noted previously, greater religios- about suicide in the classroom “makes some kids more ity has been posited as underlying the historically lower likely to try to kill themselves” (Shaffer et al., 1990). Other suicide rate among African Americans. However, only limitations of this strategy are that baseline knowledge and recently has the protective value of religiosity against sui- attitudes of students are generally sound (Kalafat and Elias, cidal behavior (Hilton et al., 2002; Siegrist, 1996; Zhang 1994; Shaffer et al., 1991), changes in attitudes and knowl- and Jin, 1996) and depression (Miller et al., 1997b) been edge are not necessarily highly correlated with behavioral documented in adolescents and young adults. Regrettably, change (Kirby, 1985; McCormick et al., 1985), and the these studies have not controlled for potential confounders, format and content of some programs might inadvertently such as substance abuse, which may be less prevalent stimulate imitation (Gould, 2001). among religious youths. To date there is insufficient evidence to either support or not support curriculum-based suicide awareness pro- PREVENTION STRATEGIES grams in schools (Guo and Harstall, 2002). Accordingly, Youth suicide prevention strategies have primarily been emphasis has shifted toward alternative school-based implemented within three domains—school, commu- strategies that will be presented below.

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Skills Training. In contrast to suicide awareness cur- ousness of missing a suicidal individual precludes this riculum in schools, skills training programs emphasize scheme. Thus a tolerance for false-positives is essential the development of problem-solving, coping, and cog- for such endeavors (Thompson and Eggert, 1999), neces- nitive skills, as suicidal youths have deficits in these areas sitating second-stage assessments to determine who is not (e.g., Asarnow et al., 1987; Cole, 1989; Rotheram-Borus actually at risk for suicide. Second-stage assessments usu- et al., 1990). It is hoped that an “immunization” effect ally employ systematic clinical evaluations, using inter- can be produced against suicidal feelings and behaviors. views such as the Suicidal Behaviors Interview (Reynolds, The reduction of suicide risk factors (e.g., depression, 1990) or the Diagnostic Interview Schedule for Children hopelessness, and drug abuse) is also a targeted outcome. (DISC), now available in a spoken, self-completion (Voice- Several evaluation studies have shown promising results, DISC) version (Shaffer and Craft, 1999). with some evidence for reductions in completed and Although a screening strategy appears to be quite attempted suicides (Zenere and Lazarus, 1997) and promising, a number of dilemmas still need to be addressed. improvements in attitudes, emotions, and distress cop- First, because suicide risk “waxes and wanes” over time, ing skills (Klingman and Hochdorf, 1993; Orbach and multiple screenings may be necessary in order to mini- Bar-Joseph, 1993). The most systematic evaluations have mize “false-negatives” (Berman and Jobes, 1995). Second, been conducted by a team of researchers (Eggert et al., school-wide student screening programs have been rated 1995; Randell et al., 2001; Thompson et al., 2000, 2001) by high school principals as significantly less acceptable who have focused on skills training and social support than curriculum-based and staff in-service programs, programs for students at high risk for school failure or although most respondents in this study have had either dropout. Enhancements of protective factors and reduc- no or minimal exposure to screening programs (Miller tions in risk factors following the “active” interventions et al., 1999). Finally, the ultimate success of this strategy were consistently found, while the control “intervention is dependent on the effectiveness of the referral. Considerable as usual” did not yield an increase of protective factors. effort must be made to assist the families and adolescents However, “intervention as usual” sometimes produced in obtaining help if it is needed. significant reductions in suicide risk behaviors (Eggert Gatekeeper Training. Programs to train school person- et al., 1995; Randell et al., 2001). Thus it is not clear nel as gatekeepers are based on the premise that suicidal which aspects of the skills training program were respon- youths are underidentified and that we can increase iden- sible for risk reduction, a limitation of other studies also tification by providing adults with knowledge about sui- (Zenere and Lazarus, 1997). While these studies yield cide. Only 9% of a national random sample of U.S. high encouraging data, additional research is sorely needed to school teachers believed they could recognize a student refine the evaluation of this type of intervention. at risk for suicide, and while the overwhelming majority Screening. A prevention strategy that has received of counselors knew the risk factors for suicide, only one increased attention is case-finding through direct screen- in three believed they could identify a student at risk ing of individuals. Self-report and individual interviews (King et al., 1999). are used to identify youngsters at risk for suicidal behav- The purpose of gatekeeper training is to develop the ior (Joiner et al., 2002; Reynolds, 1991; Shaffer and Craft, knowledge, attitudes, and skills to identify students at 1999; Thompson and Eggert, 1999). School-wide screen- risk, determine the levels of risk, and make referrals when ings, involving multistage assessments, have focused on necessary (Garland and Zigler, 1993; Kalafat and Elias, depression, substance abuse problems, recent and fre- 1995). Research examining the effectiveness of gatekeeper quent suicidal ideation, and past suicide attempts. The training is limited, but the findings are encouraging, with few studies that have examined the efficacy of school- significant improvements in school personnel’s knowl- based screening (Reynolds, 1991; Shaffer and Craft, 1999; edge, attitudes, intervention skills, preparation for cop- Thompson and Eggert, 1999) found that the sensitivity ing with a crisis, referral practices (Garland and Zigler, of the screens ranged from 83% to 100%, while the speci- 1993; King and Smith, 2000; Mackesy-Amiti et al., 1996; ficities ranged from 51% to 76%. Thus, while there were Shaffer et al., 1988; Tierney, 1994), and general satisfac- few false-negatives, there were many false-positives. tion with the training (Nelson, 1987). As previously noted, Although the number of false-positives could be mini- in-service training programs are significantly more accept- mized by using a more stringent cutoff criterion, the seri- able by principals than school-wide screening programs

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(Miller et al., 1999). This is consistent with the finding no new suicides took place during a 4-year follow-up period that 46% of school districts in Washington have gate- in schools where an adequate intervention took place, keeper training programs, while no districts use group whereas the number of suicides significantly increased after screening of students (Hayden and Lauer, 2000). suicides with no adequate subsequent crisis intervention. Peer Helpers. The rationale underlying these programs It is imperative for crisis interventions to be well planned is similar to that of suicide awareness programs: Suicidal and evaluated; otherwise, not only may they not help sur- youths are more likely to confide in a peer than an adult vivors, but they may potentially exacerbate problems through (e.g., Kalafat and Elias, 1994). The role that peers play the induction of imitation. varies considerably by program, with some limited to listening and reporting any possible warning signs and oth- Community-Based Prevention Programs ers involving counseling responsibilities. Many programs Crisis Centers and Hotlines. The rationale for crisis hot- address serious mental health problems, such as drug lines (Mishara and Daigle, 2001; Shaffer et al., 1988; abuse, eating disorders, and depression, with 24% of pro- Shneidman and Farberow, 1957) is that suicidal behav- grams in Washington State involving some suicide pre- ior is often associated with a crisis (Brent et al., 1993c; vention role (Lewis and Lewis, 1996). Empirical evaluations Gould et al., 1996; Marttunen et al., 1993; Rich et al., of these programs are quite limited (Lewis and Lewis, 1988, Runeson, 1990) and telephone crisis services can 1996) and often confined to student satisfaction mea- provide the opportunity for immediate support at these sures (Morey et al., 1993). Potential negative side effects critical times by offering services that are convenient, are rarely examined. To date, there is not a sufficient body accessible, and available outside of usual office hours. of evidence documenting the efficacy or safety of peer Evidence of their efficacy on adult suicide is equivo- helping programs, despite their widespread use (Lewis cal (Lester, 1997), and few studies have examined the uti- and Lewis, 1996). lization or efficacy of hotlines among teenagers (Boehm Postvention/Crisis Intervention. The rationale for school- and Campbell, 1995; King, 1977; Slem and Cotler, 1973). based postvention/crisis intervention is that a timely response Overall, between 1% and 6% of adolescents in the com- to a suicide is likely to reduce subsequent morbidity and munity use hotlines (Offer et al., 1991; Slem and Cotler, mortality in fellow students, including suicidality, the onset 1973; Vieland et al., 1991) and only 4% of calls concern or exacerbation of psychiatric disorders (e.g., posttraumatic suicide (Boehm and Campbell, 1995). However, between stress disorder, major depressive disorder), and other symp- 14% and 18% of suicidal youths have used hotlines toms related to pathological bereavement (Brent et al., (Beautrais et al., 1998; Shaffer et al., 1990). There is a 1993b,e, 1994b). The major goals of postvention programs dearth of information about the efficacy of telephone cri- are to assist survivors in the grief process, identify and refer sis services for teenagers and whether they adequately those individuals who may be at risk following the suicide, address suicide risk. provide accurate information about suicide while attempt- Restrictions of Firearms. The underlying rationale for ing to minimize suicide contagion, and implement a struc- means restrictions is that suicidal individuals are often ture for ongoing prevention efforts (Hazell, 1993; Underwood impulsive, they may be ambivalent about killing them- and Dunne-Maxim, 1997). selves, and the risk period for suicide is transient (Hawton The existing research on school-based postvention pro- et al., 2001; Miller and Hemenway, 1999). Restricting grams is sparse. Hazell and Lewin (1993) examined the access to lethal methods during this period may prevent efficacy of 90-minute group counseling sessions offered to suicides, although it is not clear that method restriction groups of 20 to 30 students on the seventh day following has substantially contributed to the recent secular change a suicide. No differences in outcome were found between in youth suicide. counseled subjects and matched controls. It was unclear Because the most common method of committing sui- whether this finding was due to inclusion criteria for postven- cide in the United States is by firearms (CDC, 2002), tion counseling (close friends of deceased student), the this review will focus on restricting their access. The pres- intervention itself, or the duration of the distress, or whether ence of firearms in the home is a significant risk factor short-term effects dissipated by the assessment at 8 months for suicide in youths (Brent et al., 1988, 1991, 1993d, after the death. An encouraging, though small and method- 1999) and adults (Kellermann et al., 1992). Several stud- ologically limited, study by Poijula et al. (2001) found that ies have found that restrictions on guns reduced the over-

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all suicide rate, as well as firearm-related suicides (e.g., 2001). Guidelines for media reporting now exist in sev- Boor and Bair, 1990; Carrington and Moyer, 1994; Lester eral countries. Recommendations generally include descrip- and Murrell, 1980, 1986; Loftin et al., 1991; Medoff and tions of factors that should be avoided because they are Magaddino, 1983), while others have found no overall more likely to induce contagion (e.g., front page cover- effect (Rich et al., 1990) or equivocal results (Cantor and age) and suggestions on how to increase the usefulness of Slater, 1995; Cummings et al., 1997; Sloan et al., 1990). the report (e.g., describing treatment resources). The equivocal findings largely reflected age-specific effects Following the implementation of media guidelines in (Cantor and Slater, 1995; Sloan et al., 1990), in that Austria, suicide rates declined 7% in the first year, nearly restrictive gun laws had a greater impact on adolescents 20% in the 4-year follow-up period, and subway suicides and young adults. Unfortunately, recent legislative ini- (a particular focus of the media guidelines) decreased by tiatives such as the 1994 Brady Bill, which imposes a delay 75% (Etzersdorfer et al., 1992; Etzersdorfer and Sonneck, in purchasing a handgun, did not find promising results: 1998; Sonneck et al., 1994). In Switzerland, Michel et al. A comparison of states that did and did not pass Brady (2000) found that following the implementation of guide- Bill statutes showed no impact on the proportion of sui- lines, the number of articles increased but they were sig- cides attributable to firearms except in elderly males nificantly shorter and less likely to be on the front page; (Ludwig and Cook, 2000). headlines, pictures, and text were less sensational; there Less controversial means-restriction measures in the were relatively fewer articles with pictures; and their over- United States involve education to parents of high-risk all “Imitation Risk Scores” were lower. Given the suc- youths. Kruesi and colleagues (1999) demonstrated that cessful strategy of engaging the media in Austria and injury prevention education in emergency rooms led par- Switzerland, efforts to systematically disseminate and ents to take new action to limit access to lethal means, evaluate media recommendations in the United States such as locking up their firearms. Unfortunately, Brent are recommended. et al. (2000) found that parents of depressed adolescents were frequently noncompliant with recommendations to Health Care-Based Prevention Programs remove firearms from the home. Educational/Training Programs for Primary Care Physicians A common concern is that method substitution will and Pediatricians. The need for training primary care physi- occur following a means-restriction program. Some evi- cians and pediatricians in the United States is highlighted dence of method substitution exists (Lester and Leenaars, by the finding that while 72% of 600 family physicians 1993; Lester and Murrell, 1982; Rich et al., 1990); how- and pediatricians in North Carolina had prescribed a SSRI ever, method substitution does not appear to be an inevitable for a child or adolescent patient, only 8% said they had reaction to firearms restriction (Cantor and Slater, 1995; received adequate training in the treatment of childhood Carrington and Moyer, 1994; Lester and Murrell, 1986; depression and only 16% reported that they felt com- Loftin et al., 1991). Moreover, even if some individuals fortable treating children for depression (Voelker, 1999). do substitute other methods, the chances of survival may Furthermore, although many suicidal young people (15–34 be greater if the new methods are less lethal (Cantor and years) seek general medical care in the month preceding Baume, 1998). their suicidal behavior (Pfaff et al., 1999), fewer than half Media Education. Given the substantial evidence for of physicians surveyed reported that they routinely screen suicide contagion, a recommended suicide prevention strat- their patients for suicide risk (Frankenfield et al., 2000). egy involves educating media professionals about conta- Pfaff et al. (2001) demonstrated that after a 1-day train- gion, in order to yield stories that minimize harm. Moreover, ing workshop for 23 primary care physicians in Australia, the media’s positive role in educating the public about risks inquiry about suicidal ideation increased by 32.5% and for suicide and shaping attitudes about suicide should be identification of suicidal patients increased by 130%, encouraged. although no significant change in patient management A set of recommendations on reporting of suicide were resulted and referrals of suicidal youths to mental health recently developed by an international workgroup headed specialists remained low. The effectiveness of educational by the American Foundation for Suicide Prevention and programs for health care professionals has also been demon- the Annenberg School of Communication and Public strated by the Gotland study (Rutz et al., 1992). After the Policy (American Foundation for Suicide Prevention, implementation of an intensive postgraduate training pro-

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gram aimed at improving general practitioners’ diagnosis firearms and/or lethal medications inaccessible to the and treatment of depression on the island of Gotland, child (Kruesi et al., 1999). Sweden, the adult suicide rate significantly declined. The Similarly, a written or verbal “no-suicide” contract is decline was almost totally due to decreases in female sui- commonly negotiated at the start of treatment in the hope cides with major depression (the number of male suicides that it will improve treatment compliance and reduce the was unchanged). Three years after the project ended, the likelihood of further suicidal behavior (Brent, 1997; suicide rate returned almost to baseline rates (Rihmer et al., Rotheram, 1987). However, no empirical studies have eval- 1995), suggesting that ongoing repetition of the educa- uated the effectiveness of no-suicide contracts (Reid, 1998). tional program is warranted. A similar educational pro- Rotheram-Borus et al. (1999) found that the imple- gram for pediatricians could be an effective youth suicide mentation of a brief set of specialized emergency room prevention strategy; however, other adjunctive approaches procedures increased eventual treatment adherence among to reach at-risk males should be considered. Latina adolescent suicide attempters. The procedures aug- mented typical emergency room care by (1) using a stan- TREATMENT dardized protocol for training emergency room staff, (2) Recent reviews (e.g., Hawton et al., 1998, 2002; Rudd, presenting a 20-minute videotape to patients and their 2000) note that few studies have systematically evaluated families that models realistic expectations for aftercare interventions aimed at reducing suicidal ideation and treatment, and (3) providing a bilingual crisis therapist behavior in children and adolescents, i.e., randomized to promote compliance with outpatient therapy. Suicidal controlled trials that obtain reliable and valid measures of adolescents receiving the specialized emergency room outcome variables during pretreatment, posttreatment, procedure attended 3.8 more outpatient follow-up ses- and follow-up periods. Most treatment efficacy studies of sions than those receiving standard aftercare. The research adolescent psychiatric populations exclude suicidal indi- was not able to identify which of these components were viduals, possibly because the potential risks of treating responsible for the increase in compliance. high-risk youths outweigh benefits. The National Institute of Mental Health recently published guidelines that high- Inpatient Care and Partial Hospitalization light a number of ethical, legal, and safety considerations While inpatient and partial hospitalization offer inten- associated with such studies (Pearson et al., 2001). sive multidisciplinary treatments and skilled observation and support, there is no empirical evidence that either of Treatment Service Utilization these interventions is effective in reducing rates of sui- Many adolescents contact a mental health professional cidal ideation, nonlethal attempts, or completed suicide before their suicidal behavior. Among suicide completers, among adolescents. rates of contact vary from 7% to 15% within the previous month, 20% to 25% within the previous year, and Outpatient Follow-up Treatment 25% to 35% over the lifetime (Brent et al., 1993a; Groholt Generally low rates of compliance with outpatient et al., 1997; Marttunen et al., 1992; Shaffer et al., 1996). treatment among adolescent suicide attempters (e.g., Contact rates were higher, between 59% and 78%, in a Piacentini et al., 1995) make such investigations difficult New Zealand sample of attempters admitted for 24-hour to implement. Dropout rates as high as 59% have been hospital stay (Beautrais et al., 1998). reported (Spirito et al., 1992). King et al. (1997) found that compliance rates were highest for medication fol- Emergency/Crisis-Service Interventions and Triage low-up (66.7%), relative to rates for individual therapy Procedures for the acute care of suicidal adolescents (50.8%) and family therapy/parent psychoeducation have been described elsewhere (American Academy of (33.3%). Results of that study also indicate that non- Child and Adolescent Psychiatry, 2001). These recom- compliance is associated with parental psychopathology mendations are largely based on common sense approaches and family dysfunction. and expert clinical consensus. Such guidelines emphasize that certain preconditions must be satisfied before chil- Psychotherapy dren and adolescents are discharged from the emergency Hawton et al. (1998, 2002) reviewed all randomized service, e.g., the need to “sanitize” the home—make controlled trials targeting suicide attempters. Of 23 stud-

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ies, only two explicitly obtained an adolescent sample erably less dangerous in overdose than are tricyclic anti- (Cotgrove et al., 1995; Harrington et al., 1998). Unsuccessful depressants (Ryan and Varma, 1998), and there is evi- treatments included problem-solving (e.g., Rudd et al., dence that they reduce the frequency of impulsive and 1996), enhanced access to clinical service (e.g., Cotgrove aggressive behaviors (Coccaro and Kavoussi, 1997), which et al., 1995; van der Sande et al., 1997), and home-based are a common occurrence in suicidal teenagers. family therapy (Harrington et al., 1998). The only psy- In rare instances, ruminative suicidal ideation com- chotherapy that has been shown to reduce repeat attempts bined with akathisia can occur during the course of antipsy- in a randomized clinical trial is dialectical behavior ther- chotic (Hamilton and Opler, 1992) or SSRI treatment apy (DBT), a 12-month cognitive-behavioral intervention (King et al., 1991; Teicher et al., 1990). This complica- designed for adults with borderline personality disorder tion has been reported to respond to propranolol (Adler (Linehan et al., 1991). This study found that adults assigned et al., 1985; Chandler, 1990). When SSRI treatment is to DBT engaged in fewer and less severe parasuicidal behav- started, parents should be routinely advised to inform the iors post-treatment than patients assigned to treatment- psychiatrist if akathisia develops; the suicidal teenager as-usual, but this may partly be attributable to higher should likewise be advised to inform parents or physi- baseline attempt rates characteristic of patients with bor- cians if there is an upsurge in suicidal ideation. derline personality disorder. Downward extensions of DBT In adults with bipolar or other major affective disor- such as DBT-A (Miller et al., 1997a) may be of value; how- ders, long-term lithium treatment significantly reduces ever, they have not yet been systematically evaluated in this the recurrence of suicide attempts (Tondo et al., 1997) age group or in males, who are most at risk for suicide and sudden withdrawal from lithium increases the risk of (Anderson, 2002). No studies of cognitive-behavioral ther- suicide independent of any effect on other symptoms of apy with adolescent suicide attempters have been pub- mania (Tondo and Baldessarini, 2000). Similarly, cloza- lished, although it has been used successfully in adolescent pine is effective in reducing suicidality in adults with schizo- patients with depression (Brent et al., 1997; Harrington phrenia even when there is no apparent effect or impact and Clark, 1998). on other symptoms of schizophrenia (see Meltzer, 2001). The antisuicidal effects of lithium and clozapine have not Psychopharmacological Interventions been assessed in children or adolescents. If lithium is being To our knowledge, there have been no psychophar- used to treat an adolescent, it would be wise to observe macological studies that have specifically targeted suicidal the same degree of caution as has been used in adults with adolescents. However, it is likely that in spite of the absence respect to sudden withdrawal of the medication. of documented support, the use of SSRIs is common among teenagers who have been referred for suicidal CONCLUSIONS ideation or after they have made an attempt. Rates of pre- The past decade has witnessed a surge in research on scription of antidepressants among teenagers are extremely youth suicide risk. The current review has underscored high (Olfson et al., 2002b) and almost certainly include youth psychiatric disorder, a family history of suicide and adolescents who have attempted suicide. Indeed, this prac- psychopathology, stressful life events, and access to firearms tice may be a factor leading to the dramatic and encour- as key risk factors for youth suicide. Exciting new find- aging decline in youth suicide rates over the past decade ings have emerged on the biology of suicide in adults, (Isacsson, 2000). There are few a priori reasons not to treat but, while encouraging, these are yet to be replicated in suicidal adolescents with SSRIs, providing their progress youths. Factors that had been previously thought to be and response to the medication is closely monitored. risks for youth suicide, such as divorce and impaired par- SSRI antidepressants have been shown to reduce sui- ent–child relationships, have been found to be largely cidal ideation in both depressed (Letizia et al., 1996) and explained by underlying psychiatric problems in the youth nondepressed adults with cluster B personality disorders and/or parents, whereas other risk factors, such as same- (Verkes et al., 1998) and in individuals who have made sex sexual orientation and sexual abuse, while mediated a limited number of previous suicide attempts. SSRIs by other psychosocial risks, have recently been found to have been shown to be more effective than placebo in make an independent contribution to youth suicide. treating depressed teenagers (Emslie and Mayes, 2001; Despite the burgeoning research literature on risk fac- Emslie et al., 1997; Keller et al., 2001), they are consid- tors, there remains a paucity of information on protec-

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tive factors. Family cohesiveness and religiosity may be expression in the brainstem of depressed suicide victims. Neuropsycho- pharmacology 25:892–903 somewhat protective, but much more work needs to be Asarnow J, Carlson G, Guthrie D (1987), Coping strategies, self-perceptions, done before we can have confidence that they mitigate hopelessness, and perceived family environments in depressed and suicidal children. J Consult Clin Psychol 55:361–366 the impact of accumulating risk factors. Future research Barraclough BM, Bunch J, Nelson B, Sainsbury P (1974), A hundred cases of needs to increasingly identify factors that protect against suicide: clinical aspects. Br J Psychiatry 125:355–373 suicidal behavior so that they may be enhanced. Beautrais AL (2001), Child and young adolescent suicide in New Zealand. Aust N Z J Psychiatry 35:647–653 Several promising empirically based prevention strate- Beautrais AL, Joyce PR, Mulder RT (1996), Risk factors for serious suicide gies have been identified, including school-based skills attempts among youths aged 13 through 24 years. J Am Acad Child Adolesc Psychiatry 35:1174–1182 training for students, screening for at-risk youths, edu- Beautrais AL, Joyce PR, Mulder RT (1997), Precipitating factors and life events cation of primary care physicians, media education, and in serious suicide attempts among youths aged 13 through 24 years. J Am Acad Child Adolesc Psychiatry 36:1543–1551 lethal-means restriction; however, these strategies need Beautrais AL, Joyce PR, Mulder RT (1998), Psychiatric contacts among youths continuing evaluation studies before their efficacy can be aged 13 through 24 years who have made serious suicide attempts. J Am Acad Child Adolesc Psychiatry 37:504–511 established. Bennett PJ, McMahon WM, Watabe J et al. 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McDaniel JS, Purcell D, D’Augelli AR (2001), The relationship between sex- Psychiatr Clin North Am 23:11–25 ual orientation and risk for suicide: research findings and future directions Orbach I, Bar-Joseph H (1993), The impact of a suicide prevention program for research and prevention. Suicide Life Threat Behav 31(suppl):84–105 for adolescents on suicidal tendencies, hopelessness, ego identity, and cop- McGuffin P, Marusic A, Farmer A (2001), What can psychiatric genetics offer ing. Suicide Life Threat Behav 23:120–129 suicidology? Crisis 22:61–65 Overholser JC, Adams DM, Lehnert KL, Brinkman DC (1995), Self-esteem McKeown RE, Garrison CZ, Cuffe SP, Waller JL, Jackson KL, Addy CL (1998), deficits and suicidal tendencies among adolescents. J Am Acad Child Adolesc Incidence and predictors of suicidal behaviors in a longitudinal sample of Psychiatry 34:919–928 young adolescents. J Am Acad Child Adolesc Psychiatry 37:612–619 Overholser JC, Hemstreet A, Spirito A, Vyse S (1989), Suicide awareness pro- Medoff MH, Magaddino JP (1983), Suicides and firearm control laws. Eval grams in the schools: effect of gender and personal experience. J Am Acad Rev 7:357–372 Child Adolesc Psychiatry 28:925–930 Meltzer HY (2001), Treatment of suicidality in schizophrenia. Ann N Y Acad Pearson JL, Stanley B, King C, Fisher C (2001), Issues to Consider in Intervention Sci 932:44–58 Research With Persons at High Risk for Suicidality. Bethesda, MD: National

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GOULD ET AL.

Institute of Mental Health. Available online: htttp://www.nimh.nih.gov/ Rubenstein JL, Halton A, Kasten L, Rubin C, Stechler G (1998), Suicidal research/highrisksuicide.cfm (accessed July 1, 2002) behavior in adolescents: stress and protection in different family contexts. Pfaff J, Acres J, Wilson M (1999), The role of general practitioners in para- Am J Orthopsychiatry 68:274–284 suicide: a Western Australia perspective. Arch Suicide Res 5:207–214 Rubenstein JL, Heeren T, Housman D, Rubin C, Stechler G (1989), Suicidal Pfaff JJ, Acres JG, McKelvey RS (2001), Training general practitioners to behavior in “normal” adolescents: risk and protective factors. Am J recognise and respond to psychological distress and suicidal ideation in Orthopsychiatry 59:59–71 young people. 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J Clin lescents at risk for suicidal behaviors. Fam Community Health 14:64–75 Psychiatry 60:70–74 Rich CL, Fowler RC, Fogarty LA, Young D (1988), San Diego Suicide Study, Shaffer D, Garland A, Gould M, Fisher P,Trautman P (1988), Preventing III: relationships between diagnoses and stressors. Arch Gen Psychiatry teenage suicide: a critical review. J Am Acad Child Adolesc Psychiatry 45:589–592 27:675–687 Rich CL, Young JG, Fowler RC, Wagner J, Black NA (1990), Guns and sui- Shaffer D, Garland A, Vieland V, Underwood MM, Busner C (1991), The cide: possible effects of some specific legislation. Am J Psychiatry 147:342–346 impact of curriculum-based suicide prevention program for teenagers. J Rihmer Z, Rutz W, Pihlgren H (1995), Depression and suicide on Gotland: Am Acad Child Adolesc Psychiatry 30:588–596 an intensive study of all suicides before and after a depression-training Shaffer D, Gould M, Hicks R (1994), Worsening suicide rate in black teenagers. program for general practitioners. J Affect Disord 35:147–152 Am J Psychiatry 151:1810–1812 Roberts RE, Chen Y (1995), Depressive symptoms and suicidal ideation among Shaffer D, Gould MS, Fisher P et al. (1996), Psychiatric diagnosis in child and Mexican-origin and Anglo adolescents. J Am Acad Child Adolesc Psychiatry adolescent suicide. Arch Gen Psychiatry 53:339–348 34:81–90 Shaffer D, Hicks R (1994), Suicide. In: The Epidemiology of Childhood Disorders, Roberts RE, Chen Y, Roberts CR (1997), Ethnocultural differences in preva- Pless IB, ed. New York: Oxford University Press, pp 339–365 lence of adolescent suicidal behaviors. Suicide Life Threat Behav 27:208–217 Shaffer D, Vieland V, Garland A, Rojas M, Underwood MM, Busner C (1990), Robins E, Murphy PI, Wilkinson RH Jr, Gassner S, Kayes J (1959), Some Adolescent suicide attempters: response to suicide-prevention programs. clinical considerations in the prevention of suicide based on a study of JAMA 264:3151–3155 134 successful suicides. Am J Public Health 49:888–988 Shafii M, Carrigan S, Whittinghill JR, Derrick A (1985), Psychological autopsy Ross CP (1985), Teaching children the facts of life and death: suicide pre- of completed suicide in children and adolescents. Am J Psychiatry vention in the schools. In: Youth Suicide, Peck ML, Farberow NL, Litman 142:1061–1064 RE, eds. New York: Springer, pp 147–169 Shafii M, Steltz-Lenarsky J, Derrick AM, Beckner C, Whittinghill JR (1988), Rotheram MJ (1987), Evaluation of imminent danger for suicide among youth. Comorbidity of mental disorders in the post-mortem diagnosis of com- Am J Orthopsychiatry 57:102–110 pleted suicide in children and adolescents. J Affect Disord 15:227–233 Rotheram-Borus MJ, Piacentini J, Van Rossem R et al. (1999), Treatment Shiang J, Blinn R, Bongar B, Stephens B, Allison D, Schatzberg A (1997), adherence among Latina female adolescent suicide attempters. Suicide Life Suicide in San Francisco, CA: a comparison of Caucasian and Asian groups, Threat Behav 29:319–331 1987–1994. Suicide Life Threat Behav 27:80–91 Rotheram-Borus MJ, Trautman PD (1988), Hopelessness, depression and sui- Shneidman ES, Farberow NL (1957), Clues to Suicide. New York: Blakison cidal intent among adolescent suicide attempters. J Am Acad Child Adolesc Siegrist M (1996), Church attendance, denomination, and suicide ideology. Psychiatry 27:700–704 J Soc Psychol 136:559–566 Rotheram-Borus MJ, Trautman PD, Dopkins SC, Shrout PE (1990), Cognitive Silbert KL, Berry GL (1991), Psychological effects of a suicide prevention unit style and pleasant activities among female adolescent suicide attempters. on adolescents’ levels of stress, anxiety and hopelessness: implications for J Consult Clin Psychol 58:554–561 counselling psychologists. Couns Psychol 4:45–58 Rotondo A, Schuebel K, Bergen A et al. (1999), Identification of four vari- Silverman AB, Reinherz HZ, Giaconia RM (1996), The long-term sequelae ants in the tryptophan hydroxylase promoter and association to behavior. of child and adolescent abuse: a longitudinal community study. Child Mol Psychiatry 4:360–368 Abuse Negl 20:709–723

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YOUTH SUICIDE RISK AND INTERVENTIONS

Slem CM, Cotler S (1973), Crisis phone services: evaluation of a hotline pro- Turecki G, Zhu Z, Tzenova J et al. (2001), TPH and suicidal behavior: a study gram. Am J Community Psychol 1:219–227 in suicide completers. Mol Psychiatry 6:98–102 Sloan JH, Rivara FP, Reay DT, Ferris JA, Kellermann AL (1990), Firearm reg- Underwood MM, Dunne-Maxim K (1997), Managing sudden traumatic loss ulations and rates of suicide: a comparison of two metropolitan areas. N in the schools. University of Medicine and Dentistry of New Jersey. Engl J Med 322:369–373 New Jersey Adolescent Suicide Prevention Project. 1–134 (available at Smith JC, Mercy JA, Warren CW (1985), Comparison of suicides among [email protected]) Anglos and Hispanics in five Southwest states. Suicide Life Threat Behav van der Sande R, van Rooijen L, Buskens E et al. (1997), Intensive in-patient 15:14–26 and community intervention versus routine care after attempted suicide: Sonneck G, Etzersdorfer E, Nagel-Kuess S (1994), Imitative suicide on the a randomised controlled intervention study. Br J Psychiatry 171:35–41 Viennese subway. Soc Sci Med 38:453–457 Velez CN, Cohen P (1988), Suicidal behavior and ideation in a community Sorri H, Henriksson M, Lonnqvist J (1996), Religiosity and suicide: findings sample of children: maternal and youth reports. J Am Acad Child Adolesc from a nationwide psychological autopsy study. Crisis 17:123–127 Psychiatry 27:349–356 Sourander A, Helstela L, Haavisto A, Bergroth L (2001), Suicidal thoughts Verkes RJ, van der Mast RC, Hengeveld MW, Tuyl JP, Zwinderman AH, Van and attempts among adolescents: a longitudinal 8-year follow-up study. J Kempen GM (1998), Reduction by paroxetine of suicidal behavior in Affect Disord 63:59–66 patients with repeated suicide attempts but not major depression. Am J Spirito A, Plummer B, Gispert M et al. (1992), Adolescent suicide attempts: Psychiatry 155:543–547 outcomes at follow-up. Am J Orthopsychiatry 62:464–468 Vieland V, Whittle B, Garland A, Hicks R, Shaffer D (1991), The impact of Stack S (1996), The effect of the media on suicide: evidence from Japan, curriculum-based suicide prevention programs for teenagers: an 18-month 1955–1985. Suicide Life Threat Behav 26:132–142 follow-up. J Am Acad Child Adolesc Psychiatry 30:811–815 Stack S (1998), Heavy Metal, religiosity, and suicide acceptability. Suicide Life Voelker R (1999), SSRI use common in children. JAMA 281:1882 Threat Behav 28:388–394 Wallace JD, Calhoun AD, Powell KE, O’Neil J, James SP (1996), Homicide Stack S (2000), Media impacts on suicide: a quantitative review of 293 find- and Suicide Among Native Americans, 1979–1992. Atlanta: Centers for ings. Soc Sci Q 81:956–971 Disease Control and Prevention, National Center for Injury Prevention Stack S, Lester D (1991), The effect of religion on suicide ideation. Soc Psychiatry and Control. Violence Surveillance Series, No. 2 Psychiatr Epidemiol 26:168–170 Walter HJ, Vaughan RD, Armstrong B et al. (1995), Sexual, assaultive, and Swanson JW, Linskey AO, Quintero-Salinas R, Pumariega AJ, Holzer CE III suicidal behaviors among urban minority junior high school students. J (1992), A binational school survey of depressive symptoms, drug use, and Am Acad Child Adolesc Psychiatry 34:73–80 suicidal ideation. J Am Acad Child Adolesc Psychiatry 31:669–678 Warshaw MG, Dolan RT, Keller MB (2000), Suicidal behavior in patients Teicher MH, Glod C, Cole JO (1990), Emergence of intense suicidal preoc- with current or past panic disorder: five years of prospective data from the cupation during fluoxetine treatment. Am J Psychiatry 147:207–210 Harvard/Brown anxiety research program. Am J Psychiatry 157:1876–1878 Thompson EA, Eggert LL (1999), Using the suicide risk screen to identify Weissman MM, Klerman GL, Markowitz JS, Ouellette R (1989), Suicidal ideation suicidal adolescents among potential high school dropouts. J Am Acad and suicide attempts in panic disorder and attacks. N Engl J Med 321:1209–1214 Child Adolesc Psychiatry 38:1506–1514 Wichstrom L (2000), Predictors of adolescent suicide attempts: a nationally Thompson EA, Eggert LL, Herting JR (2000), Mediating effects of an indi- representative longitudinal study of Norwegian adolescents. J Am Acad cated prevention program for reducing youth depression and suicide risk Child Adolesc Psychiatry 39:603–610 behaviors. Suicide Life Threat Behav 30:252–271 Windle M, Miller-Tutzauer C, Domenico D (1992), Alcohol use, suicidal Thompson EA, Eggert LL, Randell BP, Pike KC (2001), Evaluation of indi- behavior, and risky activities among adolescents. J Res Adolesc 2:317–330 cated suicide risk prevention approaches for potential high school dropouts. World Health Organization (2002), Suicide rates and absolute numbers of Am J Public Health 91:742–752 suicide by country (2002). Available online: http://www.who.int/mental_health Tierney RJ (1994), Suicide intervention training evaluation: a preliminary (accessed August 1, 2002) report. Crisis 15:69–76 Wunderlich U, Bronisch T, Wittchen HU (1998), Comorbidity patterns in Tondo L, Baldessarini RJ (2000), Reduced suicide risk during lithium main- adolescents and young adults with suicide attempts. Eur Arch Psychiatry tenance treatment. J Clin Psychiatry 61(suppl 9):97–104 Clin Neurosci 248:87–95 Tondo L, Jamison KR, Baldessarini RJ (1997), Effect of lithium maintenance Zenere FJ, Lazarus PJ (1997), The decline of youth suicidal behavior in an on suicidal behavior in major mood disorders. Ann N Y Acad Sci 836:339–351 urban, multicultural public school system following the introduction of Tousignant M, Bastien MF, Hamel S (1993), Suicidal attempts and ideations a suicide prevention and intervention program. Suicide Life Threat Behav among adolescents and young adults: the contribution of the father’s and 27:387–403 mother’s care and of parental separation. Soc Psychiatry Psychiatr Epidemiol Zhang J, Jin S (1996), Determinants of suicide ideation: a comparison of 28:256–261 Chinese and American college students. Adolescence 31:451–467

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64 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 • Based on self-report data collected by An estimated 14 million students presently the CDC in 1995 (National College attend more than 4,500 colleges and uni- Health Risk Behavior Survey), about versities in the U.S. This includes about 8 11% of college students ages 18-24 million students between the ages of 18-24, have seriously considered suicide with- representing about one-quarter of all 18-24 in the past year. About 8% have made a year-olds in the country. Because college suicide plan, and almost 2% have made student suicide rates are not officially a suicide attempt. tracked on either a national or state level, the current knowledge base on suicide and • In a 2002 survey of college and univer- suicidal behavior among this population is sity counseling center directors, 85% based on studies of selected universities, reported increasing numbers of stu- surveys of university officials, and surveys dents with serious mental health prob- of college students themselves. The key lems and increased demands for cam- ﬁndings of this accumulated research are: pus-based psychological services. A. Overall Rates and Secular Patterns B. Overall Rates in New York State in the U.S. • Over 1.1 million students are currently • Suicide appears to be only about half enrolled in 264 institutions of higher as frequent among college and univer- education in New York State. sity students as among an age, gender, and race-matched population. Students • 80% are enrolled as undergraduates are estimated to have a suicide rate of and 20% as graduate or professional 7.5 per 100,000, compared to 15 per students. 70% attend full time and 30% 100,000 for young adults in the general part time. About 42% are male and 58% population. are female.

• At this rate, about 1,100 suicides are • Based on national estimates, approxi- estimated to occur each year, placing mately 83 suicides are likely to occur suicide as the second leading cause of each year among college and university death among college students, follow- students in New York State, 59 among ing accidents. Suicide is the third lead- undergraduates and 24 among gradu- ing cause of death among all youth ate and professional students. ages 15-24, following accidents and homicides. • Extrapolating from CDC’s National Col- lege Health Risk Behavior Survey, more

College Students 65 Saving Lives in New York Volume 2: Approaches and Special Populations

than 122,000 college students in New and an inability to tolerate failure may York State are estimated to seriously also be risk factors for this population. consider suicide each year. It is expected that almost 89,000 have a suicide plan, • Suicidal ideation in college students is and over 22,000 make a suicide attempt. associated with other injury-related risk behaviors, such as carrying a weapon, • There is considerable diversity among engaging in physical fights, and not institutions of higher education in New using seat belts. More than 75% of York State (see Tables 1 and 2). The 61 those who seriously consider suicide campuses of the State University (SUNY) drink alcohol, often heavily. Students constitute about 23% of the 264 colleges who report suicidal ideation are signifi- and universities in NY State, and enroll cantly more likely than students who about 37% of the total number of stu- do not to drive after drinking, ride with dents. The 19 campuses of the City Uni- someone who has been drinking, and versity (CUNY) constitute about 7% of boat or swim after drinking. the institutions and enroll over 19% of all students. 184 private colleges and uni- • Many college students who die by sui- versities, which make up 70% of the cide, however, appear to be largely higher education institutions in the state, depressed, quiet, socially isolated, and enroll the remaining 44% of students. may draw little attention to themselves. Almost 35% of NY State’s colleges and universities are located within the five • A number of special groups within the boroughs of New York City. Demograph- overall college population have particu- ic differences among institutions likely lar risk factors. These include interna- have an impact on the distribution of tional students, who may have little suicide deaths and suicidal behavior social or emotional support at a time among the state’s college and university that they are making a major life transi- population. tion; gay, lesbian, bisexual and trans- gendered students, who on some cam- C. Risk Factors puses may experience discrimination • As with all adolescents and young adults, and social isolation; and older students, over 90% of college students who die by who often experience difficulties in suicide are believed to have a mental dis- returning to school. order at the time of their death. • Graduate students appear to have a • The most common diagnoses in college much higher suicide rate than under- students who die by suicide appear to graduates (10.6/100,000 vs. be depression, bipolar disorder, schizo- 6.6/100,000). Although undergraduate phrenia, and substance abuse. males have a much higher rate than undergraduate females (9.3/100,000 vs. • Overall, the suicide rate for male stu- 3.4/100,000), the suicide rate for dents is estimated to be more than female graduate students approaches twice that for females (10.0/100,000 vs. that for male graduate students 4.5/100,000), and 75% of college stu- (9.1/100,000 vs. 11.6/100,000). Intense dent suicide deaths occur among males. academic competition, mounting finan- Few gender differences are seen, how- cial burdens and uncertainties about ever, in suicide attempts and suicidal future employment are likely contribut- ideation among this population. ing factors for all graduate students.

• Suicide deaths among college students • Overall, it is estimated that only 20% of are frequently triggered by relationship suicidal students are receiving psy- losses or difficulties adjusting to new chotherapy or antidepressant medica- expectations and settings. Perfectionism tion. In 2002, schools with active counseling centers reported that less than a

66 College Students Saving Lives in New York Volume 2: Approaches and Special Populations

third of students who died by suicide geting one or more constituencies within had received treatment at their centers. the overall campus community (e.g., administrators, faculty, counselors, stu- • College students appear to be particu- dents). Such a comprehensive approach larly susceptible to suicide has been endorsed by the American Foun- contagion/imitation. In recent years, a dation for Suicide Prevention and by the number of suicide clusters, usually Jed Foundation. involving jumping from heights, have been reported on college campuses. A. Enhance Support Systems Within New York State, apparent sui- for Vulnerable Students cide clusters have occurred at Cornell (1). Efforts to Stimulate Change University and New York University. in Campus Culture Broad efforts aimed at bringing about D. Protective Factors changes in the way mental illness and sui- Although to date few, if any, factors have cide are perceived on campus are an been deﬁnitively established to protect col- essential component of suicide prevention. lege students from suicide risk, factors Social marketing strategies can be effec- thought to be particularly important for this tively employed by campus leaders includ- population include: ing the President’s Office, Student Affairs administrators, deans, mental health serv- • Availability of effective and appropriate ices personnel, and campus media, to de- clinical services for mental disorders, stigmatize mental illness, remove barriers including alcohol and drug use. to identifying and treating students in need of mental health services, and encourage • A campus atmosphere that encourages help-seeking. help-seeking and early identiﬁcation of problems that may put students at risk Resources: National Mental Health Association/Jed Foundation, Safeguarding your students against suicide: expanding the for mental disorders and suicide. safety network. Alexandria, VA. 2002. Higher Education Center for Alcohol and Other Drug • A sense of campus community and Prevention (www.edc.org/hec). Suicide Prevention Resource Center (www.sprc.org). social connectedness.

• Restricted access to lethal methods of (2) Post-Attempt Treatment Programs suicide, including barriers to jumping It is essential that campuses establish clear, and prohibitions against possession of non-punitive procedures for assessing a firearms on campus. student’s continued risk following a suicide attempt. Campus personnel should be II. Action Steps specifically trained to link the suicidal stu- Based on what is currently known about dent to evaluation and treatment risk and protective factors related to col- resources, either on or off campus. These lege suicide, the following action steps are individuals must be thoroughly knowledge- recommended for implementation by cam- able about the availability of and access to pus officials. Relatively few suicide preven- all campus and community resources. tion programs have been developed specifi- Campus mental health services should cally for college students, and thus avail- have clear procedures in place to ensure able resources to guide campuses in imple- that students who have made a suicide menting a particular recommendation are attempt are given priority access to evalua- limited. Where such resources are avail- tion and treatment services. able, they are noted. Although the recom- Resource: The American Foundation for Suicide Prevention (AFSP) mendations focus on a number of discrete (www.afsp.org) has developed educational posters high- actions, the most effective approach to sui- lighting suicide risk factors and management guidelines for cide prevention on college and university emergency personnel. campuses is a comprehensive strategy that includes multiple coordinated activities tar-

College Students 67 Saving Lives in New York Volume 2: Approaches and Special Populations

(3) Campus Policies Regarding Students (5) Outreach to Students Who Leave with Mental Illness Campus for Mental Health Reasons Campus leadership should initiate a com- Students who leave college following a sui- prehensive review of existing policies that cide attempt or because of mental health affect students with identiﬁed mental problems often struggle with their own health needs, including those who have responses to perceived failure (shame, made a suicide attempt or expressed suici- guilt, embarrassment, etc.). In addition, dal ideation or attempt. Policies that are they may face negative reactions from par- discriminatory or punitive should be ents, siblings and friends at home, as well revised and, where lacking, clear policies as increased social and emotional isola- should be established to provide medical tion. In light of research evidence that leaves for students with mental health youth who are “drifting” - neither in school needs and non-punitive procedures for or working - are at particular risk for sui- subsequent re-entry. Relevant personnel cide, efforts should be made by colleges to should be fully trained to comply with such maintain links with students who leave for policies, and in matters pertaining to conﬁ- mental health reasons, and encourage dentiality and related legal issues. them to re-enter at the appropriate time.

Policies regarding campus-based treatment B. Implement Case-Finding with Accom- services should also be reviewed and panying Referral and Treatment revised as needed to insure that the quanti- (1.) Screening Programs ty and quality of available services are Screening programs are an important strat- appropriate to the needs of seriously dis- egy in a campus suicide prevention pro- turbed students. Colleges and universities gram. Currently, screening techniques lack which are unable to provide such services precision to identify with certainty those should develop appropriate community who will attempt suicide or die by suicide. referral networks. However, screening for speciﬁc disorders associated with suicide (particularly depres- Resource: National Mental Health Association/Jed Foundation, sion and substance abuse) can identify stu- 2002. dents at risk for suicide and facilitate refer- (4) Peer-Helper and Other ral to appropriate treatment services. Support Programs Screening can be either universal (targeting all students on campus) or directed towards Programs are needed that provide support particular groups most at risk (e.g. male to students who have made a suicide students, graduate students, international attempt or are struggling with depression students, etc.). The Internet provides an or other mental disorders. Such programs, excellent mechanism for reaching college focusing on support from peers, residence students because of high access and usage. advisers, student affairs personnel, or oth- Screening programs that allow the student ers within the campus community, might to maintain anonymity until he or she is be effectively incorporated into a campus ready to self-identify, and that provide a reentry program. The responsibilities of personalized response from a trained clini- peers and other lay helpers are best limited cian appear to be most successful. to listening and reporting possible warning signs, rather than counseling. It is impera- Resources: American Foundation for Suicide Prevention’s College tive that lay helpers be carefully supervised Screening Program (www.afsp.org). Depression Screening Day Program (Douglas Jacobs, MD djacobs@mentalhealth- by fully trained mental health professionals, screening.org). ULifeline, Jed Foundation (www.jedfounda- preferably those within the campus’s own tion.org). mental health services. (2.) Residence Advisor and Other Gate- Resource: Youth-Nominated Support Team (YST) (Cheryl King, Ph.D.) ([email protected]) keeper/Caregiver Training Programs Training programs that increase the ability of potential gatekeepers to identify and refer for treatment at-risk students are an

68 College Students Saving Lives in New York Volume 2: Approaches and Special Populations important part of campus suicide preven- dents have an opportunity to talk about the tion. Because of their daily proximity to a suicide decedent and explore their own substantial number of students, residence emotional reactions to the suicide. Campus- hall advisers are in a unique position to wide memorials or other large- scale gath- recognize signs of suicide risk. Other gate- erings that honor the decedent may have keepers might include faculty, athletic per- the unintended consequence of encourag- sonnel and student life personnel. Suicide ing imitation among vulnerable students. prevention training should focus on devel- Although such events can provide an oping the knowledge, attitudes and skills to opportunity to deliver the message that identify individuals at risk, determine the depression and other conditions that levels of risk, and to make referrals. heighten suicide risk are treatable conditions, it is perhaps safest for campuses to Resources: Question, Persuade and Refer (QPR) (www.qprinsti- avoid them wherever possible. tute.com). Applied Suicide Intervention Skills Training (ASIST), Living Works Education (www.livingworks.net). Resource: Services for Teens at Risk (STAR) Center Postvention. Standards Guidelines (Mary Margaret Kerr, Ed.D. Director, (3.) Student Education to Increase STAR- Center Outreach, [email protected]) Recognition of Depression and Other Disorders C. Develop Risk Reduction Programs An important aspect of a campus suicide (1). Means Restriction on Campus prevention strategy is increasing students’ College and university officials should recognition of depression and other mental undertake a comprehensive analysis of all disorders that convey risk, both in them- structures and activities that may provide an selves and their friends. The structure of col- opportunity for suicide, and take appropriate lege and university life offers numerous actions to limit students’ access to potential- opportunities to educate students about ly lethal means. This may involve a range of depression and suicide: student orientation activities including constructing barriers on sessions, classrooms, residence hall meet- balconies, rooftops and bridges; and estab- ings, Greek organizations, and other student lishing clear policies and procedures that groups and extracurricular activities. Films, restrict the availability and use of alcohol, lectures, discussions and question-and- illicit drugs and ﬁrearms on campus. answer sessions are all helpful strategies for raising students’ awareness of suicide, sui- Resources: Reducing Underage Drinking: A Collective Responsibility. Richard Bonnie and Mary Ellen O’Connell, cide risk factors, available treatment options, Editors, Committee on Developing a Strategy to Reduce and and strategies for peer support. Prevent Underage Drinking, National Research Council, Institute of Medicine. (www.nap.edu/catalog/10729.html). Resource: Film: The Truth About Suicide: Real Stories of National Strategy for Suicide Prevention (www.mental- Depression in College, and accompanying Facilitator’s health.samhsa. gov/suicideprevention/strategy.asp). Guide, developed by the American Foundation for Suicide Prevention (www.afsp.org/collegeﬁlm). (2). Media Education Given the substantial evidence for suicide (4.) Postvention/Crisis Intervention contagion and imitative behavior on Campuses Given the very real potential for contagion among students, students and relevant and imitation, it is critical that campuses community personnel involved in print, respond effectively and appropriately fol- radio and television media that serve the lowing a student suicide. The major goals of campus population should be educated in postvention/crisis intervention programs how to responsibly report on suicide. Such are to assist students in the grief process, action steps are described elsewhere in the identify and refer those individuals who Media section of the New York State Sui- may be at risk following the suicide, provide cide Prevention Plan. 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 69 Saving Lives in New York Volume 2: Approaches and Special Populations

D. Enhance Protective Factors with suicidal behavior. American Journal of Psychiatry, 160: (1) Social Network Promotion 1-60 (2003). Promoting a sense of belonging among all students is an important element of suicide Recommendations/Action Steps prevention. Administrators, faculty, staff by Stakeholder Group and student leaders should explore ways of The following recommendations/action encouraging the development of smaller steps are taken from the preceding section groups within the larger campus communi- (II). In this section they have been organ- ty, and reaching out to student groups who ized under different stakeholder groups. may experience isolation and a lack of connectedness (e.g. racial and ethnic Administration minorities, international students, gay and Efforts to Stimulate Change in Campus lesbian students, commuter students, older Culture (II A.1) students, etc.). Broad efforts aimed at bringing about changes in the way mental illness and sui- Resources: National Mental Health Association/Jed Foundation, cide are perceived on campus are an 2002. National Strategy for Suicide Prevention (www.men- essential component of suicide prevention. talhealth.samhsa. gov/suicideprevention/strategy.asp). Social marketing strategies can be effectively employed by campus leaders includ- (2) Life Skills Development ing the President’s Office, Student Affairs Programs to improve students’ manage- administrators, deans, mental health serv- ment of the rigors of college life, and to ices personnel, and campus media, to de- equip students with tools to recognize and stigmatize mental illness, remove barriers manage triggers and stressors should be to identifying and treating students in need developed and incorporated into student of mental health services, and encourage orientation, residence hall meetings and help-seeking. other student life venues. Resources: National Mental Health Association/Jed Foundation, Resource: National Mental Health Association/Jed Foundation, Safeguarding your students against suicide: expanding the 2002. safety network. Alexandria, VA. 2002. Higher Education Center for Alcohol and Other Drug Prevention (www.edc.org/hec). Suicide Prevention Resource Center E. Enhance Effectiveness of Campus (www.sprc.org). Mental Health Services (1) Professional Education Programs Screening Programs (II B.1) Training campus mental health personnel Screening programs are an important strat- about suicide risk, assessment and treat- egy in a campus suicide prevention pro- ment is an essential suicide prevention gram. Currently, screening techniques lack strategy. Many mental health professionals precision to identify with certainty those have inadequate training in working with who will attempt suicide or die by suicide. seriously depressed or suicidal individuals. However, screening for speciﬁc disorders On-going professional education by suicide associated with suicide (particularly experts, and opportunities to collaborate depression and substance abuse) can iden- with colleagues in the treatment of serious- tify students at risk for suicide and facilitate ly disturbed students can improve the effec- referral to appropriate treatment services. tiveness of campus mental health services. Screening can be either universal (targeting Resources: American Foundation for Suicide Prevention (2003). all students on campus) or directed The Suicidal Patient: Assessment and Care. A ﬁlm available towards particular groups most at risk (e.g. at AFSP.org/index-1.htm. male students, graduate students, international students, etc.). The Internet provides American Academy of Child and Adolescent Psychiatry an excellent mechanism for reaching col- Workgroup on Quality Issues. Practice parameters for the assessment and treatment of children and adolescents with lege students because of high access and suicidal behavior. Journal of the American Academy of usage. Screening programs that allow the Adolescent and Child Psychiatry, 40 (7), 24s-51s, (2001). student to maintain anonymity until he or she is ready to self-identify, and that pro- Practice guidelines for the assessment and treatment of patients vide a personalized response from a

70 College Students Saving Lives in New York Volume 2: Approaches and Special Populations trained clinician appear to be most suc- discriminatory or punitive should be cessful. revised and, where lacking, clear policies should be established to provide medical Resources: American Foundation for Suicide Prevention’s College leaves for students with mental health Screening Program (www.afsp.org). Depression Screening Day Program (Douglas Jacobs, MD needs and non-punitive procedures for [email protected]). subsequent re-entry. Relevant personnel ULifeline, Jed Foundation (www.jedfoundation.org). should be fully trained to comply with such policies, and in matters pertaining to confi- Means Restriction on Campus (II C.1) dentiality and related legal issues. College and university officials should undertake a comprehensive analysis of all Policies regarding campus-based treatment structures and activities that may provide an services should also be reviewed and opportunity for suicide, and take appropriate revised as needed to insure that the quanti- actions to limit students’ access to potential- ty and quality of available services are ly lethal means. This may involve a range of appropriate to the needs of seriously dis- activities including constructing barriers on turbed students. Colleges and universities balconies, rooftops and bridges; and estab- which are unable to provide such services lishing clear policies and procedures that should develop appropriate community restrict the availability and use of alcohol, referral networks. illicit drugs and firearms on campus. Resource: National Mental Health Association/Jed Foundation, Resources: Reducing Underage Drinking: A Collective 2002. Responsibility. Richard Bonnie and Mary Ellen O’Connell, Editors, Committee on Developing a Strategy to Reduce and Prevent Underage Drinking, National Research Council, Outreach to Students Who Leave Cam- Institute of Medicine. (www.nap.edu/catalog/10729.html). pus for Mental Health Reasons (II A.5) National Strategy for Suicide Prevention (www.mental- Students who leave college following a sui- health.samhsa. gov/suicideprevention/strategy.asp). cide attempt or because of mental health problems often struggle with their own Outreach to Students Who Leave Cam- responses to perceived failure (shame, pus for Mental Health Reasons (II A.5) guilt, embarrassment, etc.). In addition, Students who leave college following a sui- they may face negative reactions from par- cide attempt or because of mental health ents, siblings and friends at home, as well problems often struggle with their own as increased social and emotional isola- responses to perceived failure (shame, tion. In light of research evidence that guilt, embarrassment, etc.). In addition, youth who are “drifting” - neither in school they may face negative reactions from par- or working - are at particular risk for sui- ents, siblings and friends at home, as well cide, efforts should be made by colleges to as increased social and emotional isola- maintain links with students who leave for tion. In light of research evidence that mental health reasons, and encourage youth who are “drifting” - neither in school them to re-enter at the appropriate time. or working - are at particular risk for suicide, efforts should be made by colleges to Faculty/Staff maintain links with students who leave for Residence Advisor and Other Gatekeep- mental health reasons, and encourage er/Caregiver Training Programs (II B.2) them to re-enter at the appropriate time. Training programs that increase the ability of potential gatekeepers to identify and Deans and Academic Advisors refer for treatment at-risk students are an Campus Policies Regarding Students with important part of campus suicide preven- Mental Illness (II A.3) tion. Because of their daily proximity to a Campus leadership should initiate a com- substantial number of students, residence prehensive review of existing policies that hall advisers are in a unique position to affect students with identified mental recognize signs of suicide risk. Other gate- health needs, including those who have keepers might include faculty, athletic per- made a suicide attempt or expressed suici- sonnel and student life personnel. Suicide dal ideation or attempt. Policies that are

College Students 71 Saving Lives in New York Volume 2: Approaches and Special Populations

prevention training should focus on devel- Social Network Promotion (II D.1) oping the knowledge, attitudes and skills to Promoting a sense of belonging among all identify individuals at risk, determine the students is an important element of suicide levels of risk, and to make referrals. prevention. Administrators, faculty, staff and student leaders should explore ways of Resources: Question, Persuade and Refer (QPR) encouraging the development of smaller (www.qprinstitute.com). Applied Suicide Intervention Skills Training (ASIST), groups within the larger campus communi- Living Works Education (www.livingworks.net). ty, and reaching out to student groups who may experience isolation and a lack of Public Safety Department connectedness (e.g. racial and ethnic Means Restriction on Campus (II C.1) minorities, international students, gay and College and university officials should lesbian students, commuter students, older undertake a comprehensive analysis of all students, etc.). structures and activities that may provide Resources: National Mental Health Association/Jed Foundation, an opportunity for suicide, and take appro- 2002. National Strategy for Suicide Prevention (www.men- priate actions to limit students’ access to talhealth.samhsa.gov/suicideprevention/strategy.asp). potentially lethal means. This may involve a range of activities including constructing Life Skills Development (II D.2) barriers on balconies, rooftops and bridges; Programs to improve students’ manage- and establishing clear policies and proce- ment of the rigors of college life, and to dures that restrict the availability and use of equip students with tools to recognize and alcohol, illicit drugs and ﬁrearms on cam- manage triggers and stressors should be pus. developed and incorporated into student orientation, residence hall meetings and Resources: Reducing Underage Drinking: A Collective Responsibility. Richard other student life venues.

Bonnie and Mary Ellen O’Connell, Editors, Committee on Resource: National Mental Health Association/Jed Foundation, Developing a Strategy to Reduce and Prevent Underage 2002. Drinking, National Research Council, Institute of Medicine. (www.nap.edu/catalog/10729.html). National Strategy for Student Counseling Services/Campus Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp). Mental Health Professionals Post-Attempt Treatment Programs (II A.2) Residential Life Staff It is essential that campuses establish clear, Residence Advisor and Other Gatekeep- non-punitive procedures for er/Caregiver Training Programs (II B.2) Training programs that increase the ability assessing a student’s continued risk follow- of potential gatekeepers to identify and ing a suicide attempt. Campus personnel refer for treatment at-risk students are an should be speciﬁcally trained to link the important part of campus suicide preven- suicidal student to evaluation and treat- tion. Because of their daily proximity to a ment resources, either on or off campus. substantial number of students, residence These individuals must be thoroughly hall advisers are in a unique position to knowledgeable about the availability of and recognize signs of suicide risk. Other gate- access to all campus and community keepers might include faculty, athletic per- resources. Campus mental health services sonnel and student life personnel. Suicide should have clear procedures in place to prevention training should focus on devel- ensure that students who have made a sui- oping the knowledge, attitudes and skills to cide attempt are given priority access to identify individuals at risk, determine the evaluation and treatment services. levels of risk, and to make referrals. Resource: The American Foundation for Suicide Prevention (AFSP) Resources: Question, Persuade and Refer (QPR) (www.qprinstitute.com). (www.afsp.org) has developed educational posters highlighting suicide risk factors and management guidelines for emergency personnel. Applied Suicide Intervention Skills Training (ASIST), Living Works Education (www.livingworks.net).

72 College Students Saving Lives in New York Volume 2: Approaches and Special Populations

Postvention/Crisis Intervention on Cam- Outreach to Students Who Leave Cam- puses (II B.4) pus for Mental Health Reasons (II A.5) Given the very real potential for contagion Students who leave college following a sui- and imitation, it is critical that campuses cide attempt or because of mental health respond effectively and appropriately follow- problems often struggle with their own ing a student suicide. The major goals of responses to perceived failure (shame, postvention/crisis intervention programs are guilt, embarrassment, etc.). In addition, to assist students in the grief process, identify they may face negative reactions from par- and refer those individuals who may be at ents, siblings and friends at home, as well risk following the suicide, provide accurate as increased social and emotional isola- information about suicide while attempting to tion. In light of research evidence that minimize suicide contagion, and implement a youth who are “drifting” - neither in school structure for ongoing prevention efforts. Par- or working - are at particular risk for sui- ticularly helpful are individual or small group cide, efforts should be made by colleges to sessions in which students have an opportu- maintain links with students who leave for nity to talk about the suicide decedent and mental health reasons, and encourage explore their own emotional reactions to the them to re-enter at the appropriate time. suicide. Campus-wide memorials or other large- scale gatherings that honor the dece- Students dent may have the unintended consequence Peer-Helper and Other Support Pro- of encouraging imitation among vulnerable grams (II A.4) students. Although such events can provide Programs are needed that provide support an opportunity to deliver the message that to students who have made a suicide depression and other conditions that height- attempt or are struggling with depression en suicide risk are treatable conditions, it is or other mental disorders. Such programs, perhaps safest for campuses to avoid them focusing on support from peers, residence wherever possible. advisers, student affairs personnel, or others within the campus community, might Resource: Services for Teens at Risk (STAR) Center Postvention. be effectively incorporated into a campus reentry program. The responsibilities of Standards Guidelines (Mary Margaret Kerr, Ed.D. Director, STAR- Center Outreach, [email protected]) peers and other lay helpers are best limited to listening and reporting possible warning Professional Education Programs (II E.1) signs, rather than counseling. It is imperative that lay helpers be carefully supervised Training campus mental health personnel by fully trained mental health professionals, about suicide risk, assessment and treat- preferably those within the campus’s own ment is an essential suicide prevention mental health services. strategy. Many mental health professionals have inadequate training in working with Resource: Youth-Nominated Support Team (YST) (Cheryl King, seriously depressed or suicidal individuals. Ph.D.) ([email protected]) On-going professional education by suicide experts, and opportunities to collaborate Student Education to Increase Recogni- with colleagues in the treatment of serious- tion of Depression and Other Disorders ly disturbed students can improve the effec- (II B.3) tiveness of campus mental health services. An important aspect of a campus suicide prevention strategy is increasing students’ Resources: American Foundation for Suicide Prevention (2003). The Suicidal Patient: Assessment and Care. A ﬁlm available recognition of depression and other mental at AFSP.org/index-1.htm. disorders that convey risk, both in them- American Academy of Child and Adolescent Psychiatry selves and their friends. The structure of col- Workgroup on Quality Issues. Practice parameters for the assessment and treatment of children and adolescents with lege and university life offers numerous suicidal behavior. Journal of the American Academy of opportunities to educate students about Adolescent and Child Psychiatry, 40 (7), 24s-51s, (2001). depression and suicide: student orientation Practice guidelines for the assessment and treatment of patients with suicidal behavior. American Journal of sessions, classrooms, residence hall meet- Psychiatry, 160: 1-60 (2003). ings, Greek organizations, and other student

College Students 73 Saving Lives in New York Volume 2: Approaches and Special Populations

groups and extracurricular activities. Films, Outreach to Students Who Leave Cam- lectures, discussions and question-and- pus for Mental Health Reasons (II A.5) answer sessions are all helpful strategies for Students who leave college following a sui- raising students’ awareness of suicide, suicide attempt or because of mental health cide risk factors, available treatment options, problems often struggle with their own and strategies for peer support. responses to perceived failure (shame, guilt, embarrassment, etc.). In addition, Resource: Film: The Truth About Suicide: Real Stories of they may face negative reactions from par- Depression in College, and accompanying Facilitator’s Guide, developed by the American Foundation for Suicide ents, siblings and friends at home, as well Prevention (www.afsp.org/collegeﬁlm). as increased social and emotional isolation. In light of research evidence that Media Education (II. C.2) youth who are “drifting” - neither in school Given the substantial evidence for suicide or working - are at particular risk for sui- contagion and imitative behavior among cide, efforts should be made by colleges to students, students and relevant community maintain links with students who leave for personnel involved in print, radio and tele- mental health reasons, and encourage vision media that serve the campus popu- them to re-enter at the appropriate time. lation should be educated in how to responsibly report on suicide. Such action Parents steps are described elsewhere in the Media Efforts to Stimulate Change section of the New York State Suicide Pre- in Campus Culture (II A.1) vention Plan. Broad efforts aimed at bringing about changes in the way mental illness and sui- Social Network Promotion (II D.1) cide are perceived on campus are an Promoting a sense of belonging among all essential component of suicide prevention. students is an important element of suicide Social marketing strategies can be effec- prevention. Administrators, faculty, staff tively employed by campus leaders includ- and student leaders should explore ways of ing the President’s Office, Student Affairs encouraging the development of smaller administrators, deans, mental health serv- groups within the larger campus communi- ices personnel, and campus media, to de- ty, and reaching out to student groups who stigmatize mental illness, remove barriers may experience isolation and a lack of to identifying and treating students in need connectedness (e.g. racial and ethnic of mental health services, and encourage minorities, international students, gay and help-seeking. lesbian students, commuter students, older Resource: National Mental Health Association/Jed Foundation, students, etc.). Safeguarding your students against suicide: expanding the safety network. Alexandria, VA. 2002. Higher Education Resources: National Mental Health Association/Jed Foundation, Center for Alcohol and Other Drug Prevention ( 2002. National Strategy for Suicide Prevention (www.men- www.edc.org/hec). talhealth.samhsa.gov/suicideprevention/strategy.asp). Suicide Prevention Resource Center (www.sprc.org).

Life Skills Development (II D.2) Outreach to Students Who Leave Cam- Programs to improve students’ manage- pus for Mental Health Reasons (II A.5) ment of the rigors of college life, and to Students who leave college following a sui- equip students with tools to recognize and cide attempt or because of mental health manage triggers and stressors should be problems often struggle with their own developed and incorporated into student responses to perceived failure (shame, orientation, residence hall meetings and guilt, embarrassment, etc.). In addition, other student life venues. they may face negative reactions from parents, siblings and friends at home, as well Resource: National Mental Health Association/Jed Foundation, 2002. 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-

74 College Students Saving Lives in New York Volume 2: Approaches and Special Populations cide, efforts should be made by colleges to Resources: Reducing Underage Drinking: A Collective Responsibility. Richard Bonnie and Mary Ellen O’Connell, maintain links with students who leave for Editors, Committee on Developing a Strategy to Reduce and mental health reasons, and encourage Prevent Underage Drinking, National Research Council, them to re-enter at the appropriate time. Institute of Medicine. (www.nap.edu/catalog/10729.html). National Strategy for Suicide Prevention (www.mentalhealth.samhsa. gov/suicideprevention/strategy.asp). Local Community 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.

College Students 75

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 • A 1996 report that adolescent suicide The relationship between the family unit victims had significantly less frequent and a suicidal adolescent family member is and less satisfying communication with both complex and compelling. Despite a their mothers and fathers; historical bias that emphasized how a negative family life could pose a risk to their • Family aggression has been noted to be offspring’s mental health, there is growing prevalent in suicidal children in the evidence that a family’s influence can and general community and in clinical set- should be considered as a protective factor tings. against their adolescent’s suicidal behavior. The key seems to turn on whether family • A family history of suicidal behavior influences - genetic, biological or environ- greatly increases the risk of completed mental - are, on balance, essentially posi- suicide by an offspring. It may reflect a tive or negative for the family member’s genetic factor rather than family chaos mental health. The capacity of the family and psychopathology. unit to exert influence is undeniable; the content of that relationship varies from • Families of suicide attempters and family to family. It is also not static, in that completers share an increased risk of like individuals, family life can change over affective illness, substance abuse, time in response to inner growth and exter- assaultive behavior and suicide nal forces. Research has begun to examine attempts. (Brent, 1997) the under-studied half of the equation - that of families as protective forces against suici- • The families of adolescent suicide dal behavior, including repeated attempts attempters are characterized by sub- by their adolescent members. stantial levels of dysfunction (Spirito et al., 1989) The Family as Risk Factor Psychiatric research has well established a • There is a strong and specific associa- family history of mental illness or suicide tion between deliberate self- poisoning and general family dysfunction presently in adolescence and family dysfunction both increase the risk that an adolescent (Harrington et al., 1998) will become suicidal. • A family history of suicidal behavior has been shown to increase suicide risk even when controlled for poor

Families 77 Saving Lives in New York Volume 2: Approaches and Special Populations

parent-child relationships and parental exerts a critical influence - environ- psychopathology. mentally, genetically, and biologically - upon their offspring. • High rates of parental psychopathology, especially depression and substance While school personnel, mental health abuse, have been associated with com- professionals, and others with whom pleted suicide in adolescence. the suicidal adolescent interacts must be part of any comprehensive suicide The Family as Protective Factor prevention strategy, it is arguably family Psychiatric research has long established members who are in the best position that a past suicide attempt is a powerful to reduce the risk of repeated attempts predictor of a subsequent attempt at virtual- because they are there, with the at-risk ly any age. Regrettably, psychiatric research adolescent. has not paid sufficient attention to: • Gould et al, (2003) point out that ado- • The interrelationships between family lescent suicide prevention strategies variables, adolescent feelings and have .”..primarily been implemented behaviors, and adolescent suicidality. within three domains - school, commu- (Brinkman et al., 2000) nity, and health-care system.” Many of these strategies, including suicide • The impact the return of an adolescent awareness curricula, skills training, to the family after a suicide attempt has screening and gatekeeper training, are on the family’s system and dynamics. undoubtedly valuable. However, corre- sponding research on and implementa- • The positive role the adolescent’s family tion efforts with the family’s role in the can play in the prevention of another secondary prevention of adolescent suicide attempt. While many studies suicide has not been done. Moreover, have investigated the communication little research has been done on the and behaviors of the family as back- closely related question of the impact ground to the initial suicide attempt by of the adolescent’s first suicide attempt an adolescent, very few have gone on to on the family. As Magne-Ingvar and evaluate the post-suicide attempt family Ojehagen, (1999) observed, “Most fol- environment, or to gauge the family’s low-up studies after a suicide attempt capacity to serve as a protective force focus on the situation of the patient against a repetition of the first attempt. (but)...a suicide attempt also affects significant others.” • Brinkman-Sull et al., (2000) observed that adolescent suicide risk factors Because the family is the first line of focused primarily on psychiatric symp- defense in the secondary prevention of toms of the suicide attempter, neglecting adolescent suicide, it is the family that the impact of the family. They further bears the stress of adapting to the suicidal point out that in the follow-up period adolescent and acting to prevent another following a first attempt, the suicidal attempt. This adaptation can take the form adolescent is more likely than not to be of constant, close observation of the ado- living apart from a parent or parents. lescent, driven by concern, fear and guilt, as well as by practical need; insistence on • The scant attention afforded the family the adolescent’s compliance with outpa- as a primary source of prevention for tient treatment, including medication man- the adolescent who has attempted sui- agement and making scheduled appoint- cide is remarkable, in view of the fact ments with therapists. that it is the family with which an adolescent spends much, if not most, of Both adaptation and action inevitably his/her time; the family that knows the exhaust family members, and underscore adolescent best; and the family that

78 Families Saving Lives in New York Volume 2: Approaches and Special Populations the need for both respite care and treat- Individuals who have attempted suicide ment. tend to be non-compliant with treatment, and many, perhaps most adolescents do II. Action Steps. not readily share their thoughts and feel- I. Modifying Suicidal Behavior. ings with parents. Moreover, these suggest- To overcome the propensity for ﬁrst suicide ed steps require the family to vigilantly attempts to lead to subsequent others will observe the adolescent’s behavior and require a coordinated strategy by the family affect - observation which the adolescent employing a range of protective elements. may interpret as interference and control. Ideally, evidence-based models of how For the family, there is no easy or sure path families succeed in preventing adolescent to the prevention of a second suicide suicide attempts can guide families and attempt. treatment professionals alike. The reality is given the paucity of both evidence and III. The Need for more Knowledge. models, family members must depend on There is a need for more research on the their own experience and intuition to pre- impact of an adolescent’s suicide attempt vent another attempt. on their family. Similarly, there is a need for more research on the ways that families While invariably each family will respond cope in the aftermath of such an attempt. differently to this challenge, there are rec- Much research has been focused on the ommended practices that have worked for family’s role, both genetic and environmen- other families faced with this challenge. tal, in the etiology of adolescent suicide. Similarly, there has been research on the • Closely observe the adolescent’s behav- effect of a completed adolescent suicide on ior and mood. surviving family members. Yet the family system after the adolescent returns home • Pay Close Attention to all the adoles- from an initial suicide attempt remains cent’s references to suicide. Pay particu- largely unknown. lar attention to any reference to another attempt. Once an adolescent has attempted suicide, the risk of a second attempt increases dra- • Encourage the adolescent to attend out- matically. Once the adolescent has patient treatment. attempted suicide, parents and other family members are directly confronted with the • Facilitate the adolescent’s compliance very real possibility that they might lose with treatment recommendations, their loved one to another attempt. Fami- including taking medication as pre- lies may well be key to preventing another scribed. such attempt. Many, if not most, families are willing to face their fear and meet the • Communicate often with the treatment challenge, but they need the guidance that professionals involved. can only come from the psychiatric research community, and the support that • Remove all ﬁrearms from the home. must come from their extended family, communities and the wider society. • Secure other potentially lethal agents, e.g. poisons and prescribed and over- III. Action Steps the-counter medications, away from 1. Respite care for families having a suici- the adolescent. dal individual is a critical service, as is therapy for family members and other • Attempt to keep the adolescent away care-providers. Respite care comes in from alcohol and illegal drugs. many forms, including natural supports such as that provided by family and Implementing any of these measures with close friends. Whenever possible, such an adolescent is likely to be very difficult.

Families 79 Saving Lives in New York Volume 2: Approaches and Special Populations

resources should be the first option Journal of the American Academy of Child and Adolescent Psychiatry, 37, 512-518. sought. Hawton, K. Studying survivors of nearly lethal suicide attempts: an important strategy in suicide research. (2001). Suicide 2. Much research has been focused on and Life-Threatening Behavior. 32 (Supplement), 76-84. Hawton, K. and VanHeeringen, K. (eds.). (2000). The International the family’s role, both genetic and envi- Handbook of Suicide and Attempted Suicide. London: John ronmental in the etiology of adolescent Wiley and Sons, Ltd. suicide. However, there has been scant Magne-Ingvar, U. and Ojehagen, A. (1999). One year follow-up of significant others of suicide attempters. Social Psychiatry research conducted on the and Psychiatric Epidemiology, 34, 470-476. positive/protective role that families Mann, J. (2002). A current perspective of suicide and attempted can play in recovery of a suicidal ado- suicide. Annals of Internal Medicine, 136, 305-311. Miller, A., Rathus, J., Linehan, M., Wetzler, S. and Leigh, E. (1997). lescent family member. This gap in our Dialectical behavior therapy adapted for suicidal adoles- knowledge should be filled. cents. Journal of Practical Psychiatry and Behavioral Health, 3, 78-86. REFERENCES O=Carroll, P., Crosby, A., Mercy, J., Lee, R. and Simon, T. (2001). Barnes, L., Ikeda, R., and Kresnow, M.J. (2001). Help-seeking Interviewing suicide Adecedents@: a fourth strategy for risk behavior prior to nearly lethal suicide attempts. Suicide and factor assessment. Suicide and Life-Threatening Behavior, Life-Threatening Behavior, 32, 68-75. 32 (Supplement), 3-6. Brent, D. (2001). Assessment and treatment of the youthful suici- Otto, U. (1972). Suicidal acts by children and adolescents; a fol- dal patient. Annals of the New York Academy of Sciences, low-up study. Acta Psychiatrica Scandinavia (Supplement 932, 106-131. 233), 5-23. Brent, D. (1997). Practitioner review: the aftercare of adolescents Pfeffer, C., Klerman, G., Hurt, S., Kakuma, T., Peskin, J. and with deliberate self-harm. Journal of Child Psychology and Siefker, C. (1993). Suicidal children grow up: rates and psy- Psychiatry and Allied Disciplines, 38, 277-286. chosocial risk factors for suicide attempts during follow-up. Brent, D., Mortiz, G., Bridge, J., Perper, J. and Canobbio, R. (1996). Journal of the American Academy of Child and Adolescent The impact of adolescent suicide on siblings and parents: a Psychiatry, 32, 106-113. longitudinal study. Suicide and Life-Threatening Behavior, Pfeffer, C., Klerman, G., Hurt, S., Lesser, M., Perkin, J. and Siefker, 26, 253-259. C. (1991). Suicidal children grow up: demographic and clini- Brent, D., Perper, J., Goldstein, C., Kolko, D., M. Allman, C., and cal risk factors for adolescent suicide attempts. Journal of Zelenak, J. (1988). Risk factors for adolescent suicide: a the American Academy of Child and Adolescent Psychiatry, comparison of adolescent suicide victims with suicidal inpa- 30, 609-616. tients. Archives of General Psychiatry, 45, 581-588. Powell, K., Kresnow, M.J., Mercy, J., Potter, L., Swann, A., Brinkman-Sull, D., Overholser, J. and Silverman, E. (2000). Risk of Frankowski, R., Lee, R., and Bayer, T. (2001). Alcohol con- future suicide attempts in adolescent psychiatric inpatients sumption and nearly lethal suicide attempts. Suicide and at 18-month follow-up. Suicide and Life-Threatening Life-Threatening Behavior, 32 (Supplement), 30-41. Behavior, 30, 327-340. Rathus, J. and Miller, A. (2002). Dialectical behavior therapy Cotgrove, A., Zirinksy, L., Black, D. and Weston, D. (1995). adapted for suicidal adolescents. Suicide and Life- Secondary prevention of attempted suicide in adolescence. Threatening Behavior, 32 (Supplement), 146-157. Journal of Adolescence, 18, 569-577. Rubenstein, J., Halton, A., Kasten, M., Rubin, C., and Stechler, G. Dubow, E., Kausch, D., Blum, M. and Reed, J.(1989). Correlates of (1998). Suicidal behavior in adolescents: stress and protec- suicidal ideation and attempts in a community sample of tion in different family contexts. American Journal of high school students. Journal of Clinical Child Psychology, Orthopsychiatry. 68, 274-284. 18, 158-166. Smith, K. and Crawford, S. (1986). Suicidal behavior among Garland, A. and Zigler, E. (1993). Adolescent suicide prevention: Anormal@ high school students. Suicide and Life- current research and policy implications. American Threatening Behavior, 16, 313-325. Psychologist, 48, 169-182. Spirito, A., Brown, L., Overholser, J. and Fritz, G. (1989). Goldacre, M. and Hawton, K. (1985). Repetition of self-poisoning Attempted suicide in adolescence: a review and critique of and subsequent death in adolescents who take overdoses. the literature. Clinical Psychology Review, 9, 335-363. British Journal of Psychiatry, 146 ,395-398. Stengel, P. and Cook, N. (1958). Attempted Suicide. London: Goldsmith, S., Pellmar, T., Kleinman, A., and Bunney, W. (Eds.). Oxford University Press. Talseth, A.G., Gilje, F., and Norberg, (2002). Reducing Suicide: A National Imperative. A. (2001). Being met-a passageway to hope for relatives of Washington, D.C.: National Academies Press. patients at risk of committing suicide: a phenomenological Gould, M., Greenberg, T., Velting, D. and Shaffer, D. (2003). Youth hermeneutic study. Archives of Psychiatric Nursing, 15, 249- suicide and preventive interventions: a review of the past 256. 10 years. Journal of the American Academy of Adolescent Tomborou, J. and Gregg, E. (2002). Impact of an empowerment- and Child Psychiatry, 42, 386-405. based parent education program on the reduction of youth Gould, M., Jamieson, P. and Romer, D. (2003). Media contagion suicide risk factors. Journal of Adolescent Health, 31, 277- and suicide among the young. American Behavioral 285. Scientist, 46, 1269-1284. Veiel, H., Brill, G., Hafner, H. and Welz, T. (1988). The social sup- Gould, M. and Kramer, R. (2001). Youth suicide prevention. ports of suicide attempters: the different roles of family and Suicide Prevention Now: Linking Research to Practice. friends. American Journal of Community Psychology, 16, Atlanta: Centers for Disease Control and Prevention. 839-861. Harkavy-Friedman, J., Asnis, G., Boeck, M. and DiFiore, J. (1987). Wagner, B., Aiken, C., Mullaley, M., and Tobin, J. (2000). Parents= Prevalence of specific suicidal behaviors in a high school reactions to adolescents= suicide attempts. Journal of the sample. American Journal of Psychiatry, 144, 1203-1206. American Academy of Child and Adolescent Psychiatry, 39, Harrington, R., Kerfoot, M., Dyer, E., McNiven, F., Gill, J., 429-436. Harrington, V., Woodham, A. and Byford, S. (1998). Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves.

80 Families Saving Lives in New York Volume 2: Approaches and Special Populations Suicide Survivors Mary Jean Coleman, MSW, President Samaritans USA

Sorrow These are where my feelings of agony dwell As I wonder if death wasn’t more of a hell. Sorrow is a word that I never knew Not only for you, but also for me till I thought about the gun, the trigger you ‘cause I couldn’t help you and I’ll never be free... placed at your temple as you defied strife. Steadily pulling the trigger, you ended your life. I’ll never be free of this feeling which haunts Which clutches my throat and constantly taunts I wish little brother, as you’d marched tall to die that I couldn’t help you enough just to give that you’d stopped for a moment to whisper “goodbye.” you faith in tomorrow - give you faith just to live. ‘Cause sometimes when I’m lonely and missing you most I’ll pray that the angels have now taken you home an agonizing feeling seems to clutch at my throat. 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. Mary Jean Reed-Coleman, December 1979 Are you peaceful now Eddie, are you finally at rest?

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

I.Findings one of the most devastating losses of all to bear (Bailey, Kral & Dunham, 1999; “On October 30, 1979, Edgar Francis Campbell, 1997; Hogan, 2001; Kneiper, Reed celebrated his 17th birthday. Three 1999; Jamison, 1999; Leenaars and weeks later, on November 20, he went Wenckstern, 1998). It has long been out alone into the wooded area behind believed that survivors of a loved one’s his grandmother’s house. With him, he suicide anguish in feelings of blame, carried a very heavy heart and his dad’s anger, responsibility, guilt, and abandon- hunting rifle. In a single, deafening blast - ment (Ellenbogen and Gratton, 2001). with one bullet to the head - he took his own life. In that single decision, when • Survivors tend to possess greater psy- he became a statistic, I became a sur- cho-social vulnerabilities that cause vivor. Shame, sorrow, stigma, silence, sur- specific complications in the grieving vivor; I didn’t choose it. It chose me.” and recovery process. The Surgeon Mary Jean Reed-Coleman, July 2003 General’s Call To Action to Prevent Sui- cide (1999) notes that suicide evokes A. Prevalence complicated and uncomfortable reactions in most of us. Too often, blame is • Based on over 752,000 suicides from placed on the victim. This stigmatizes 1972 - 1997, it is estimated that the the surviving family members and number of survivors of suicides in friends. These reactions add to the sur- America is 4.5 million (1 of every 59 vivors’ burden of hurt, intensify their Americans in 1997). (Hoyert, Kochanek isolation, and shroud suicide in mys- & Murphy, 1999) tery. Unfortunately, secrecy and silence only diminishes the accuracy and • Centers for Disease Control and Pre- amount of information available about vention (CDC) reported 28,322 Ameri- persons who have completed suicide - can deaths as suicides in the year 2000. information that might help prevent Conservative estimates are that 6-10 other suicides (Satcher, 1999). people are intimately affected by each death. However, a study by the Baton • To understand the complicated Rouge, LA Crisis Intervention Center bereavement associated with suicide, (Bland, 1994), the combination of pos- one must first acknowledge the long sibly affected individuals reached over history of the stigma of suicide and the 28 people per suicide. In some families, litany of acts and rituals practiced the estimated numbers exceed 50 peo- throughout the world to “mark the ple (Coleman, 2003). Since, on average, shameful act.” To prevent the suicide’s 1,200 New Yorkers die by suicide each ghost from wandering, corpses have be year, the latter estimate means approx- decapitated, buried outside the city lim- imately 60,000 people qualify as suicide its or in tribal territories, burned, beaten survivors each and every year. This is with chains, thrown to wild beasts, or equivalent to the population of the city buried at crossroads with a stake of Utica (pop. 59,947, July 1, 2002). through the heart. (Berman and Jobes, 1991). B. Bereavement • Survivors of suicide were often forced “Death by suicide is not a gentle to forfeit goods and property (theirs as deathbed gathering; it rips apart lives well as the victim’s) and on occasion, and beliefs, and it sets its survivors on a family survivors of the victim were prolonged and devastating journey.” required to pay a fine to the suicide’s (Dr. Kay Redfield Jamison, 1999) in-laws in redemption for the “shame brought to their name” (Berman and • Research suggests that for those left Jobes, 1991). behind, losing a loved one to suicide is

82 Suicide Survivors Saving Lives in New York Volume 2: Approaches and Special Populations

• Early theologians regarded suicide as a • Future research that addresses these taboo. Over time, these theological per- and related questions will certainly spectives were translated into both assist social workers working to help criminal and civil laws (Grollman, guide people through what is one of 1988). Statutes were enacted to deter the most difficult grief experiences. And others from attempting suicide. Not it may even help suicide survivors find until 1961 was the act of suicide answers to the one question that does removed by the English Parliament as a unite them – “why?” type of felony. While recently, the belief that suicide is a crime has been C. Responding to Bereavement: A changed, it continues to plague those Practice Model left behind in its wake. Too often, “sui- • Research on the needs of suicide sur- cide became the family secret, the vivors is limited. Within this population, neighbor’s gossip, and a source of it is hard to obtain random samples, blame and public shunning.” (Berman quantitative data is incomplete and a and Jobes, 1991) Despite eradication low response rate is characteristic. from the law books, these pressing Ellenbogen and Gratton found that social stigma issues are lingering left- research was hampered by concepts overs from the Victorian era (1840- that are not operationalized, sample 1900). Although society no longer sizes that are too small, measures mis- openly punishes suicide survivors, it is used, underlying theories left unclear, still profoundly difficult for them to refusal rates are high, and white, break their silence and give their sor- upper/middle class female grievers row words (Knieper, 1999). overrepresented. Besides, why should we presume that a specific set of reac- • Does suicide bereavement differ from tions will be elicited by every act of mourning after other types of death? completed suicide? (Ellenbogen and Comparative research has yet to establish Gratton, 2001) a difference in kind. There are three facets to consider: different grief reac- • Provini, Everett and Pfeffer, 2000 state: tions, postvention and needs assessment. “relatively little is known about the perceptions of the needs and types of help 1. Different grief reaction: Are there any desired by adults who have experi- significant trends within the survivors’ enced suicides by relatives.” We do population? The grief response may know that survivors ask the same indeed run deeper for suicide than for questions, search for motives, and the other modes of death. reason for the death. They often deal with issues of sin and whether their 2. Postvention: Postvention consists of loved one has an afterlife. Many even activities that help reduce the after deny that it was a suicide. Because of effects of the traumatic event in the guilt and often little social support, lives of survivors. “Postvention is many do not share the suicide with prevention for the next generation” those around them. However, research (Schneidman, 1997). suggests that a primary need of survivors is to share thoughts and feelings 3. Needs Assessment: Survivors’ needs in a ‘safe’ environment where they will will tell us if there are any unique prob- not be judged. lems and kinds of help required. “If we can identify what is different about sui- • Kay Redfield Jamison poses the ques- cide from other losses, yet common to tions: “How do people survive such most or all suicide bereavement, we impassable grief and rage? How do should be able to plan more targeted they keep from being destroyed by guilt and effective interventions in the popu- and sorrow that they sacrifice the lation.” (Jordan, 2001). remainder of their own lives for the

Suicide Survivors 83 Saving Lives in New York Volume 2: Approaches and Special Populations

one lost earlier to suicide?” There are 1. Results suggest bereaved suicide many ways: the support of family and survivors endure overwhelming psy- friends, religious faith, the passage of chosocial changes, placing them at a time, psychotherapy or counseling. One higher health risk than those whose of the most effective has been through loved ones died of natural causes the establishment of self-help groups (Constantino, Sekula, and Rubin- for those who have survived another’s stein, 2001). Suicide survivors may suicide.” (Jamison, 2001) (See chapter avoid intense emotional or stressful on Resilience) situations, but when they can’t be avoided the individual may shut Support groups are effective for at least down emotionally. This can lead to four reasons: additional health problems. A wide range of symptoms has been identi- 1. Normalization. One of the most signifi- fied: tearfulness, sleep disturbances, cant and helpful realizations for a sur- irrational behavior and depression. vivor of suicide to have is that his feel- Regarding this latter condition, up to ings are normal, given the situation. In a 50% of bereaved individuals can group setting, it is reassuring to hear that develop major depression. others share their fears and their losses, and that it is not pathological to feel this 2. Those working in suicide postven- way. In fact, it is perfectly normal. tion must recognize that the cognitive sets of the individuals and 2. Understanding. This begins when the his/her thoughts about the current person starts to open up. By telling situation can serve to increase or his/her story – by verbalizing it - they decrease their own susceptibility to are beginning a process of organizing suicide. Survivors may fear the pos- thoughts and feelings. This may be the sibility that they too will complete first step in understanding the “whys,” suicide. A family history of suicide is “what ifs,” and “why didn’t I?” a significant risk factor. In 1864, Pro- fessor John Ordronaux lectured an 3. Monitoring. The third benefit is moni- audience of students at Columbia toring suicide risk. Given the link College in New York City “so potent between the suicide of a family mem- in fact is the influence of hereditary ber and the increased risk for other transmission in the production of family members, this is a critical bene- suicide that not less than one-sixth fit. Peer support groups may simultane- of all recorded cases have been ously provide healthy role models for traced to this source.” This statistic grieving survivors while increasing has transcended time. (Jamison, social support. 1999)

4. Finally, making sense of the suicide of a 3. Survivors are left to sort out the com- loved one is an emotional journey. plex emotions of trying to under- Support groups provide educational standing what has happened. They resources to help educate survivors may over or under-react to daily life regarding the nature of suicide and sui- situations, perhaps in socially unac- cide bereavement. Coming together to ceptable ways. These reactions can share and interact with other survivors pose obstacles to daily functioning may be their ﬁrst step in the journey and interfere with personal happi- toward healing. ness and relationships. Some survivors suffer from low self-esteem, There are three issues to consider regard- not only from the reactions and stig- ing the impact on survivors of the mode of ma of family and friends, but from death: misunderstanding their own grief related responses. Some may abuse

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drugs and alcohol as a maladaptive in need. It is critical to find way to way of coping with their loss. reach them using police, EMTs, coro- ners, funeral home directors – rather The problem: How do we best offer emo- than waiting for them to call. tional support, compassion, assist in promoting self-help and resiliency, and • Outcome measures should help identify encourage family and community net- if the time schedule and means of works? engagement are reaching those who actually need assistance. Process eval- IV. Action Steps: uation is critical to gauge the effective- • We must understand that surviving the ness of the intervention. loss of a loved one is a slow process that doesn’t come easily or painlessly. • Success in suicide postvention will The survivor must be heard, feel under- probably arise by tailoring interventions stood, to be able to reconnect to a to specific client needs. Most important, community. there is no cookbook.There is no universal principle regarding how to • Science of biology has enabled a deep- respond in postvention. One can speak er understanding of suicide and the fac- of understanding, but never with preci- tors that correlate with suicidal behav- sion. When the subject matter is ior, and the possibility of a genetic postvention after suicide, we can be no foundation. Those who lose loved ones more accurate or scientific than the to suicide are at greater risk for compli- available ways of responding and the cated grief. The impact of suicide and subject matter permit. Yet, understand- the isolation from support networks ably, the yearning for a universal pre- places survivors of suicide at much vention law persists. A sweeping psy- greater risk for suicide themselves. chological statement with a ring of truth, such as ‘postvention is group • Survivors need short and long term therapy’ becomes a dictum, a platitude. help themselves. Communities need to The search for a singular universal be pro-active and not reactive to the response to trauma is chimera. There is needs of survivors. Social supports and no one method of postvention. the access to them are important con- (Leenaars & Wenck, 1998). siderations. A service contract for working with groups of suicide sur- • One survivor has concluded after 20 vivors must ensure availability, accessi- plus years of life after a suicide: Grief is bility, accountability, integrity, quality, something that never truly goes away. and comprehensive coordination. It remains one of the few things that still has the power to silence us. Loss is • Survivors may need a variety of servic- forever and two decades after Eddie’s es, including a mix of access to suicide death, I still find myself sometimes cry- prevention/crisis hotlines; support ing out at his continuous presence of groups composed of others who share his absence. However, what was once grief experience; referrals to profession- a massive, weighty ball of grief has al counselors; destigmatizing suicide now become smaller and more man- through education. ageable. It gets tucked away into one of my pockets. It’s there so I remember • Implementation is not a one-time that I must not forget. But certainly the effort. Postvention programs must outcome of any postvention support extend over a number of months and may well be the reaching out of “old require constant monitoring and survivors” to “new survivors” as they improvement. The biggest hurdle may begin their journey...” (Coleman, 2003) be that their grief is so absorbing that survivors do not seek help when most

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Appendix

Eddie I found myself sad, when asked if I had any poems I wish he could, have seen something good,...that about my brother. the demons didn’t bind him. I’d not written a one, since he picked up that gun, Because today he would be, a father probably, with ..nor had I written of mother. the torment he felt behind him. She too passed away, though not the same way; We’d all have spaghetti, with Uncle Eddie, invited death’s hand still won the deal. for dinner at 3:00. Brought now to attention, I sit down with inten- And then after we ate, we’d all stay up late, and tion, to share the thoughts that I feel. watch a little t.v.

My feelings is, that his life was his, and...I guess And occasionally, he might share with me a foot- that gave him the right, ball game, or a beer. What I don’t understand, with a gun in his hand, But his horrible choice, silenced the voice, which I was why he wasn’t willing to ﬁght. now would treasure to hear. As his lowest level, he turned to the devil, without I know what he hated, but I wish he had waited, even knowing he had. because life often turns on a dime. He hated here, I say through a tear, as I too have And I now wouldn’t be, presently, grieving my felt that sad. brother in rhyme.

So I can see, how it came to be, but that doesn’t So I guess you could say, that still today, some lesson the pain. twenty years after the fact, And I have to ask, regarding the past, was there all I mourn him still, and always will, until I get him that much to gain? back. A mother destroyed, a family’s void, and they all say “rest in peace.” Sandi Reed-Barrett Then that is that, no going back; it’s all in the November 2001 suicide lease.

86 Suicide Survivors Saving Lives in New York Volume 2: Approaches and Special Populations

References Jordan, J. (2001). Is suicide bereavement different? A reassess- Bailley, S., Dunham, K., & Kral, M. (2000). Factor structure of the ment of the literature. Suicide and Life Threatening grief experience questionnaire. Death Studies. 24 (8), 721- Behavior, 31 (1), 91-102. 739. Knieper, A. (1999). The suicide survivor’s grief and recovery. Bongar, B. (1996). The Suicidal Patient: Clinical and legal stan- Suicide and Life Threatening Behavior, 29, (4), 353-364. dards of care. Washington, DC: American Psychological Leeners, A. & Wenckstern, S. (1998). Principles of postvention: Association. Applications to suicide and trauma in schools. Death Berman, A.L., & Jobes, D. (1997). Adolescent Suicide: Studies, (22), 357-391. Assessment and intervention. Washington DC: American Lott, D. (2000). Risk management with the suicidal patient. Psychological Association. Psychiatric Times, 17 (8) Bland, D. (1994). The Experiences of Suicide Survivors 1989-June Murphy. (2000). The use of research findings in bereavement pro- 1994. Baton Rouge, LA: Baton Rouge Crisis Intervention grams: a case study. Death Studies, 24 (7), 585-603. Center. Parkes, C. (2002). Grief: lessons from the past. Death Studies, Cain, A.C. (Ed.). (1972). Survivors of Suicide. Springfield, IL: (26), 367-385. Charles C. Thomas. Provini, C., Everett, J.R. & Pfeffer, C.P. (2000). Adults mourning sui- Callahan, J. (2000). Predictors and correlates of bereavement in cide: Self-reported concerns about bereavement, need for suicide support group particiants. Suicide and Life assistance, and help seeking behavior. Death Studies, 24 Threatening Behavior, 30 (2), 102-124. (1), 1-19. Campbell, F. (1997). Changing the legacy of suicide. Suicide and Range, L. & Knott, E. (1997). Twenty suicide assessment instru- Life Threatening Behavior, 27, (4), 329-338. ments: evaluations and recommendations. Death Studies, Carlson, T. (2000). Suicide Survivors Handbook. Duluth, MN: 21 (1), 25-51. Benline Press. Reed, M. (1998). Predicting grief symptomology among the sud- Constantino, R., Sejula, K., & Rubenstein, E. (2001). Group inter- denly bereaved. Suicide and Life Threatening Behavior, 28 vention for widowed survivors of suicide. Suicide and Life (3), 285-301. Threatening Behavior, 31 (4), 428-441. Stevens, R. (1995). Everybody Hurts: Coping with our son’s Doka, K. & Gordan, J. (1996). Living with Grief After Sudden Loss. suicide. Hong Kong: Kings Time. Bristol, PA: Taylor & Francis. Stillion, J. & McDowell, E. (1996). Suicide Across the Lifespan: Ellenbogen, S. & Gratton, F. (2001). Do they suffer more? Premature Exits. (2nd Ed). Washington, DC: Taylor and Reflections on research comparing suicide survivors to other Francis. survivors. Suicide and Life Threatening Behavior, 31 (1), 83- U.S. Public Health Service, The Surgeon General’s Call to Action 90. to Prevent Suicide. Washington, DC: 1999. Gilbert, K. (1996). We’ve had the same loss, why don’t we have Williams, J. & Ell, K. (1998). Mental Health Research. the same grief? Loss and differential grief in families. Death Washington DC: NASW Press. Studies, (20), 269-283. Yalom, I. (1995). The Theory and Practice of Group Psychotherapy. Grollman, E. (1998). Suicide: Prevention, intervention, postvention. New York, NY: Harper Collins Publishers, Inc. Boston, MA: Beacon Press. Hoff, L.A. (1995). People in Crisis: Understand and Helping. San World Wide Web References: Francisco, CA: Jossey-Bass Publishers. http://www.cdc.gov Hoyert, D.L., Kochanek, K.D., & Murphy, S.L. (1999). Deaths: Finals http://www.hhs.gov data for 1997. National Vital Statistics Report, 47 (19). http://www,mentalhealth.org/suicideprevention/survivorfacts.asp Hyattsville, MD: National Center for Health Statistics. http://www.psych.org/public_info/teenag~1.cfm DHHS Publication No. (PHS) 99-1120. Jamison, K. (1999). Night falls fast: Understanding Suicide. New York, NY: Random House, Inc.

Suicide Survivors 87

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 • Like all health and mental health serv- There were 258,455 births in New York in ices, screening and treatment for PPD 2000. While new mothers are not generally must be culturally appropriate to be considered to be at high risk of suicide, effective. serious postpartum mood disorders that require hospitalization are associated with B. Risk Factors for PPD death from natural and unnatural causes. • Previous incidence of PPD (50% will re-develop PPD) A. Prevalence and Patterns • Postpartum depression (PPD) is the • Previous depression (25% will most common disorder after childbirth. develop PPD) More women develop depression following birth than at any other time. • Previous bipolar disorder

• PPD is a treatable illness, but it is often • Depression during pregnancy unidentiﬁed by health care professionals. • Depression or bipolar disorder • 50-80% of new mothers get the “baby in the family blues,” depressive symptoms which resolve within 12 days after birth. 20% • Previous signiﬁcant premenstrual of these women will develop PPD. syndrome (PMS)

• 10-15% of mothers - 22% of multiethnic • Stressful situations, including difficult inner city mothers -develop PPD. childbirth, health problems in the baby or mother, marital discord, lack of • .1%-.2% (one in 1,000 or 2 in 1,000) of assistance with baby care, and lack new mothers develop postpartum psy- of emotional support chosis, a serious disorder characterized by paranoia, mood shifts, and/or hallu- C. Barriers to Identifying cinations or delusions. Immediate med- and Treating PPD ical attention is required. • In general, those who screen for PPD (e.g. obstetricians) do not provide eval- • Besides the symptoms experienced by uation and treatment (e.g. mental the mother, PPD may affect the moth- health clinics). This makes access to er-infant interaction and may lead to appropriate care more complex. problems as the baby grows.

New Mothers 89 Saving Lives in New York Volume 2: Approaches and Special Populations

• Stigma of mental health treatment • A prenatal depression question was added to the Statewide Perinatal Data • Medical personnel receive little or no System. training in identifying PPD III. Action Steps • Family members may fail to recognize 1. There are strong risk factors for post- PPD partum depression (PPD), and prenatal/perinatal screening can help to • Mothers may not seek treatment due to identify those most likely to develop it lack of energy caused by the illness, as well as deliver services to them in stigma and/or feeling guilty about the hospital with follow-up to start right being depressed when she is supposed after delivery. Obstetricians, pediatri- to be “happy.” cians and other medical personnel in contact with new mothers should II. Current State Efforts screen mothers for PPD during the • The Healthy Families New York (HFNY) child’s first year. program provides home visiting services by trained home visitors who work with 2. Home visiting services have been expectant families and families with shown to be effective in improving out- newborns who have certain risk factors comes for children. All at-risk new that may lead to child abuse and neglect mothers should receive home visita- and poor health outcomes. Home Visi- tions services and be screened for post- tors provide weekly home visits until the partum depression, including follow-up child is at least six months old and may care for women who screen positive continue less frequently based on the and an emergency protocol for women needs of the family until the child is five in a peri-suicidal state or homicidal years old or in school or Head Start. Vis- state. Involvement of the new mother’s its are aimed at promoting positive par- partner or support person in their treat- ent-child interaction and optimal child ment is highly desirable. health and development. Home visitors also assist in linkage to other services to 3. A media campaign that highlights the increase the families’ self-sufficiency. prevalence and risk factors for post- The HFNY program is currently located partum depression, linkages to service in 28 sites serving high need areas providers and training inevidence- across the state. based treatment for post-partum depression are necessary ingredients of • Association of Perinatal Networks of a prevention program. New York received a grant to create training programs and resources to References increase awareness of PPD and American Association of Health Plans: Current Issues Report, Approaches to Depression Care. Washington, DC; AAHP, increase service utilization. 2000. American College of Obstetricians and Gynecologists, Answers to • Information on PPD has been added to Common Questions about PPD. January 2002. www.acog.org the Maternity Information leaflet, dis- Georgiapoulos, AM, Bryan, TL; Wollan, P; Yawn, BP. Routine seminated to all obstetrical hospitals Screening for PPD Journal of Family Practice, 50 (2), 2001. statewide, and to “Your Guide to a Moline, ML; Kah, DA; Ross, RW; Altshuler, LL; Cohen, LW. PPD: A Guide for Patients and Families, Expert Consensus Healthy Birth,” which is also available Guideline Series. A Postgraduate Medicine Special Report, to pregnant women statewide. March 2001, 112-113. Sobey, WS, Barriers to PPD Prevention and Treatment: A Policy Analysis Journal of Midwifery & Women’s Health, Vol.47, • The Pregnancy Risk Assessment Moni- no.5, Sept/Oct. 2002, 331-336. toring System (PRAMS), a national screening program, now includes a question on PPD.

90 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 presi- Another reason may be deeply rooted cul- dent and chief executive officer of a major tural belief: a “macho” world view that bank in western New York, who was also rewards men for taking risks and tackling chairman of a university board of trustees, danger head on. (Ibid.) In other words, went home from work and killed himself. It males are praised for “being in control” of was the second suicide of a prominent the situation, even when it is inherently local resident in less than three weeks. Col- dangerous or challenging. Could the sui- leagues and friends said both men were cide of these prominent western New York- hard workers and high achievers who had ers have been prompted by their sense of been troubled recently by public embar- loss of control over a situation they were rassments. While it is tempting to say that expected to master, but could not? Could these upsetting circumstances caused the they, like thousands of other successful men’s suicides, experts warn, it’s not that people who die from suicide seemingly out simple. (Neville: 2003) of the blue, have actually suffered from depression? It’s likely to have been a con- It is not surprising that both victims were tributing factor, if not the root cause, since males. Men outrank women in all of the 15 mental disorders are involved in 90-95% of leading causes of death, except one: all suicides. Alzheimer’s disease. In fact, men’s death rates are at least twice as high as women’s According to Dr. Richard Carmona, Sur- for suicide, homicide, and cirrhosis of the geon General of the United States, about 6 liver. At every age, according to a study million men have clinical depression, but published in the May 2003 issue of the research shows they are less likely to seek American Journal of Public Health, American treatment than women. Many men do not males have poorer health and a higher risk realize that some health symptoms may be of mortality than females. (DR Williams, caused by depression. For generations, The Health of Men: Structured Inequalities men have been told that they have to act and Opportunities) More of them smoke tough. As a result, men tend to self-med- (although women are catching up), drink icate, and avoid going to see a physician, heavily and are far more likely to engage in even when their symptoms are acute. The behaviors that put their health at risk, from result: men are four times more likely to abusing drugs to driving without a seat die from suicide as women in New York. Is belt. Men also drive more rollover-prone it another manifestation of men wanting to SUVs and suffer more motorcycle fatalities. control the situation that they typically use (Sanjay Gupta, M.D.: 2003) more lethal means to die, thereby leaving less to chance?

Men in the Middle Years 91 Saving Lives in New York Volume 2: Approaches and Special Populations

Figure 1 Figure 2 New York Suicides by Gender New York Suicide Rates 2002, all races, all ages by Age and Gender 2002, all races. 16

Males 14 14.63 (n=989) (81%) 13.62 12 11.62 Females 10 (n=239) (20%) 8

Rate per 1,000 6

4 3.25 3.56 2 2.62 0.38 0.17 0 1-14 15-24 25-54 55-85+ Source: CDC, WISQARS, 2005 Years Years Years Years

Males Females The typical suicide death in New York is a white, middle-age male who resides alone, Source: CDC, WISQARS, 2005 upstate, suffers from depression, and uses a firearm to end his life. Forty percent of all suicides in New York in 2000 fit this demo- Figure 3 graphic profile. While elderly white males New York Suicide Prevalence (>65) die at a higher rate, those in the middle by Age and Gender years die in the largest numbers. (NYSDOH: 2002, all races. 2001) By contrast, there were zero suicides among black women older than 65 and 600 none among Hispanic women, ages 25-34 562 and older than age 75. (NYSDOH: 2001) 500 The differences between males and females with respect to suicidal behavior 400 holds across the life course as shown in the following chart of suicide rates. 300 Actual 267 In terms of sheer numbers of deaths, mid- 200 dle year males experience by far the largest number of suicides in New York. This is 153 140 shown in Figure 3. 100 33 10 3 63 0 1-14 15-24 25-54 55-85+ Years Years Years Years

Males Females

Source: CDC, WISQARS, 2005

92 Men in the Middle Years Saving Lives in New York Volume 2: Approaches and Special Populations

There are signiﬁcant differences in the sui- These men died at a rate (13.63/100,000) cide rates of males depending on their race more than twice the statewide average for as illustrated by the following: the general population (6.42). The rates in descended order by race: White (15.38/100,000) Figure 4 African-American (9,41) New York Suicide Rates Native-american (7.19) in Males by Race Others (6.3) 2002, ages 25-54. Source: CDC, WISQARS, 2005 16 15.38 Risk factors common to both males and 14 females in the middle years are: Major psychopathology, Depression and alcohol 12 use/dependence, Interpersonal disruptions, 10 Social isolation, Poor work performance 9.41 and unemployment, Violence and legal 8 problems, Variable impact of marital and 7.19 parental status, Prior suicide attempts and Rate per 1,000 6 6.3 Family history of suicide(ED Caine, MD, 4 2005)

2 A distinct sub-population of would-be suicides are white males who appear to har- 0 bor little suicidal risk. For them, untreated African Native White Other American American depression can magnify a personal reversal such as bankruptcy, arrest, a career setback Source: CDC, WISQARS, 2005 or a personal scandal, and propel a person into a death spiral. Many of these individuals are outwardly successful and their Based on the foregoing: record of achievement can ﬁnd them ill- prepared for a perceived failure. Lacking In 2002, death by suicide among New York experience in coping with “failure,” and males, ages 25-54: feeling a sense of shame at letting others down - of losing all they have achieved - • Was the 3rd leading cause of death for they see their deaths as relieving their fam- those ages 25-34; 5th leading cause of ilies of a burden. In such cases, an underly- death for those ages 35-44; and 6th ing mental illness can and does distort their leading cause of death for those ages thinking and lead them to rationalize their 45-54.; self-destruction.

• Comprised 45.7% of all suicides in New The fear of emotional disintegration - of York that year (562/1228); lives unraveling, collapsing or falling apart - has been described as greater than the • Constituted 57% of all male suicides fear of death itself. For many desperate across the lifespan (562/989); and people, death seems to be the only way to attain both relief and control. (Hendin et al: • Occurred at a rate (13.63/100,000) that 2004) A similar scenario has unfolded on was 29% higher than for all males college campuses where high-achieving, (10.7); 4x the rate for female cohorts even brilliant students from privileged (25-54), and nearly 6x the rate for backgrounds become trapped by self- females overall (2.42). imposed perfectionistic expectations and resort to suicide.

Men in the Middle Years 93 Saving Lives in New York Volume 2: Approaches and Special Populations

The impact of premature death is immeas- career and family responsibilities grow. urable in many ways, especially for family “Central to this task (of preventing suicide) and loved ones. It is also an enormous loss will be the installation of interventions earli- for the society and economy in which they er in the course of individual episodes of live. Dr. Eric Caine and colleagues have (mental) illness, such that the emergence of calculated the economic value of such loss- a suicidal state is precluded... (Such activi- es in terms of lost earnings. These lost ties could take place) at work sites, mental earnings peak in value nationally at about health and chemical dependency treatment age 37, to the sum of $1.8 billion. The YPLL settings, primary medical settings, religious for American women are fewer due to their and community programs, the courts and much lower suicide rate, higher health con- criminal justice sites, as well as state and sciousness, and less risk-taking. Overall, federal supported program sites.” (Caine women are “early adopters” of good health and Conwell: 2003) However, even as one habits, whereas men tend to be “late embraces this population-based approach, adopters.” 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 Past suicide prevention efforts were decid- University of Rochester Center for the Study edly one-sided, focusing almost entirely on and Prevention of Suicide (CSPS) have those who were imminently suicidal and in advanced a multi-layer prevention strategy great distress. Interventions were often in a for men, ages 25-54. Following the Nation- personal crisis environment, often in emer- al Strategy for Suicide Prevention, they gency rooms (ERs), intensive care units advocate a comprehensive approach to (ICUs), psychiatry clinics, inpatient services, saving men’s lives. These involve universal or the offices of mental health clinicians. measures (covering the whole male popu- Little attention was focused on the much lation), selective (for those at risk), and larger number of asymptomatic males in indicated measures (for those in imminent the general population, who were at risk danger). Taken together, these are intended for suicide but unrecognized to be as such. to diminish the risk factors leading to sui- As noted, compared to women, males are cide, and enhance the protective factors disinclined to seek regular checkups and leading to life-affirming behavior. physicals. Even if they did, primary care practitioners are sometimes reluctant or As men move out of the early adult years unable to bring up issues of mood, suicidal into middle age, issues regarding work,

Figure 5 Suicide Prevention for Men, Ages 25-54

Peri-suicidal state

Depression, hopelessness Risk Symptoms, Resiliency

Role changes, medical illness, acute and chronic stress Suicide

Personality factor, social ecology, cultural values and perceptions

ìDistal ” Risk factors “Proximal” Time Source: Caine and Cronwell CSPS, 2003

94 Men in the Middle Years Saving Lives in New York Volume 2: Approaches and Special Populations thoughts or behaviors that could lead to a antidepressant prescription rates and have diagnosis of clinical depression. 4 times the suicide rate of females. Most of those who die by suicide are found to have Depression Among Men major depressive disorder at the time of Depression remains a subject that neither death as either untreated or receiving sub- physician nor patient seems eager to tack- therapeutic doses of antidepressants. le. It is the leading cause of disability (Grunebaum, M.F., Ellis, S.P.,Li, S, Oquendo, worldwide among persons older than 5 M.A., Mann, J.J., MD,: 2004) . For all types of years. (NIMH: 2001) Major depression is antidepressant (SSRI, TCA, and others), second only to ischemic heart disease in women’s usage exceeds their male coun- terms of disease burden (morbidity and terparts use by a wide margin, as shown in mortality) in the developed world, including the following : the United States. The cost of reduced pro- ductivity 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 satis- ﬁed with the situation. Last year, enrollees in New York’s health plans rated treatment Figure 6. of depression among the lowest of 18 Prescription Antidepressant Use physical or behavioral health condition in by Medication and Gender, their coverage. According to the New York 1997-2000 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.

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 95 Saving Lives in New York Volume 2: Approaches and Special Populations

The following shows that this ‘usage gen- Figure 8. der gap’ holds true across the lifespan: SSRI antidepressant drug visits among adults 18 years of age Figure 7. and over by sex: United States, Antidepressant Prescription Usage 1995-2002. by Gender.

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 The ‘gender gap’ in antidepressant usage of drug therapy. Previous research has has grown in recent years, as SSRI’s have found that appropriate diagnosis and quali- come to dominate the market of prescribed ty care are lagging in the primary care set- medications for depressive disorders. ting. A lack of resources and time, reluc- tance on the part of primary care physicians to screen for depression, and unfa- miliarity 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” where- by people show up for work but are largely unproductive because they are depressed. This problem could stem from the lack of

96 Men in the Middle Years Saving Lives in New York Volume 2: Approaches and Special Populations follow-up monitoring by doctors, the high By taking an integrated approach - com- cost of continuing treatment, or the fact bining attention to high-risk individuals that many reluctant patients don’t like to and the broader population that has not yet see themselves as having chronic depres- manifested suicidal thoughts or deeds - we sion and drop out of treatment too soon. can hopefully reduce the overall suicide (Munoz: 2003) rate for men in the middle years. In addition, an educational intervention for pri- Adding to the gravity of the situation is the mary care physicians to improve recogni- recent finding that the risk of suicide is tion and treatment of mood disorders may greatest when patients begin taking an lower suicide rates, (Ibid.) Finally, the study antidepressant medication. Previous think- supports the need for enhanced screening ing was that the risk was greatest in the and treatment. days after antidepressant therapy was dis- continued. The study found no difference in We need not wait for more fundamental risk between newer and older drugs. “It’s research findings to begin our suicide pre- starting treatment itself, more than what vention work with the male population. We drug you start with, that’s the important know enough about the risks and precur- factor.” (Carey: 2004) sors of suicide to intervene actively and encourage those in need to seek treatment. Disorders of the central nervous system, In the words of Charles Curie, the adminis- such as Epilepsy, AIDS, Huntington’s Dis- trator of SAMHSA: “We need to raise (pub- ease, head injuries and cerebrovascular lic) awareness that help is available, treat- accidents, carry a much higher relative risk ment is effective, and recovery is possible.” of suicide. Many of these occur after age 25. They may trigger depression and suici- References dal ideation and may impair restraint or Altan, DJ, “Follow-up care found lacking in treatment for depression,” Los Angeles Times, July 2, 2004. inhibition of the desire to act on such Caine,E.D. M.D. and Knox, K.L., Ph.D., Preventing Suicide and thoughts. (Mann: 2002) Moreover, a history Reducing the Burden of Suicidal Behaviors, University of of physical or sexual abuse during child- Rochester: CSPS, 2003 Caine, E.D., M.D., Suicide Risks and Prevention: Presentation to hood, a history of head injury or neurologi- Psychiatry Grand Rounds. New York State Office of Mental cal disorder, and cigarette smoking Health. September 17, 2003 increase the risk of suicide. (Mann: 2002) 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. Public health officials in Washington Presentation to National Council on Suicide Prevention, appear to be following the lead of former New York City, January 20, 2005 Carey, B., “Study of Antidepressants Finds Little Disparity in Surgeon General David Satcher who did Suicide Risk.” The New York Times, July 21, 2004 much to raise the profile of suicide as a Centers for Disease Control and Prevention (CDC), national health issue. The National Institute WISQARS, 2005 Grunebaum, MF, Ellis, SP, Li, S, Oquendo, M, and Mann, JJ, of Mental Health has launched a campaign “Antidepressants and Suicide Risk in the United States, to raise awareness that men, too, suffer 1985-1999, “ Journal of Clinical Psychiatry, 65:11, from depression and that they need to seek November 2004, 1456-1462 Gupta, S, M.D. Why Men Die Young. Time, May 4, 2003 help (See Appendix). Called Real Men, Real Lewis, G., Hawton, K., and Jones, P. (1997), Strategies for Depression, the campaign includes a series Preventing Suicide, British Journal of Psychiatry, 171, 351- of multi-media public service announce- 354 Hendin, Herbert, MD et al., Desperation and Other Affective ments featuring people telling their person- States in Suicidal Behavior, Suicide and Life-threatening al stories about how they confronted their Behavior, 34 (4), Winter 2004, 386-394 own depression. Its intent is to attack the Kessler, Ronald, MD, Results of the National Cormorbidity Study, JAMA, 6/18/03 stigma that “tough guys can’t seek help.” Mann, J.John, MD, A Current Perspective of Suicide and They can and they should, according to Dr. Attempted Suicide. Annals of Internal Medicine. 2002; 136; Richard Carmona, Dr. Satcher’s successor. 302-311 MSNBC, Men Need to Talk About Depression. October 23, 2003 “Today we’re saying to men, it’s OK to talk (www.msnbc.com/news/893794.asp) to someone about what you’re thinking, or Munoz, SS, Cost to Treat a Depression Case Falls, The Wall how you’re feeling, or if you’re hurting.” Street Journal, December 31, 2003 Neville, A. The Specter of Suicide, Buffalo News, August 26, (MSNBC: 2003) 2003

Men in the Middle Years 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

98 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 • Loss of interest or pleasure in hobbies Depression is a serious but treatable med- and activities that were once enjoyed, ical condition that can strike anyone including sex regardless of age, ethnic background, socioeconomic status, or gender. However, • Decreased energy, fatigue, being depression may go unrecognized by those "slowed down" who have it, their families and friends, and even their physicians. Men, in particular, • Difficulty concentrating, remembering, may be unlikely to admit to depressive making decisions symptoms and seek help. But depression in men is not uncommon: in the United States • Trouble sleeping, early-morning awak- every year, depressive illnesses affect an ening, or oversleeping estimated seven percent of men (more than six million men). • Appetite and/or weight changes

Depression comes in different forms, just • Thoughts of death or suicide, or suicide as is the case with other illnesses such as attempts heart disease. The three main depressive disorders are: major depressive disorder, • Restlessness, irritability dysthymic disorder, and bipolar disorder (manic-depressive illness). Not everyone • Persistent physical symptoms, such as with a depressive disorder experiences headaches, digestive disorders, and every symptom. The number and severity chronic pain, which do not respond to of symptoms may vary among individuals routine treatment and also over time. Research and clinical ﬁndings reveal that Symptoms of depression include: while both men and women can develop the standard symptoms of depression, they often • Persistent sad, anxious, or "empty" experience depression differently and may mood have different ways of coping. Men may be more willing to report fatigue, irritability, loss • Feelings of hopelessness, pessimism of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, • Feelings of guilt, worthlessness, help- worthlessness, and excessive guilt. lessness

Men in the Middle Years (Appendix) 99 Saving Lives in New York Volume 2: Approaches and Special Populations

Some researchers question whether the ing depressive symptoms in men and help- standard deﬁnition of depression and the ing them get treatment. diagnostic tests based on it adequately capture the condition as it occurs in men. Seek Help for Depression If you are having symptoms of depression Men are more likely than women to report or know someone who is, seek help. There alcohol and drug abuse or dependence in are several places in most communities their lifetime; however, there is debate where people with depressive disorders among researchers as to whether sub- can be diagnosed and treated. Help is stance use is a "symptom" of underlying available from family doctors, mental depression in men, or a co-occurring con- health specialists in mental health clinics or dition that more commonly develops in private clinics, and from other health pro- men. Nevertheless, substance abuse can fessionals. mask depression, making it harder to recognize depression as a separate illness that A variety of treatments, including medica- needs treatment. tions and short-term psychotherapies (i.e., "talking" therapies), have proven effective Instead of acknowledging their feelings, for depressive disorders: more than 80 per- asking for help, or seeking appropriate cent of people with a depressive illness treatment, men may turn to alcohol or improve with appropriate treatment. Not street drugs when they are depressed, or only can treatment lessen the severity of become frustrated, discouraged, angry, irri- depression, but it may also reduce the table and, sometimes, violently abusive. duration of the episode and may help pre- Some men may deal with depression by vent additional bouts of depression. throwing themselves compulsively into their work, attempting to hide their depres- For More Information sion from themselves, family, and friends; National Institute of Mental Health other men may respond to depression by Public Inquiries engaging in reckless behavior, taking risks, 6001 Executive Boulevard and putting themselves in harm's way. Room 8184, MSC 9663 Four times as many men as women die by Bethesda, MD 20892-9663 suicide in the United States, even though Toll-Free: 1-866-227-NIMH (6464) women make more suicide attempts dur- FAX: 1-301-443-4279 ing their lives. In light of research indicat- TTY: 1-301-443-8431 ing that suicide is often associated with E-mail: [email protected] depression, the alarming suicide rate Website: http://www.nimh.nih.gov among men may reﬂect the fact that men NIH Publication No. 03-5297 are less likely to seek treatment for depres- Printed March 2003 sion. Many men with depression do not Department of Health & Human Services obtain adequate diagnosis and treatment, National Institute of Mental Health which may be life saving.

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 The following items summarize research New York is arguably the most culturally findings and expert opinion. diverse state in the nation. The borough of Queens in the City of New York is the most General information on ethnic and racial ethnically diverse large county in the Unit- minorities: ed States. According to the 2000 Census, 46% of Queens residents are foreign born. • While suicide rates vary between peo- Its 2.2 million residents are drawn from ple of different cultural backgrounds, more than 90 countries and speak 138 dif- rates of mental illness are generally ferent languages. However, very little is similar across ethnic groups. known about suicide rates, mental health status, and the effectiveness of mental • Evidence-based treatments have not health treatments in ethnic and linguistic been sufficiently tested on individuals minorities because few studies have been from diverse cultures. Therefore, effec- done on the subject. tiveness across cultures is not known and cannot be assumed. While the following recommendations refer to the four most recognized cultural minori- • Ethnic minorities are under-represented ties (African-Americans, Hispanics, Asian among recipients of mental health serv- American/Pacific Islanders, and Native ices. It is well documented that these Americans/Alaska Natives), there is great individuals are less likely to seek mental diversity within these groups. For example, health treatment than whites. Asian Asian Americans/Pacific Islanders speak Americans/Pacific Islanders have the over 100 different languages; Native Ameri- lowest utilization rate of all minorities. cans/Alaska Natives come from over 500 tribes, Hispanic persons are from Puerto • Studies have consistently documented Rico, Cuba, Mexico, or any Central or South disparities in the health and mental American country, and include a significant health treatment of minorities that number of immigrants. African-Americans remain after controlling for income, are diverse as well, with some descendants insurance, and clinical factors. from populations that were brought to the U.S. more than 200 years ago, while others • Ethnic minorities are more likely to recently emigrated from the Caribbean, seek assistance from community mem- South America and Africa. bers, natural supports, and traditional healers. When they do seek treatment,

Cultural, Ethnic and Racial Groups 101 Saving Lives in New York Volume 2: Approaches and Special Populations

it is more likely to be from a primary A. Prevalence and Patterns care physician than a specialist. • The rate of suicide for American Indi- ans/Alaska Natives is 1.5 times higher • Mood disorders and substance abuse than the national rate. Native American disorders, both highly correlated with males aged 15 to 24 have a rate two to suicide, are very prevalent among three times the national suicide rate. some ethnic/racial minorities, and are believed to be more influenced by envi- • The rate of suicide among African ronmental factors than other mental ill- American males aged 10-14 jumped by nesses. Ethnic minorities also have 233% between 1980 and 1995, com- higher rates of post-traumatic stress pared to a 120% increase for white disorder, possibly due to an elevated males of the same age. exposure to violence. • Statistics report that whites are twice • Ethnic minorities who belong to other as likely to commit suicide as African- at-risk populations, e.g. lesbian, gay, Americans. However, the incidence of bisexual or trans-gender youth, may be “suicide by cop” has led to a mis-classi- at increased risk for suicide. fication of this behavior as a homicide. Among the elderly, African-American • Ethnic minorities face inequality that women have a lower suicide rate than includes greater exposure to discrimi- their white counterparts. Possible rea- nation and poverty, which, in turn, may sons are the protective role of spirituali- contribute to mental illness. ty among them, and their extended role as care givers to their family, especially • Cultural minorities are over-represent- their grandchildren. ed among populations who are poor, in jail, homeless, HIV/AIDS positive, and • Asian American women have the high- exposed to violence/trauma. est suicide rate of all women over 65. Of girls in grades 5-12, Asian Ameri- • Symptom presentation may be different can/Pacific Islanders show the highest in various cultural groups, which may level of depressive symptoms. lead to mis-diagnosis and inappropriate treatment. There may be “culture- • While the reported suicide rate for His- bound syndromes” only seen in per- panics is lower than the general popu- sons of particular ethnic groups. lation, a national survey found increased levels of suicidal ideation and • Poverty and lack of health insurance attempts among Hispanic high school make health and mental health care less students. accessible to many minority persons. B. Risk and Protective Factors • Other risk factors cited: lack of cultural The greatest risks for suicide in the general and spiritual development, loss of eth- population as well as among ethnic and nic identity (especially for Native Amer- racial minorities are depression and sub- icans), and acculturation -the adopting stance abuse disorders. Exposure to vio- of a majority culture by minorities or lence and other traumatic events creates a the loss of ethnic culture. suicidal risk, as does access to firearms. In addition, risk factors that disproportionately • While some cultural minorities have affect minorities include: poverty, immigra- expressed greater comfort in being treat- tion, violence, racism, and discrimination. ed by health care professionals of the Protective factors for minorities include: same ethnic background, there is a short- supportive families, strong communities, age of minority health care providers. spirituality and religion.

102 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 New York’s initiatives include the following: linkages with varied communities and to meet the language needs of the • Tiered Certification – Cultural compe- recipients to be served. tence is one of eight stated values underlying the certification process for • Project Liberty, developed by OMH to OMH-licensed mental health programs. meet the needs of communities, fami- Certified programs are expected to lies and individuals affected by the ensure that “human rights, cultural dif- events of 9/11, offered services, out- ferences and the dignity of those served reach and information in several lan- are preserved.” guages.

Following are examples of survey guide- • Building Effective Relations in a Diverse lines: Workplace train-the-trainer program was provided to OMH in 2000. • Program employs staff who are of the same or similar ethnicity or culture as • Cultural competence considerations in the recipients served, by: screening treatment have been the topic of potential candidates for cultural com- statewide training programs. petence; recruiting culturally competent staff; and providing staff training to fos- III. Action Steps ter staff’s cultural competence and eth- 1. Imbue cultural competence in all pre- nic awareness. vention strategies. New York is arguably the most culturally-diverse • Multi-cultural training should include state. Varying cultures regard mental in-service training on: cultural and eth- illness quite differently. To engage these nic differences of the program recipi- populations, we need to appreciate ents; culturally appropriate treatment those differences and design programs practices; and the program’s approach and services that reﬂect cultural under- to working with culturally diverse serv- standing. ice recipients. 2. Develop community-based suicide pre- • OMH has compiled a directory of staff vention and mental health wellness proﬁcient in several languages that has outreach programs that are culturally been disseminated to all State-operated appropriate, multi-disciplinary and mental health programs. delivered by community members.

• OMH Core Curriculum, a mandatory 3. Increase the cultural competence of training program for all psychiatric cen- health care and mental health care pro- ter staff, includes a section on cultural fessionals and staff. competence. 4. Implement culturally appropriate sui- • In 2001, OMH created the position of cide screening and prevention training Cultural Competence Coordinator. for medical and mental health professionals and staff, including emergency • OMH collects data on service utilization room staff. by race/ethnicity by program type, e.g. type of emergency, inpatient, outpa- 5. Evidence-based treatments have not tient, residential, and community sup- been sufficiently tested on individuals port. from diverse cultures. Therefore, their effectiveness across cultures is not • Integrating cultural competence is part known and cannot be assumed. of the OMH strategy for change as stated in the agency’s 5.07 Plan. Some

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6. Collect and report data on access and References utilization of health and mental health American College of Mental Health Administration, Summary of Conference Proceedings, Santa Fe Summit (NM), August 28, care, including disparity measures by 2003 race, ethnicity, primary language, Collins, KS, Hughes, DL, Doty, MM, Ives, BL, Edwards, JN, socioeconomic status, age, gender, Tenney, K, Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority American: sexual orientation, geographic location, Findings from the Commonwealth Fund 20021 Health Care housing situation, and criminal justice Quality Survey, March 2002 involvement. Also monitor progress Smedley, BD, Stith, AY, Nelson, AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, toward elimination of disparities, and Committee on Understanding and Eliminating Racial and increase the dissemination of strategies Ethnic Disparities in Health Care, Board on Health Sciences proven to be effective across cultural Policy, Institute of Medicine, National Academy (of Sciences) Press, Washington, DC and linguistic groups. The President’s New Freedom Commission on Mental Health Final Report: Achieving the Promise: Transforming Mental 7. Invest in research to identify and Health Care in America. Washington, DC July 2003 US Department of Health and Human Services (1999), Mental overcome disparities in mental Health: A Report of the Surgeon General, Rockville, MD health service utilization and treat- US Department of Health and Human Services (2001), Mental ment of minorities. 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

104 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. Specific groups of recipients have a signifi- New York State’s mental health system is cantly increased rate of suicide. Those working to embrace the goals of the Presi- diagnosed with depression, schizophrenia dent’s New Freedom Commission on Men- and schizoaffective disorder are at elevated tal Health (2003): that mental health is risk. Estimates of suicide rates range from essential to overall health; mental health 6% in broadly depressive samples to as care is consumer and family-driven; dispar- many as 25% among severely depressed or ities in mental health services are eliminat- bipolar patients (Tondo et al., 2001). ed; early mental health screening and treatment in multiple settings are important; Approximately 50% of patients with schizo- care offered is the best science can provide; phrenia or schizoaffective disorder attempt and information technology can help us suicide, and about 10% of them die by sui- access care. cide (Meltzer, H. et al., 2003). A small proportion of those suffering from a severe Besides preventing suicides among recipi- mental illness actually receive treatment, ents of mental health services, we must so we must first ensure that individuals also work toward reducing suicide who seek treatment are given adequate attempts and disease morbidity. The bur- care in hopes that their risk for suicide will dens of mental illnesses, such as depres- be lowered. We also need to strengthen sion, alcohol dependence and schizophre- our outreach to those not currently receiv- nia have been seriously underestimated by ing services who could benefit from them. traditional approaches in public health that take account only of deaths and not dis- The U.S. mental health system is complex ability. Psychiatric conditions account for and connects to many sectors (public -pri- almost 11 per cent of disease burden vate, speciality-general health, social wel- worldwide. By 2020, it is estimated that the fare, housing, criminal justice, and educa- second leading cause of disability among tion). As a result, care may become organi- the general population will be unipolar zationally fragmented, creating barriers to depression; among women it will be the access. The system is also financed by many first (World Health Organization, 1999). funding streams, adding to the complexity, This is the context within which we consid- given sometimes competing incentives er how to improve the improve the experi- between funding streams. (U.S. Surgeon ences of mental health recipients and General, Mental Health: A Report. 1999) reduce their mortality from suicide One of the most compelling predictors of suicide is a previous attempt. If a recipient

Recipients of Mental Health Services 105 Saving Lives in New York Volume 2: Approaches and Special Populations

of mental health services moves from one sion or anxiety disorders are extremely provider to another and their previous sui- common, yet treatable, will encourage cide attempt history is not shared, this puts help-seeking behavior among those suffer- the recipient at risk. We need to address ing from mental health problems. Educa- the need for long-term case management tion programs like NAMI’s “Family to Fami- and continuous care in some cases, as in ly” and “In Our Own Voice” for consumers, depression. The chronic nature of depres- as well as community outreach like Red sion places its suffers in a life-long elevated Flags, Yellow Ribbons, SOS, etc. all help risk for suicide. Our system needs to great- bring light to issues surrounding depres- ly improve its integration, communication sion and suicide risk. and co-operation so that consumers are not allowed to “fall through the cracks.” Individuals diagnosed with a mental illness, Loss of hope is also an important predictor particularly mood disorder, can benefit of suicide. Seriously ill patients, are vulner- greatly from membership in a peer-led sup- able to homelessness and social isolation. port group. A recent article by Sheffield Over 80% are unemployed and poverty is, (2003) discussed the benefits of referral to for them, often the norm. peer support groups to both patients with mood disorders and their physicians. Con- Mental health services are best delivered sumer surveys indicate that peer-led support using a partnership approach. Forging a groups improve communication between therapeutic alliance depends on mutual patients and physicians, increase medication respect between a client and provider and a compliance and reduce crises. Similar realistic assessment of needs and assets. groups for family members provide relatives Self-help should be the first pillar of recov- with accurate information, enabling them to ery. This is particularly needed when the participate constructively in treatment deci- other pillars - family and community - are sions and act as an early warning system at disconnected or dysfunctional. Key to self- home. The benefits to physicians include help is development and use of natural sup- avoiding many of the drawbacks commonly port networks - individuals and organiza- associated with the treatment of depression, tions from which people seek advice and such as poor professional education about support. They provide a listening post that depression and inadequate time to evaluate people can access when they need to talk and treat depression. The author recom- or seek guidance and understanding. They mends that physicians should become more provide information to members of their active in informing patients of the benefits of communities as a community service and support groups; and mental health organi- would likely provide assistance to recipients zations that run support groups should seek living in the community. Together, they can the involvement of physicians in their com- build “islands of resilience.” (Allen: 2003) munities.

Education of consumers, their families and By educating, involving and supporting the the community will help advance the long family of a person with a mental illness we term goal of reducing stigma associated stand a much better chance for successful with having a mental illness and receiving outcomes. Of special importance is sup- services for it. Increased education will porting the family of children and adoles- empower consumers to become more cents with mental disorders. These services active partners in their own treatment. If enable children with mental health prob- recipients of mental health services lems to remain at home and in the com- become engaged in their own treatment munity. Families need to be educated and receive education about their mental speciﬁcally in suicide prevention - know illness, its management, potential side the signs of depression and suicidal effects of medication and alternative possi- ideation, remove lethal means from the bilities for intervention, they stand a better home, restrict access to alcohol, develop chance of recovery. Receiving education an emergency plan - should a family mem- explaining how illnesses such as depres- ber attempt suicide.

106 Recipients of Mental Health Services Saving Lives in New York Volume 2: Approaches and Special Populations

Increasing education in the community is References essential if we are to move forward in our Allen, John, Enhancing Outreach Efforts through Indigenous Natural Support Networks, (Prepared for Project Liberty), plan to prevent suicides in New York State. OMH, Albany, NY: 2003 (8 pp.) New York’s citizens need to be educated Centers for Disease Control and Prevention. (2000) WISQARS and engaged in the goal of preventing sui- Leading Causes of Death Report. (Available at http://webapp.cdc.gov/sasweb/ncipc/leadcaus10.html). cide and treating mental illness, especially Edlund, MJ; Wang, PS; Berglund, PA; and Katz, SJ.,(2002). among our younger population, where sui- Dropping out of mental health treatment patterns and pre- cide is the third leading cause of death dictors among epidemiological survey respondents in the United States and Ontario. The American Journal of among 15-24 year olds (Centers for Disease Psychiatry, 159 (5), 845-851. Control and Prevention, 2000). By educat- Kessler, RC, Ph.D. et al. (2005), “Trends in Suicide Ideation, Plans, ing and encouraging recipients of mental Gestures, and Attempts in the United States, 1990-92 to 2001-03, JAMA, 293 (20), 2487-2495 health services, their families and the com- Meltzer, HY; Alphs, L; Green, AI; Altamura, AC; Anand, R; Bertoldi, munity, in addition to moving mental A; Bourgeois, M; Chouinard,G; Islam, MZ; Kane, J; Krishnan, health services into the community and R; Lindenmayer, JP; and Potkin, S. Clozapine treatment for suicidality in schizophrenia: International suicide prevention integrating mental and physical health trial (Inter SePT). Archives of General Psychiatry, 60 (1), 82-91. services, we can look forward to a future New York State Office of Mental Health (2002). Statewide where mental illness is as widely accepted Comprehensive Plan for Mental Health Services, 2002-2006. Rickert, A. and Ro, K. (2003). Mental Health Parity: State of the and treated as physical illness. 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.mentalhealth- commission.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), 163- 172. US Department of Health and Human Services. (1999). Mental Health: A Report of the Surgeon General. Rockville: SAMH- SA, 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.)

Recipients of Mental Health Services 107

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

Goal 8 of the National Strategy for Suicide • In a Veterans Administration study, Prevention is to improve access to and investigators found 77% of suicide com- community linkages with mental health pleters who were diagnosed with sub- and substance abuse services. It is stance abuse had an additional diagno- designed to prevent suicide by ensuring sis, most commonly, an affective disor- that individuals who are at high risk due to der (39%). Of patients who completed mental health and substance use problems suicide, 5% had a co-morbid psychosis can receive prevention and treatment serv- and substance abuse; 67% of people ices. with PTSD who completed suicide had a co-morbid disorder, usually an affec- I. FINDINGS tive disorder or substance abuse. A. Overall Rates and Patterns (Lehmann, McCormick & McCracken, • In any given year, approximately 10 1995) million people in the United States have a substance-related disor- • Psychological autopsies have found der and at least one other mental ill- that over 90% of all completed suicides ness. (SAMHSA/NAC, 1997) in all age groups are associated with psychopathology (Shaffer et al., 1996). • Approximately two-thirds of suicide completers suffered from either a mood B. Risk Factors disorder or alcoholism. The risk of suicide is often increased in people with co-occurring disorders who • Approximately one-half of those diag- may present with multiple risk factors at nosed with a psychiatric disorder also any given time. For example, the individual have a substance abuse problem may be non-compliant with medication, be (NAMI). infected with HIV, and experiencing command hallucinations. The individual may • 51% of suicide completers have both be at greater risk for cognitive problems substance abuse and mood dis- due to extensive substance abuse or lack orders (Suominen et al., 1996) supportive relationships due to stigma associated with having a psychiatric and • Suicide in alcoholics is largely depend- substance abuse disorder. ent on the co-occurrence of a depressive episode. Typical risks for this population are: trauma history, cognitive/ neurological problems, family history of suicide, history of losses

Dually Diagnosed 109 Saving Lives in New York Volume 2: Approaches and Special Populations

and deaths, history of medication non- severe substance disorder. Locus of compliance, impulsive behavior, history of care: primary health care settings. psychosis, chronic medical problems, chronic pain, difficulty controlling or Quadrant II expressing anger, history of self-injury, and More severe mental disorder/less a criminal history. severe substance disorder. Locus of care: mental health system C. Precipitating Factors This includes losses of many kinds, such as Quadrant III physical health, vocational, ﬁnancial, psy- Less severe mental disorder/more chological, interpersonal (one-third had a severe substance disorder. Locus of relationship loss within six weeks of com- care: alcohol and other drug treatment pleting suicide), access to weapons, current facility medication non-compliance, substance abuse, suicidal ideation, shame, guilt, Quadrant IV humiliation, command hallucinations, sui- More severe mental disorder/more cide by friend or family member, pain, severe substance disorder. Locus hopelessness, recent trauma or abuse, of care: “No man’s land”(joint alcohol family conﬂict. and mental health systems).

D. Protective Factors Individuals located in Quadrant IV are Many factors can decrease the risk for sui- most at-risk and New York State. As cide by those with a dual diagnosis. Among such a Quadrant IV Task Force was them are: cognitive ﬂexibility, good coping jointly supported by the NYS Office of skills, strong social support, hopefulness, Mental Health (OMH) and Office of hobbies and interests, short-term plans, Alcohol and Substance Abuse Services ability to develop alternatives to self-harm, (OASAS) and it produced a report, Treat- good compliance with treatment, hobbies ment of Co-Occurring Mental Health and and interests, sobriety, education of pri- Addictive Disorders in New York State: A mary care physicians, media education, Comprehensive View (May 2001). The lethal means restriction, screening of at- report contains an action plan that risk youth, and school-based skills training addresses problems such as the need for students. for integrated treatment, stigma, funding issues, and staff competency. E. The New York Model New York State has taken great strides in 2. Additionally, OMH has directed its psy- improving care and treatment for individu- chiatric centers to provide evidence- als with co-occurring disorders. Some of based treatments (EBT). A SAMHSA the evidence of progress is as follows: Evidence Based Practice Implementa- tion Kit for Co-Occurring Disorders is 1. Evidence-Based Practices being developed and will be distributed to adult psychiatric centers. The Kit will The New York Model is a framework include: Fidelity scales, a user’s guide, for describing symptom severity, locus workbook, practice demonstration of care, and level of service integration video tapes, and recipient outcome needed among mental health, sub- measures. stance abuse, and primary health care systems. 3. Other evidence-based practices being implemented in New York State should The Model consists of four quadrants with also have a positive impact: the locus of care for each: SAMHSA’s Wellness Self-Management Quadrant 1 EBP plan is beginning to be implement- Less severe mental disorder/less ed in New York State’s psychiatric cen-

110 Dually Diagnosed Saving Lives in New York Volume 2: Approaches and Special Populations

ters. Although the curriculum is not general public, emergency room physi- designed specifically for the co-occur- cians, and family members. ring patient, it addresses many risk factors for suicide such as relapse, stress, 3. Increased integration and co-operation medication compliance, and relation- between substance abuse and mental ships. It can be an important part of health services, and between public treatment for those with a co-occurring and private care systems. Poorly coor- disorder. dinated treatment among multiple providers is a real barrier to recovery. 4. New York State has funded Dual Long-term case management is one Recovery Coordinators who bring way to ensure continuity of care involv- together administrators and service ing chronic illnesses like depression providers from substance abuse, men- and addiction. tal health, corrections, and social service agencies to address current issues 4. Dual recovery coordinators and intera- in the treatment of co-occurring disor- gency workgroups can provide inte- ders. Action plans are being developed grated treatment that decreases both and efforts have already begun to homelessness and hospitalization for improve services. Issues being those diagnosed with mental illness addressed include: housing, standard- and addiction disorders. This involves ized assessment instruments, funding, treatment of both disorders in one set- training and competencies for both ting at the same time. Treatment can agencies (OMH, OASAS). consist of outreach, pharmacological treatment, mental health and sub- 5. Improve training and assessment to stance abuse counseling, group treat- increase identification of mood disor- ment, family psycho-education and ders and suicide risk factors. community-based self-help. Train more individuals in the New York Model and II. ACTION STEPS other evidence-based practices; provide 1. Promote access to mental health and more appropriate housing for those not substance abuse treatment. Treatments yet abstinent; and assist with trans- for mental disorders and substance portation and medical needs of the abuse are increasingly effective. The dually diagnosed. New York Model is a proven approach to improving care and treatment for 5. Share the results of the Seeking Safety individuals with co-occurring disorders. program developed by Dr. Lisa Najavits Early interventions that are evidence- at Harvard Medical School/McLean based also reduce the need for emer- Hospital. It is the first integrated pro- gency health care services and costs. gram for persons who, in addition to Avoided costs could also be expected in being dually diagnosed, also suffer law enforcement, corrections, and from Post-Traumatic Stress Disorder. social services. Most importantly, access to early interventions could pre- 6. Screen chemical dependency patients vent pain and suffering among those for depression or mood changes, and affected by mental disorders and sub- violence toward an intimate partner or stance addiction. spouse.

2. Promote greater awareness of co- 7. Educate and train family members and occurring psychiatric and addictive dis- community gatekeepers to detect orders, and the consequent risk of sui- changes in those at suicidal risk outside cide to this population among the clinical care systems. Signs include providers, law enforcement, correc- reduced performance in the workplace tions, and homeless shelter personnel, and unexplained absences from work or school. Knowing how and where to

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respond and refer individuals for treat- 2511-2518. Rich, C.L., Fowler, R.C., Fogarty, L.A. & Young, D. (1988). San ment should be part of the training. Diego suicide study: III Relationships between diagnoses Gatekeepers would include health, men- and stressors. Archives of General Psychiatry, 45, 589-592. tal health, substance abuse, social work Shaffer, D.A., Gould, M.S., Fisher, P. et al. (1966). Psychiatric Diagnosis in Child and Adolescent Suicide. Archives of and human service professionals and General Psychiatry, 53, 339-348. lay people including clergy, teachers, Suominen, K., Henriksson, M.M., Suokas, J. et al., (1996). Mental correctional workers, coaches, youth Disorders and co-morbidity in attempted suicide. Acta Psychiatrica Scandinavica, 94, 234-240. workers, nurses’ aides, and faith leaders. Weiss, R.D., & Hufford, M.R. Substance abuse and suicide. In D.G. Jacobs (ed.) The Harvard Medical School Guide to 8. Substance abuse is a signiﬁcant risk Suicide Assessment and Intervention. (pp. 300-310). San factor for suicidal behavior, especially Francisco: Jossey-Bass, Pfeiffer. among older adolescent males. Strate- gies 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. 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: Jossey- Bass/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 26- 2/99/102/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),

112 Dually Diagnosed 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 level, education, family configurations, public health problem here in New York living arrangements and health. Minori- and across the United States. In 2002, the ty elderly populations will increase the suicide rate for elders (age 55 and up) was fastest: black, non-Hispanic (up 27%); 24 % higher than the rate for New Yorkers Hispanic (up 76%); and Asian/Pacific under the age of 55.* * In coming decades (up over 110%). it is likely to take an even greater toll on senior citizens and their families. The 2. Weakened Family Support Structures. determined and aggressive nature of self- The large cohort of baby boomers mov- destructive behaviors in late life makes sui- ing into the older population will be cide an especially challenging problem to more likely than the preceding cohort address. The challenge must be taken up to enter old age without spouses, and on a variety of fronts simultaneously. more will be childless or parents of only children. Still, more grandparents Key Trends will be involved in the raising of their The Office of Mental Health’s (OMH) analy- grandchildren, and the most significant sis of population projections prepared from mental health problem for this group is 2000 U.S. Census data identifies five major depression, with one in four grandpar- trends that will have a major impact on the ent care givers nationally experiencing mental health needs of New York elders in a significant level of depression. the next ten years. (NYSOMH: 2002) 3. Major Growth in Two Important 1. Increased Racial and Ethnic Diversity. Groups. Rapid population growth of While New York’s projected population younger and older minority popula- growth of 4.2% between 2000 and tions, as well as major growth in the 2015, is expected to be among the low- older worker and pre-retirement popu- est in the nation, significant changes lations as the baby boomers age out is will occur in the composition: the expected. Cultural factors, immigration, group of older New Yorkers will socioeconomic status, language and lit- increase faster, up 19%, and be more eracy will need to be considered in diverse than any preceding old age designing responses to the mental group in terms of ethnicity, income 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)

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4. Dramatic Increases in Dementia. One of tive interventions are underway. The recog- the fastest rising age groups will be those nition and optimal treatment of clinical 85 and older. By 2010, the number of depressive illnesses in older people, particu- cases of Alzheimer’s disease and other larly in primary care settings, must remain dementias will have increased by at least an area of special emphasis. 25 percent. Alzheimer’s disease poses an enormous burden to health service and Outreach to those elders at risk in the com- public health resources. Also, improve- munity who avoid, or lack access to, med- ments in general health and health care ical care is a second important element in techniques will lengthen the survival of any comprehensive plan for late life suicide patients with dementia, increasing the prevention. The cost-effectiveness and number of severely affected patients and reproducibility of these and other strategies raising the level of morbidity among informed by pre-intervention research must patients with dementia. be tested in rigorously designed randomized, controlled trials. The relatively small 5. More Demand for Care, Less supply of scale of many programs precludes their use Care Givers. New York’s dependency of attempted or completed suicide as out- ratio is changing: there are fewer care come measures. givers available for more older persons needing care. Therefore, the family, Empirically established risk factors for late life which currently provides 80% of the suicide should be used in those circum- long-term care services, will be provid- stances as the benchmarks against which to ing less and the “systems of care” must measure success. Opportunities should be provide more. At the same time, we encouraged for programs to collaborate, should recognize that many senior citi- sharing methodology and procedures, to zens are reluctant to utilize traditional increase the likelihood of observing a signifi- mental health services which will cant impact on suicide outcomes. To facilitate require OMH to work with county men- that effort, a national database for suicide tal health departments to increase the prevention strategies should be established to accessibility of mental health services serve as a clearinghouse for information in locations where the elderly reside regarding program design and evaluation. and spend their time, especially home and congregate living situations. Finally, biased attitudes towards aging, Accomplishing this goal will require deficits in knowledge about depression and review of regulations and reimburse- suicide on the parts of health care ment methodologies, as well as providers and their older patients, and sys- focused training of providers in such temic barriers to mental health care access issues as the risk/treatment of sui- make suicide prevention more difficult in cide.(Project 2015:: OMH: 2000) this population than in younger age groups. A comprehensive approach to suicide pre- I. Conclusions vention in late life, therefore, must include A great deal of pre-intervention research the creative input of health policy makers remains to be done before we have an with regard to the financial, medicolegal, adequate understanding of suicide’s patho- and organizational barriers to effective sui- genesis in older people. Biological, psycho- cide prevention. It also should include edu- logical, and social factors all warrant rigor- cation programs aimed both at health care ous study. Even as pre-intervention providers as well as elderly consumers and research continues, however, the ongoing their families. The objectives of the educa- loss of senior citizens to suicide demands tion programs should be to foster an appre- that preventive interventions be designed ciation of healthy aging, improve under- and implemented. Indeed, major advances standing of signs and symptoms of clinical in the identification of modifiable risk fac- depression, and to teach older people and tors are being made, and major initiatives their support systems about the risks, to test the effectiveness of specific preven- warning signs, and treatment responsive-

114 Elders Saving Lives in New York Volume 2: Approaches and Special Populations ness of suicidal ideation and behavior in cide among elders. Death of a spouse, late life. loss of companions and socialisolation are also contributing risk factors. Reduction of late life suicides is a realistic goal. Creative partnerships of primary care 7. Greater emphasis should be placed in providers, the mental health care sector, medical, nursing and social service aging services, and other agencies and training on recognizing and treating insurers will be needed to achieve it. depressive disorders and suicidal states in elders. II. Action Steps 1. State policy should reflect the fact that 8. Research should seek to determine the suicide rate for elderly (>65)males is whether treatments designed to miti- the highest for any sub-population in gate hopelessness and related effects in New York. older people are effective in lowering suicide risk. 2. Depression is more prevalent among elders than the general population. 9. Include high-risk suicidal elders in con- However, it is not a normal part of the trolled clinical trials of preventive inter- aging process and should be treated ventions, while guaranteeing the ethi- appropriately. Validated, self-adminis- cal conduct of the research and the tered voluntary screening tools for rights of the subjects themselves. depression should be routinely used with elderly patients in primary care III. Prevalence health offices. Diagnosis and treatment Older people in the United States have a of depression in elders should be higher suicide rate than any other segment aggressively pursued in the primary of the population. While the elderly consti- care practitioner’s office. tute 12.7% of the population in 1998, they accounted for 19.0% of completed suicides 3. Gatekeeper programs and telephone (Murphy, 2000). The suicide rate for the support (warm lines) systems should be general population was 11.3/100,000. implemented and evaluated as “indicat- Combined rates for men and women of all ed” preventive interventions for isolated, races rose through young adulthood to a high-risk elders. These services should high of 15.5/100,000 in the 40-44 year age be part of a comprehensive network of group, plateaued through mid-life, and rose offerings, including case-finding, acute to a peak of 22.9/100,000 in 80-84 year response, multi-disciplinary assess- olds. The increased suicide risk with aging ments, and other support services. is accounted for in large part by the strik- ingly high rates for white males in later life. 4. Elders tend to employ more lethal In 1998, the group at highest risk was means of self-harm in the act of sui- white males aged 85 and older, whose rate cide. Restricting access to such means of 62.7/100,000 was almost six times the of self-harm as firearms and household nation’s age-adjusted average (National poisons could save lives. Center for Health Statistics, 2001).

5. Since the vast majority of elders who In contrast, rates for women peak in mid- die by suicide have seen their health life and remain stable, or decline slightly, care provider within 30 days of their thereafter. This pattern is unlike patterns in death, it is essential that such visits most other countries of the world where, include an assessment of suicidal according to statistics reported by the thoughts, intent and plans they may World Health Organization, later life is the have. highest risk for both men and women (Pearson and Conwell, 1995). Suicide rates 6. Chronic pain and debilitating physical for the general population have remained illnesses are frequent precursors to sui- relatively stable throughout the second half

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of the 20th century. However, rates among than an isolated cause, a knot of circum- older people declined by up to 50% stances tightening around a single time and between 1930 and 1980 (McIntosh et al; place.” General understanding of suicide 1994). Optimistic explanations offered for among older people is often oversimplified, this decline include increased economic ascribed to a single factor such as severe security for older people resulting from the physical illness or depression. The reality is implementation of Social Security and far more complex. There is no single cause Medicare legislation (Busse, 1994) and the for any suicide, and no two can be under- more widespread and effective use of anti- stood to result from exactly the same con- depressant medications (Conwell, 1994). stellation of factors. As no single factor is Others ascribe such variation to genera- universally causal, no single intervention tional or cohort effects, a propensity to sui- will prevent all suicide deaths. The multi- cide that is characteristic of a group born determination of suicide present great chal- within a specific time frame (Blazer et al., lenges but also has important implications 1986; Manton et al., 1987). For example, for prevention (O’Carroll, 1993). people who entered old age before 1930 had higher rates of suicide at all points in IV. Preventive Interventions the life course than did birth cohorts that Two general approaches to suicide preven- entered late life from 1930 to 1980. If tion in late life have been identified: public cohort effects do influence suicide rates, health or population based strategies, and then the trend for lower suicide risk among high-risk models (Lewis et al., 1997). The older people would be expected to reverse. public health model advocates universal prevention through interventions that have At all ages, the large postwar “baby boom” a potential impact on large segments of a cohort has had substantially higher suicide society. Examples include gun control leg- rates than preceding generations (McIn- islation (Kellerman et al., 1992), detoxifica- tosh, 1992). As more of these people enter tion of a domestic gas (Charlton et al., later life, their suicide rates are likely to rise 1992), or restrictions on access to drugs above those of the current elderly cohort. with a low therapeutic index (Gunnell & Perhaps presaging this trend, a recent Frankel, 1994). The high-risk model targets report by the Centers for Disease Control more highly selected populations. Among and Prevention (CDC) found that the sui- the elderly, two approaches to selective cide rate for the population aged 65 and interventions in high-risk samples have over rose 9% between 1980 and 1992 been proposed: interventions in primary (MMWR, 1996). Rates among men and care settings designed to improve recogni- women aged 80-84 showed rises of 35% tion and treatment of depressed and suici- and 36% respectively. Some authors have dal older patients, and community out- argued that the size of the baby boom gen- reach to isolated elders at risk. eration may work to the benefit of that cohort in later life through greater political Interventions in Primary Care influence and accumulated resources The majority of older people at greatest risk (McIntosh, 1992). Nonetheless, older peo- for suicide already have access to health ple are the fastest growing segment of the care services in which preventative inter- population. Haas and Hendin (1983) pro- vention should be feasible. At least six jected that the number of suicides commit- studies conducted in Great Britain and the ted in later life would double by the year United States have demonstrated that from 2030 as a function of this demographic 43% to 76% of older people who committed shift alone. There is, therefore, an urgent suicide saw a primary care provider (PCP) need for efficient and effective measures to within 30 days of death (Barraclough, 1971; prevent suicide in older people. Clark, 1991; Carney et al., 1994; Cattell & Jolley, 1995; Conwell, 1994; Miller, 1976). Havens (1965) characterized suicide as “the From 19% to 49% saw a physician within final common pathway of diverse circum- one week of their suicide. This observation stances, of an independent network rather is critical for prevention as it suggests a

116 Elders Saving Lives in New York Volume 2: Approaches and Special Populations means for providing access for elders in, or most vulnerable segment of the population, immediately preceding, the development of outreach is required. the suicidal state. Although older adults are reluctant to use Depression is the most common psy- crisis or “hot” lines, telephone support sys- chopathology associated with suicide in tems should be tested further as indicated late life, and the most prevalent mental dis- preventive interventions for the most iso- order seen among older patients in primary lated segments of the elderly population. care settings. Yet many studies in the med- However, they must be embedded in a ical and psychiatric literature have demon- more comprehensive network that includes strated that PCP’s have difficulty recogniz- means for case finding, acute response, ing treatable depression in their patients. multi-disciplinary in-home assessment, and Screening tools for depression have been other support services. Although telephone validated for use in elderly primary care services offer a promising means of sup- patients. Such measures should be used port to isolated elders, their effectiveness routinely in primary care offices. In addi- as a suicide prevention measure hinges on tion, greater emphasis should be placed in the availability of other services. undergraduate, graduate, and continuing medical education on recognition and Coupled with education of health care effective treatment of depressive disorders providers, a public campaign should be and suicidal states in older people. Since mounted to educate older Americans and older people rarely utilize mental health their families about the signs and symp- services, active collaborations between toms of clinical depression and the risks psychiatry and primary care in medical set- and warning signs of suicide in late life. tings may yield optimal outcomes. They should be informed of the benefits of available treatments, and dispelled of the Suicidal people are frequently excluded myths that depression and suicidal ideation from treatment research because of liability are a “normal” aspect of aging. This cam- concerns (Linehan, 1997). Without their paign should be coupled with the develop- participation, we lack the evidence with ment of gatekeeper programs. These net- which to judge the interventions’ efficacy works of lay people trained to recognize and effectiveness at reducing suicidal out- and refer elders who may be at risk for sui- comes. The ethical and medicolegal impli- cide cannot operate effectively in isolation. cations are profound. Nonetheless, it is They must be linked to systems capable of important that regulatory mechanisms be providing a full range of social, medical, devised that shield investigators from and psychiatric services. unjustified liability claims, enabling the inclusion of individuals at high risk, while Benefits of Prevention at the same time guaranteeing the ethical Prevention of late-life suicide can be conduct of the research and the rights of expected to have benefits of reduced mor- the subjects themselves. bidity and mortality among the surviving spouse and other loved ones. There is a Community Outreach great deal of evidence to suggest that pre- Although initiatives in primary care settings vention of suicide in older people by promise to provide access for prevention to improved recognition and treatment of its the majority of older people at risk for sui- most potent risk factor, depression, will cide, a substantial minority would slip result in a host of other “ancillary” benefits. through the cracks: those without In addition to being at greater risk of sui- resources to pay for care, those who are cide, older people with depression have homebound and physically unable to higher mortality from all causes. Their access care, and those who, out of fear and functioning is significantly more impaired, misunderstanding, choose not to seek help. their quality of life is diminished, and uti- For these elders, who may indeed be the lization of health care resources is greatly increased.

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A range of studies have confirmed an asso- McIntosh, JL (1992). Older adults: The next suicide epidemic? Suicide and Life-Threatening Behavior, 22, 322-332. ciation between depression and increased McIntosh, JL, Santos, JF, Hubbard, RW,Overholser, JC (1994) morbidity due to stroke, acute myocardial Elder Suicide: Research, Theory, and Treatment. American infarction, chronic obstructive pulmonary, Psychological Association, Washington, DC. Miller, M. (1976). Geriatric suicide: The Arizona study. hip fracture, Parkinson’s disease, and Gerontologist, 18,488-495 arthritis (see review by Katz, 1996). More- Murphy, S.L. Deaths: Final data for 1998. National Vital Statistics over, depression has been shown to signifi- Report, 48(11) Hyattsville, MD: National Center for Health Statistics. DHHS No. PHS, 2000-1120. cantly predict mortality at six month and 18 National Center for Health Statistics (NCHS) web site. month follow-up of patients with acute Http://www.cdc.gov/nchs/datawh/statab/unpubd/ myocardial infarction (Frasure-Smith et al., mortabslgmwk291.htm NYS Office of Mental Health, Project 2015: State Agencies 1993, 1995), and to be associated with Prepare for the Impact of an Aging New York (2002). increased all-cause mortality in both the O’Carroll, P. (1993). Suicide causation: Pies, paths, and pointless general population (Bruce et al., 1994) as polemics. Suicide and Life Threatening Behavior, 23, 27-36. Pearson, JL and Conwell, Y. (1995). Suicide in late life: Challenge well as among older people in nursing and opportunities for research. International homes (Rovner et al., 1991). Psychogeriatrics, 7, 131-136. Rovner, BW et al., (1991). Depression and mortality in nursing References homes. Journal of the American Medical Association, 265, Barraclough, BM (1971). Suicide in the elderly: Recent develop- 993-996. ments in psychogeriatrics. British Journal of Psychiatry. (Spec. Supp.#6), 87-97 Blazer, DG, Bachar, JR, Manton, KG (1986). Suicide in late life: Review and commentary. Journal of the American Geriatric Society, 34, 519-525. Bruce, ML et al.,(1994) Psychiatric status and 9-year mortality data in the New Haven Epidemiologic Catchment Area Study, American Journal of Psychiatry, 151, 716-721. Busse, EW (1974). Geropsychiatry: Social Dimensions, in Survey Reports on the Aging Nervous System (DHEW Publ #74- 296). GJ Maletta (Ed.), 195-225 Washington, DC: Government Printing Office. Carney, SS, Rich,CL, Burke, PA, Fowler, RC (1994) Suicide over 60: The San Diego study. Journal of the American Geriatric Society, 42, 174-180. Cattell, G, Jolley, DJ (1995) One hundred cases of suicide in elderly people. British Journal of Psychiatry, 166, 451-457. Charlton, J, Kelly,S., Dunnell, K. et al., (1992). Trends in suicide deaths in England and Wales. Population Trends, 69, 10-16. Clark, DC (1991). Final Report to the AARP Andrus Foundation. Suicide Among the Elderly. January 28, 1991. Conwell, Y. (1994) Suicide in elderly patients. In LS Schneider, CF Reynolds III, B. Lebowitz, AJ Friedhoff (Eds.) Diagnosis and Treatment of Depression in Late Life, 397- 418. APA Press: Washington, DC. Frasure-Smith et al.; (1995) Depression and 18-month prognosis after myocardial infarction. Circulation, 91, 999-1005. Frasure-Smith et al. Depression following myocardial infarction: Impact on 6-month survival. Journal of the American Medical Association, 270, 1819-1825. Gunnell, D., Frankel, S. (1994). Prevention of suicide: Aspirations and evidence. British Medical Journal, 308, 1227-1233. Haas, AP, Hendin, H. (1983). Suicide among older people: Projections for the future. Suicide and Life Threatening Behavior, 13, 147-154. Havens, L. (1965). The anatomy of a suicide. New England Journal of Medicine, 272, 401-406. Katz, IR (1996). On the inseparability of mental and physical health in aged persons. American Journal of Geriatric Psychiatry, 4, 1-6. Kellerman, AL, Rivera, FP, Somes, G etal. (1992). Suicide in the home in regard to gun ownership. New England Journal of Medicine, 327, 467-472. Linehan, MM (1997). Behavioral treatment of suicidal behaviors. Definitional obfuscation and treatment outcomes. Annals of the New York Academy of Sciences. 836, 302-338. Manton, KG, Blazer, DG, Woodbury, MA (1987). Suicide in middle age and later life: Sex and Race specific life table and cohort analyses. Journal of Gerontology, 42, 219-227.

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