Cultivating Protective Environments: Suicide and the Need for Interdisciplinary Health Equity Planning

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CULTIVATING PROTECTIVE ENVIRONMENTS: SUICIDE AND THE NEED FOR INTERDISCIPLINARY HEALTH EQUITY PLANNING

Kelli M. Peterman

A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in City and Regional Planning School of Architecture Pratt Institute

January 2021

CULTIVATING PROTECTIVE ENVIRONMENTS: SUICIDE AND THE NEED FOR INTERDISCIPLINARY HEALTH EQUITY PLANNING

Kelli M. Peterman

Received and approved:

______Date: January 11, 2020 Thesis Advisor Signature

Courtney Knapp

Thesis Advisor Name

______Date: January 11, 2020 Thesis Advisor Signature

John Shapiro Thesis Advisor Name

______Date______Chairperson Signature

______Chairperson Name Acknowledgments:

Many people contributed to this thesis. First, thank you to my academic advisors, Courtney Knapp and John Shapiro, for your keen eyes and encouragement. Your expert guidance and steadfast interest in a challenging topic kept me going. To the entire GCPE staff and faculty, but especially Sadra Shahab, learning from you has been a privilege. Thank you for your patience, accessibility, dedication, and good humor.

To my fellow students: my time with you has been well spent. Your passion and knowledge made graduate school worthwhile. What a challenge it has been to write a thesis in the midst of a global pandemic, in isolation from one another. But we did it. I am looking forward to continuing our journey together as planning professionals.

I am humbled by the many individuals who generously donated their time to informing and editing this thesis. Every conversation, interview, and draft review mattered. To my primary interviewees - Catherine, Elizabeth, Jerry, and Scott – I can only hope my words do your expertise justice. Thank you to Pablo Sadler, my public service moral barometer, and Alison Peterman, my wise and thoughtful sister, for providing feedback, and to Gary Belkin for your mentorship.

I am grateful to my employer, the New York City Department of Health and Mental Hygiene, for giving me an on-the-job public health education. Thank you to my boss, Shirley Berger, who has unquestionably supported my academic studies and given me the freedom to innovate and excel. To the members of the Health Equity in Planning Workgroup and the Suicide Prevention Workgroup: I am lucky to be a sponge absorbing your brilliance. While I may critique the very real structures that impede our work, it is because of you that I know anything at all about public mental health. I would be remiss to not acknowledge The Trevor Project, for providing me with the foundation for a lifetime of suicide prevention work. Phoenix Schneider, Michael Vacha Jr., and Brock Dumville: you will forever hold a special place in my heart.

I could not have completed this thesis without the support of my friends and family. Thanks especially to my parents, Corinne, Duane, Emily, Glo, Keith, Laurel, Steve, Talia, Timna, Verna, and the Monday Movie crew (Cecy, Janessa, Lindsay, and Steph). Your friendship, generosity, and motivation this year lifted my spirits and gave me much needed reprieve from my research.

Finally, this thesis stands on the shoulders of scholars in the Critical Suicide Studies Network (Ian Marsh, Jennifer White, Mark E. Button, et al.). Many of the themes presented herein draw from your ideas. Thank you for your disruptive work.

Dedication:

This thesis was written in memory of Tony and is dedicated to anyone who has thought about suicide. You deserve an abundant and just life.

Table of Contents

Glossary…………………………………………………………………………………………...5

List of Figures…………………………………………………………………………………..…6

Organization of the Study…………………………………………………………………….…...7

Chapter 1: Introduction…………………………………………………………………………8 Statement of the Issue……………………………………………………………………………..8 Goals and Objectives of the Study……………………………………………………………….11 Methodology……………………………………………………………………………………..11 Study Limitations………………………………………………………………………………...13

Chapter 2: Background………………………………………………………………………...15 The Relationship between Urban Planning, Public Health, and Suicide………………………...15 Interdisciplinary Alignment through Health Equity……………………………………………..17 Brief History of Western, Mainstream Thought on Suicide……………………………………..18 The Production of Knowledge and Racial Bias in Research…………………………………….22

Chapter 3: Literature Review………………………………………………………………….28 The Planned and Built Environment………………………………………………………….….29 Trends in urbanization…………………………………………………………………...29 Spatial patterning………………………………………………………………………...32 Quality of the built environment…………………………………………………………34 Means accessibility………………………………………………………………………36 The Natural and Geographic Environment………………………………………………………38 Climate……………………………………………………….…………………………..38 Altitude…………………………………………………………………………………..39 Air quality………………………………………………………………………………..41 Green and blue space…………………………………………………………………….42 The Social and Economic Environment…………………………………………………………43 Economic insecurity………………….…………………………………………………………..43 Connectedness……………………………………………………………………………………44

Chapter 4: Existing Conditions………………………………………………………………..47 Global and National Suicide Trends……………………………………………………………..47 New York City Suicide Trends…………………………………………………………….…….51 The Evolution and Current State of Suicide Research and Prevention Efforts………………….55

Chapter 5: Qualitative Research Analysis…………………………………………………….60 Description of Qualitative Analysis…….………………………………………………………..60 Presentation of Qualitative Analysis……………………………………………………………..61

Chapter 6: Recommended Future Directions………………………………….……………..88 Conclusion……………………………………………………………………………………….93

Bibliography……………………………………………………………………………………..94

Appendix A. Timeline of the Urban Planning and Public Health Relationship………………..115

Appendix B. Interviewee Biographies………………………………………………………….116

Glossary:1

A group of suicides or suicide attempts that occurs closer together in time and space Cluster than would normally be expected in a given community. A phenomenon whereby susceptible persons are influenced towards suicide-related Contagion behavior through knowledge of another person’s suicide. The instrument or object whereby suicide or self-harm is carried out (e.g., firearm, Means medication). Actions or techniques whereby suicide or self-harm is carried out (e.g., overdose, Methods jumping). Protective Factors (attributes, characteristics, or environmental exposures) that make it less likely factor that an individual will attempt suicide. Factors (attributes, characteristics, or environmental exposures) that make it more Risk factor likely that an individual will attempt suicide.

Suicide Death intentionally caused by self-directed injurious behavior. An organized response in the aftermath of a suicide to facilitate the healing of Suicide individuals involved, mitigate negative effects of exposure, and prevent suicides of postvention affected community members. Suicide A collection of efforts to reduce the risk of suicide at the individual, interpersonal, and prevention societal level.

Suicide rate* The number of deaths by suicide per 100,000 people in a given geographic area.

Suicide-related A spectrum of activities related to thoughts and behaviors that include thinking about behavior suicide, self-harm, and suicide attempts.

Suicidology The scientific study of suicide and suicide-related behavior.

*Author’s note: Suicide rate, or the number of deaths by suicide per 100,000 people in a given geographic area, is generally associated with decedents’ residences. Suicide location refers to the place where a suicide occurred. A decedent’s residence and their suicide death location are two different data points, though they may overlap.

1 Terms and definitions informed by the Suicide Prevention Resource Center and the Center for Disease Control.

List of Figures

Figure 1. Age-adjusted suicide rates, by county urbanization level: United States, 1999 and 2017. Source: Center for Disease Control, Morbidity and Mortality Weekly Report (2017)…………………………………………………………………………………….30

Figure 2. Age-adjusted suicide death rates by state, 2018. Source: Center for Disease Control, National Center for Health Statistics…………………………………………………….40

Figure 3. Annual age-adjusted suicide rates and deaths in the world, the United States, and New York City based on the most recent data available for each geographic region. Sources: World Health Organization (2018), Center for Disease Control (2018), NYC Department of Health and Mental Hygiene (2017)…………………………………………………...47

Figure 4. Age-adjusted suicide rates for U.S. females and males, by race and ethnicity, 1999 and 2017. Source: Center for Disease Control, National Center for Health Statistics, National Vital Statistics System…………………………………………………………...………49

Figure 5. NYC total reported suicide deaths, 2000-2017. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self-Harm (Suicide), 2017………………………………………………………………………………………52

Figure 6. NYC age-adjusted suicide rates by borough, sex, race/ethnicity, and age group, 2017. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self-Harm (Suicide)………………………………….………………..53

Figure 7. NYC age-adjusted suicide rates by community district of residence, multiple years. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self-Harm (Suicide), interactive mapping tool.……………………….54

Organization of the Study

Chapter 1 introduces the issue statement this study aims to address and provides an overview of the study’s goal, objectives, methodologies, and limitations.

Chapter 2 describes the historical and contemporary context for understanding suicide as it relates to this study’s overall claim that urban planning plays a unique role in prevention.

Chapter 3 provides the evidence to support this study’s claim that urban planning can influence many of the socio-environmental factors that contribute to area-level suicide rates.

Chapter 4 describes the existing conditions (i.e., current rates and trends) of suicide globally, nationally, and locally as well as the current state of suicide prevention.

Chapter 5 presents this study’s contribution to the literature through a qualitative analysis of interviews with multidisciplinary experts.

Chapter 6 concludes the thesis with recommended future directions for the City of New York and other cities to consider with respect to coordinating an interdisciplinary citywide effort for suicide prevention.

Chapter 1: Introduction

Statement of the Issue

In 2015, eight New York City taxi and professional drivers died by suicide. Most of these

drivers were immigrant New Yorkers, working in a shifting industry financially ravaged by ride-

hailing apps and the rapid devaluation of taxi medallions (Fitzsimmons, 2018; Rosenthal, 2019).

The news of these deaths, which happened over the course of several months, was devastating.

Siblings, parents, and friends – entire communities – publicly mourned the loss of their loved ones while attempting to make sense of what happened. These suicides, because of their abruptness and the collective grief they incited, jointly served as a canary in the mine to deeper structural issues. In this case, suicide, like other forms of violence, appeared to be a matter of social, rather than individual, concern; a tragedy brought about as much by systemic inequities as by individual unwellness. The system that promised economic prosperity and a good quality of life had failed so completely that death seemed a worthier option.

Suicides in New York City are infrequent compared to other places, but patterns have emerged over time. Eight suicides in one year among taxi drivers with similar socioeconomic backgrounds, affected by a common hardship, is not a pattern. Suicide trends based on sociodemographic and environmental factors are not anomalies, either. Despite advancements in research that aim to explain suicide beyond individual pathology, mainstream messages linking suicide largely with mental illness remain pervasive. In a 2020 survey on national public perceptions of mental health and suicide, 93% of respondents believed something can be done to prevent suicide. Yet, more than half of those respondents believed only clinical professionals have the expertise to intervene (Action Alliance, 2020). It was just two years ago that the Center for Disease Control reported that 54% of individuals who died by suicide did not have a known

mental health condition, an enormous upward shift from previous estimates (Brådvik, 2018;

CDC Vital Signs, 2018).

Mainstream and academic narratives no longer exclusively pathologize suicide, but they

continue to prioritize mental health and individual explanations over socio-environmental ones.

Mental health remains an important part of how we conceptualize and treat suicide, as it should.

However, key root causes of mental health inequities, influenced by planned environments and

that contribute to suicide rates, are finally being recognized. Many toolkits exist to help

municipalities diversify their approach to addressing suicide outside of the clinical realm.

Leading suicide prevention organizations endorse both healthcare and non-healthcare strategies,

ones that aim, for example, to strengthen household economic security, reduce access to lethal means, and promote social connectedness (Stone et al., 2017). Credible population health

organizations such as The Center for Disease Control, the World Health Organization, and the

American Public Health Association assert that a comprehensive suicide prevention plan is

incomplete without specific strategies for creating healthy built and social environments.

Likewise, the fields of urban planning and public health assert that planning for livable cities and

health equity go hand-in-hand. Yet, mental health is often left out of these conversations, and

innovations in suicide prevention stop short of urban planning and design.

An interdisciplinary approach to suicide prevention, one that explicitly includes urban

planning, is vitally needed in New York City. Rampant socioeconomic disparities due to

centuries of structural racism continue to grow and evolve, the effects of which are seen in the

City’s premature mortality rates (DOHMH Summary of Vital Statistics, 2019). The COVID-19

pandemic is disproportionately impacting communities of color, with Black and Latinx

communities experiencing excess COVID-related deaths (Bassett et al., 2020). Google searches

for “anxiety,” “panic attack,” and “insomnia” rose significantly during New York’s PAUSE

lockdown (Stijelja & Mishara, 2020). While it is too soon to tell if the COVID-19 pandemic has had an impact on suicide rates, previous pandemics and economic recessions have resulted in significant additional suicides in North America, Europe, and Asia dating back to the Great

Depression (Cheng et al., 2013; Lester et el., 2020; McKee et al., 2014; Oyesanya et al., 2015;

Philips & Nugent, 2014; Reeves et al., 2012). The suicide death rate among Black youth is increasing faster than any other racial or ethnic group (Congressional Black Caucus, 2018).

Deaths due to despair (i.e., suicide, drug overdose, alcoholism) have risen exponentially in the past 20 years (Deaton & Case, 2020). U.S. overdose-related cardiac arrests surged at the start of the COVID-19 pandemic and remained more than double the 2018 and 2019 baseline for months thereafter (Friedman et al., 2020). Capitalism, with its discriminatory effect on depression rates, is literally killing us (Muntaner et al., 2015; Platt et al., 2016; Prins et al., 2015).

Urban areas, despite their inequitable premature mortality patterns, have lower suicide rates than rural areas (Helbich et al., 2017; WHO, 2016). New York City has one of the lowest rates of any major city nationwide (CDC, 2020). Just because New York City’s suicide rate is low does not mean we can ignore it. Inequities exist within the rates we do have (Protacio &

Norman, 2016). It is time to proactively consider how our planned environments can protect against suicide and promote individual and collective wellness. Such a targeted focus is likely to unearth deeper structural deficiencies in our confidence and ability to plan for livable, equitable, and healthy cities, as well as opportunities for redress.

Goal and Objectives of the Study

The goal of this thesis is to demonstrate that urban planning has the power to influence key socio-environmental risk and protective for suicide, which I aim to achieve through four primary objectives:

1. Describe the problem of suicide and how it has come to be seen predominantly as an

individual, mental-health related phenomenon.

2. Present the evidence of the effect of urban planning’s influence on local and regional

suicide rates.

3. Argue that urban planning plays an important role in suicide risk mitigation.

4. Outline the broad opportunities and challenges for addressing suicide within an

interdisciplinary framework.

Methodology

To my knowledge, this thesis will introduce the broad role of urban planning in suicide

prevention for the first time. As such, a qualitative analysis was deemed most appropriate for the

intended audience of this thesis. Several reasons influenced my selection of qualitative methods:

1. Suicide is a complex and context-dependent topic, requiring a deeper understanding that

cannot always be found in quantitative research (Hjelmeland, 2007, 2019).

2. This study aims to demonstrate the need for an interdisciplinary approach to suicide

prevention. To achieve this goal, it was important to interview a diverse range of

professionals about the opportunities and challenges for interdisciplinary collaboration.

3. While a mixed methods analysis of hyper-local suicide trends in New York City,

combined with participatory action research, would be a stronger approach, suicide data

is highly protected. The process to develop, submit, and receive approval for a data

agreement plan would have been prohibitively time-consuming for a master’s thesis,

especially during a national pandemic.

4. Qualitative research allows for a holistic, dynamic, and discovery-oriented approach to

data collection and analysis (Gaber & Gaber, 2007). Exploring the topic primarily

through conversations, rather than through quantitative analysis, was essential for

confirming, countering, or expanding certain guiding assumptions (Smalls, 2011).

Thus, the primary research methodology of this study is a qualitative analysis of

interviews and conversations with key stakeholders. Participants represent a purposive sampling

of 15 professionals and practitioners from the Colorado Department of Public Health and

Environment, Education Development Center, New York City Department of City Planning,

New York City Department of Health and Mental Hygiene, New York City Public Design

Commission, New York State Office of Mental Health, Reyerson University, Center for Health

Design, and Volpe National Transportation Systems Center.

Several interviews followed an informal conversational approach, the content of which substantiated or illustrated examples of concepts discussed throughout this thesis. The remaining interviews followed a general guide approach, allowing for a systematic, but flexible, question and answer process (Patton, 1990). I conducted all interviews and conversations via Zoom, a web-based video conferencing tool, and recorded and transcribed some interviews, with

permission from interviewees. I selected the following four primary interviews for full qualitative analysis:

• Scott Gabree, PhD, Engineering Research Psychologist at the Volpe National

Transportation Systems Center

• Elizabeth Hamby, Director of Take Care New York (TCNY) at the New York City

Department of Health and Mental Hygiene

• Jerry Reed, PhD, Senior Vice President for Practice Leadership at Education

Development Center

• Catherine Stayton, DrPH, MPH, Director of the Injury and Violence Prevention Program

at the New York City Department of Health and Mental Hygiene

I selected these four interviewees based on their professional expertise, level of knowledge of the

subject, and willingness to participate. Their biographies are listed in Appendix B. I generated a

set of themes and associated codes to guide and analyze the interviews. Additional data and

information supplement the qualitative analysis to help educate the reader or provide further explanation of the content discussed.

Study Limitations

I chose to introduce the reader to many facets of suicide which I deemed essential context for this thesis. Some of these facets, such as the problem of racial bias in suicide research, are

deserving of entire studies on their own. A comprehensive, critical race analysis is

unquestionably needed in any effort to critique and transform contemporary suicide prevention frameworks, which I was unable to do. Additionally, although I sought out literature and work by researchers and authors of color, my primary interviewees lack diversity. This is partly due to a lack of representation in suicidology and its related fields. It is also due to my positionality within city government, which allowed me to access existing professional relationships with relative ease. All interviewees will likely agree that representation in public mental health is lacking and we must do everything we can to elevate the work and employment pathways for suicide scholars of color.

Finally, the focus of this thesis is on upstream (i.e., structural, institutional, political) risk and protective factors for suicide. As a result of this focus, as well as my experience and

familiarity with New York City government, I largely direct my attention to City agencies. There

are many excellent and effective community-based and advocacy suicide prevention

organizations engaging in innovative work across New York City and the nation. Though they

may not appear in this thesis, they are central and vital components of a comprehensive suicide

prevention agenda.

Chapter 2: Background

This chapter orients urban planners to the topic of suicide. It describes how the professional fields of urban planning and suicide prevention are connected, the history of

mainstream thought on suicide, and enduring biases that obscure contemporary research and

prevention practices.

The Relationship between Urban Planning, Public Health, and Suicide

Practically and theoretically, the professional fields of suicide prevention and urban

planning are connected through the field of public health. The evolving and devolving

relationship between urban planning and public health is therefore foundational context for this

study.2

Modern urban planning emerged in the mid-19th century in response to the harmful

effects of industrialization on human health (Corburn, 2007; Hensley et al., 2020). Unsanitary

neighborhood conditions, overcrowded housing, and the rapid spread of communicable diseases

united urban planning and public health professionals around shared priorities. Their

collaboration proved useful, resulting in dramatically improved urban conditions and population

health outcomes, including a reduction in overall mortality rates. Having achieved joint

successes in the areas of sanitation, open space planning, and housing, the fields slowly drifted

apart. By the late 19th century, public health began a conceptual shift to bacteriology and disease

management while physical planning emerged as the dominant planning method for responding to urban challenges (Corburn, 2004, 2007; Farre & Rapley, 2017; Giles-Corti et al., 2016; Hall,

2014). Theoretical shifts and deepening professionalization in each field only increased, driving a chasm between the two by the early 20th century. As a result, urban planning practices can and

2 Appendix A presents a timeline of this relationship.

15 do occur entirely without health in mind. Public health, with its lingering biomedical model of illness, is otherwise preoccupied with influencing individual behavior change (Farre & Rapley,

2017).

The public health field has long segregated mental health from physical health (Druss et al., 2018). The New York City (NYC) Health Department and the NYC Department of Mental

Hygiene, Mental Retardation & Alcoholism Services were entirely separate agencies until 2002, when they finally merged (Archives of the Mayor’s Press Office, 1998). Due to the pervasive stigma surrounding mental illness for centuries, mental health treatment and research evolved primarily in institutional settings (Colaizzi, 2005; Deutsch, 2014; Foucault, 1961; Parcesepe,

2012; Whitaker, 2019). It was not until 1962, with the passage of the Community Mental Health

Act, that mental health became a matter of broad public concern. Suicidology, or the scientific study of suicide, followed a similar trajectory and is today generally considered a component of public mental health.

Most health experts now agree that suicide and mental health are not merely biological predispositions. Both mainstream and radical narratives acknowledge that a vast array of individual, social, cultural, and geographic factors contribute to suicide rates and population mental health. Good mental health is not merely an absence of mental illness; it is fundamental to and shaped by one’s interaction with the world. A person’s sense of purpose, ability to engage in civic life, social connections, or exposure to discrimination all contribute to their mental wellbeing. In the United States, where lives are valued by race and class, the systems and structures meant to protect and nurture wellbeing – and life in general - are inequitably distributed. Suicide is therefore never an isolated incident and should be treated like the health inequity that it is.

Interdisciplinary Alignment through Health Equity

In the past ten years, efforts have been made to better integrate mental health and by association, suicide, into public health. Urban planning and public health have begun to gravitate towards one another again, recognizing a shared interest in that ways in which urban development practices exacerbate health disparities. Each field has reached a tipping point to either commit deeply and intentionally to health equity and anti-racist action or to return to their profession’s status quo.

Health inequities are population-based health disparities resulting from systemic and unjust social and economic policies and practices. Health equity, or social justice in health, is a conceptual shift from doing the greatest good for the greatest number of people to redirecting attention to those who are most impacted by unjust systems (Braveman, 2014; E. Hamby, personal communication, 2020). In practice, health equity is the fair distribution of social determinants, outcomes, and resources within and between populations (Ramirez et al., 2008). In recent years, the fields of urban planning, public health, suicide prevention, and public mental health have separately created action plans towards achieving health equity. These plans are iterative, evolving in real time in response to the COVID-19 pandemic and its unjust impact on communities of color. The COVID-19 pandemic has forced urban planners to think about public health in practice, whether they wanted to or not.

The American Planning Association has made efforts to identify, evaluate, and share planning strategies that integrate public health goals. But these efforts and their subsequent findings noticeably lack mental health awareness. A 2011 American Planning Association survey of its members found that less than 10% of respondent’s jurisdictions address mental health in their comprehensive plans (APA, 2011). A 2014 analysis of comprehensive planning processes

revealed that most plans had very weak coverage of topics such as mental health and social

cohesion (Ricklin & Kushner, 2017). Despite these findings, the American Planning

Association’s 2020 toolkit to help jurisdictions integrate health and equity into comprehensive

plans excludes mental health strategies (Shah & Wong, 2020).

Together, the projected long-term social and economic impacts of COVID-19, the

nation’s rising suicide rate, and multidisciplinary commitment to health equity present a unique

moment in time opportunity to realign public health and urban planning. Jason Corburn, an urban

planning and public health scholar, writes extensively about the urgency to reconnect the two

fields. In order to reconnect, the fields must work together to achieve the following: develop an

interdisciplinary framework, articulate a strategy for understanding and minimizing urban-rural variations in health disparities, adopt a more relational and dynamic approach to place, and create a new conception of participatory democracy that ensures accountability to communities

(Corburn, 2004).

I argue that suicide, with its multifaceted risk and protective factors, can act as a strong

case study for testing the intersectional realignment of planning and health. Unique complexities

related to data collection, research, and stigma make realigning around suicide a challenge; but a challenge is needed to test whether these disciplines can jointly move the needle on a complex

health outcome. Before delving into such a test, the following section provides an overview of

why socio-environmental factors have played a relatively small role in suicide thinking over

time.

Brief History of Western, Mainstream Thought on Suicide

Suicide occurs in every culture and has since the dawn of civilization (Cholbi, 2017;

Weaver & Wright, 2009). The stigma attached to it is almost as old and just as pervasive.

Although the term “suicide” is considered a Western historical neologism, documented cases of

suicide (i.e., self-murder, self-destruction, self-killing, self-homicide, self-slaughter, and self- accomplished death) go back millennia (Alvarez, 1990; Brancaccio et al., 2013). Mainstream perceptions of suicide have shifted over time, as they are based on individual notions of morality shaped by prevailing cultural norms (Sawada et al., 2017). Modern Western thinking on suicide treats suicide predominately as a biomedical, mental health-related phenomenon despite its known associations with a broad range of socio-environmental factors. Understanding how this thinking has evolved sheds light on why another evolution is needed today.

Two premises guided Western antiquity’s treatment of suicide: bodies and souls were the properties of the gods and individuals had unique, predisposed responsibilities to their communities. Plato, who believed that suicide flouted the gods and society as a whole, articulated if not promulgated his era’s moralizing of suicide. According to Plato, suicide was both an ethical and legal matter. To “self-kill” meant to treat oneself and one’s community unjustly and was therefore punishable by law; he insisted that any person who self-killed be buried in unmarked graves (Cholbi, 2017; Minois, 2001). Plato’s ideologies about suicide would persist throughout the Middle Ages, gaining strength through institutionalized Christianity. It was common and legal during the Middle Ages to desecrate the corpse of an individual who died by suicide, confiscate their property, excommunicate their family, and disallow a Christian burial. These corpses were often left in the middle of roads on the outskirts of villages where the devil could claim their souls (Alvarez, 1990; Cholbi, 2017; Brancaccio, 2013).

Suicide remained a blasphemous matter, met with near-total rejection and punishment,

until the mid-19th century when three important shifts occurred. First, suicide began to be seen in

secular terms, relating to an individual’s psychological disposition rather than to their sins.

Second, an emphasis on personal freedom, spurred by the Enlightenment, had spread across

Europe, influencing popular thought around self-autonomy and thus an individual’s right to take

their own life. Third, thanks to rapid advancements in social science, suicide was ripe for

quantitative analysis (Brancaccio, 2013; Cholbi, 2017; Marsh, 2010). At the end of the 19th

century, sociologist Émile Durkheim embarked upon a scientific exploration of suicide, which he

perceived to be a social, rather than individual, phenomenon (Durkheim, 1897).

Durkheim is widely credited with being the first person to demonstrate associations

between suicide and sociodemographic variables (e.g., gender, age, and religious affiliation),

theorizing that anomie (the uprooting of social bonds and contracts due to rapid societal

transformation) led to an increase in population-level suicide rates (Calhoun, 1992; Hsu et al.,

2015; Marsh, 2010). Studies such as Durkheim’s Suicide, as well as Enrico Morselli’s Suicide:

An Essay on Comparative Moral Statistics, despite their well-documented methodological

flaws,3 are important texts for urban planners to recognize as they are early explorations into the

complex link between social forces and individual behavior.

This shift in thinking about suicide from individually-based and moralistic to societally-

influenced and scientific ultimately led to the medicalization of suicide (Marsh, 2010). What

began as a humane evolution, dawning the treatment rather than condemnation of suicide-related

behavior, resulted in an overemphasis of biomedical interpretations and interventions. Dr. Ian

Marsh, a suicide scholar from Canterbury Christ Church University, charted the Western truth-

making (i.e., the production, dissemination, and circulation of authoritative knowledge of a

subject) of suicide throughout history and found that suicidology’s emphasis on medical

3 Moral statistics were deeply influenced by the religious and political discourses of Europe in the late 19th and early 20th centuries. On Suicide and Comparative Moral Statistics have been cited as having biases towards positivism, determinism, and social Darwinism (Brancaccio, 2013; Brancaccio & Lederer, 2018; Lederer, 2013).

explanations and practices has overshadowed the economic and political aspects of suicide. This

overshadowing fixed suicide thinking and prevention practices firmly within the clinical realm.

Most suicide-related texts since Durkheim’s On Suicide, including The International Handbook

of Suicide and Attempted Suicide, treat suicide as primarily a psychiatric or pathological concern

(Button et al., 2020; Marsh, 2010; Marsh et al., 2016).

The medicalization of suicide has persisted and been reinforced by its own self-fulfilling

bias. Late 19th and early 20th century asylums, dominant mechanisms for the management of

mental illness and professionalization of psychiatry, became breeding grounds for producing

medical truths about madness and suicide. These so-called truths informed clinical practices,

biased the research, and elevated medically-derived interventions for decades (Foucault, 2001;

Marsh, 2010; Rothman, 2017; Whitaker, 2019).

The shift from punishing suicide to understanding it coincided with other strategies to

preserve the potential of lives at a population level. Dr. Ian Marsh describes this shift as an example of bio-power, Michel Foucault’s theory of the State’s ability to regulate bodies in effort to maximize or control them (Marsh, 2010). Much of the historical literature on the cultural

aspects of suicide reveal how societies have used suicide rates as a reflection of a nation’s quality

of life or measure of its sickness (Tousignant & Mishara, 1981). Suicide came to represent a failure of governments, not individuals, to preserve lives. What could have been a critical shift in the narrative and treatment of suicide as a social problem never materialized; it had already been too deeply pathologized.

Advancements in the science of suicide, particularly those that target mental health- related causes and symptoms, have been necessary and they continue to save lives; mental health is still an essential component of understanding and addressing suicide at both an individual and

societal level, but it has played far too big a role for far too long. Furthermore, mental health is

often misunderstood. When a dominate explanation emerges for a universal phenomenon, the many other ways of knowing are overlooked or discounted entirely. Mainstream narratives of suicide have historically failed to present the isolation and othering of individuals as cultural

products needing structural solutions (Button, 2020; Fitzgerald, 2020; Marsh, 2020; White,

2020).

The Production of Knowledge and Racial Bias in Research

By official counts, in the United States, white males comprise the largest share (69.67%)

of suicide deaths (American Foundation for Suicide Prevention, 2020). Many nuanced

environmental, cultural, and analytical factors contribute to and complicate this statistic. Suicide

research suffers from a deep and at times insidious history of explicit bias, implicit bias, and

discrimination (Akthubaiti, 2016; Bassett et al., 2018; Blair et al., 2011).

Racism has dominated public health practice for centuries, centering whiteness and

vilifying blackness in investigations of population-based health disparities. This legacy, or what

Dr. Mary Bassett, Director of the François-Xavier Bagnoud Center for Health and Human

Rights at Harvard University and former Health Commissioner for New York City, refers to as

“institutional racism as public health practice,” influences how we think about, analyze, and treat

health disparities. It also perpetuates the very racial inequities in health outcomes it seeks to

erase. To this day, white people have outlived Black people every year since the United States

was established (Bassett & Galea, 2020).

Public mental health, where suicide is nestled, has its own specific history of bias that

must be reckoned with. In 1851, psychologist Dr. Samuel A. Cartwright coined “drapetomania,”

a term used to describe the “serious mental illness” of enslaved individuals who escaped their

captors (Eakin, 2000). Equating the act of defying chattel slavery with mental illness was only

the beginning of the manifestation of institutional racism within the U.S. mental health system.

Countless other examples, such as the over- and mis-diagnosing of schizophrenia in Black men, exist and persist, too many to explicate in this thesis (Metzl, 2011).

Despite the well-documented history of racism in mental health practice, mainstream messages overemphasize suicide as a white person’s disease (Crosby, 2006). Decades of Euro- western research on the etiology of suicide have favored white subjects and white explanations, allowing racialized assumptions of suicide to endure (Fearnley, 2009; Marsh, 2016; White,

2020). Not only did racism inform investigations of suicide, but ideas about race were produced

– and reproduced - within the suicidology and health fields. From the mid-18th to the mid-20th

centuries, journal articles, books, and news reports promulgated the notion that Black people

neither considered nor died by suicide. In 1929, the American Psychiatric Association presented

a paper at an annual meeting claiming that Black suicide was less prevalent than white suicide

because Black individuals did “not worry as much as the white man” (Fearnley, 2009).

Researchers often made sweeping generalizations, speculating that if and when Black people

died by suicide, it was a result of frustration and rage, rather than introspection or depression.

Even when data collection and analytic processes improved, biases remained. In a 1982

New York Times article titled Why are Blacks Less Suicide Prone Than Whites? Dr. Richard H.

Seiden proposed the “survivor” hypothesis, positing that the suicide rate among older Black individuals was low due to the “triumph in surviving adversity.” In that same article, two additional researchers presented similar explanations for the prevailing Black-white suicide disparity; namely, that Black people had more “survivorship, wisdom and experience” and tribal support as a result of “successfully handling the rage” of racism. Although these were plausible

23 explanations coming from credible sources, each researcher was white and was afforded the opportunity to publicly theorize on behalf of the Black experience (Williams, 1982).

Misclassification of Black and Brown suicide deaths momentarily aside, versions of Dr.

Richard H. Seiden survivor hypothesis have evolved over the decades. Recent studies suggest that the strain of racism and living in chronically stressful environments are paradoxically associated with lower suicide rates among Black U.S. adults, specifically (Pérez-Stable &

Rodriguez, 2020). Two key explanations of this presumed paradox have emerged. The first is that unique protective factors exist within Black populations, such as cultural identity, strong familial bonds, community support, and religion or spirituality (Crosby & Davis Molock, 2006;

Droege et al., 2017; Wang et al., 2014). But not everyone experiences these protective factors equally. For example, decades of studies have indicated that religion plays a significant role in explaining variations in suicide rates. However, a recent systematic review suggests that the social support that religion offers is likely more protective than religion itself (Lawrence et al.,

2016). In some cases, religion serves as a risk rather than protective factor. Lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth raised in homophobic religious households are twice as likely to attempt suicide than their heterosexual peers (Gibbs & Goldback, 2015).

A second explanation is that, due to structural racism, Black U.S. adults experience numerous stressors that white U.S. adults do not and are therefore more skilled at coping with acute stress. While it may be true that Black U.S. adults are more skilled at coping with acute stress, this point fails to acknowledge the cumulative negative health effects of racism on Black communities. Two recent studies led by Black researchers showed that perceived racial discrimination alone is associated with depression and can contribute to suicide ideation (Brooks et al., 2020, 2020).

Information about suicide and race is still often presented without acknowledgment of racism’s effect on research. Race and ethnicity reporting on death certificates are exceedingly more accurate for white decedents than for Asian, Alaska Native, American Indian, Black,

Hispanic, and Pacific Islander decedents (Arias et al., 2016; Huguet et al., 2012; Rockett et al.,

2019). Non-white deaths are more likely to be misclassified or undetermined, especially when suicide death indicators are not present, such as a suicide note or history of diagnosed mental illness (Frankt, 2020).

Large and diverse sample sizes of living subjects can also be hard to obtain for the purpose of research. Suicide is a sensitive topic shrouded in stigma, so a tremendous amount of trust is needed between researchers and subjects. Yet, the mental health research and clinical fields are overwhelmingly white. As a result, research agendas, which inform interventions, underwhelmingly account for cultural and historical factors relevant to people of color (McGuire

& Miranda, 2008; Ruiz, 2020). This Euro-western approach to research hurts white people, too.

Suicidology’s positivist, biomedical framework for understanding suicide views research subjects as “de-contextualized bundles of risk factors” who must be saved (White, 2020). Suicide is preventable, but a positivist framework that prioritizes intervening over understanding will treat suicide as irrational rather than a legitimate response to unlivable situations (Fitzpatrick,

2020; Jaworski, 2020; Marsh, 2020; White, 2020).

In the past decade, the field of suicide prevention has evolved, and its research has improved. Data analysts, policy experts, and program officers at public health agencies and advocacy organizations are keenly aware of suicidology’s race problem. In the last few years, leading suicide prevention organizations have crafted equity goals, largely due to the Black Lives

Matter movement.4 The American Foundation for Suicide Prevention, the nation’s largest funder

for prevention research, incorporated diversity metrics into its grant award criteria. The National

Suicide Prevention Lifeline reassessed its policy for how crisis call centers should respond to an

imminently suicidal person, using police intervention only as a last resort (Ruiz, 2020).

Nonetheless, the field has not yet fully grappled with its legacy of bias. The American

Association of Suicidology, the field’s preeminent membership organization, has only two Black

members on its otherwise entirely white board of directors. Given that suicide rates are high or

on the rise for several communities of color, greater efforts must be made to diversify the

workforce and elevate leaders who are Black, Indigenous, and People of Color (BIPOC). Doing so is urgently needed but comes with a unique challenge. The President of the American

Association for Suicidology, Jonathan Singer, puts it succinctly:

The work of suicide prevention is ‘grounded in the assumption that people live in a world

that believes their life matters,’ says Singer, who is white. Many people of color,

however, do not see that world as their own. ‘On a practical, daily level [society] gives

explicit and implicit messages that it's white lives that matter and not Black lives or

Brown or Indigenous lives (Ruiz, 2020).

The legacy of bias in health research, combined with the socio-political climate of today,

requires a social justice approach to deciphering suicide trends, which are described in Chapter 4.

To achieve more national accuracy, every U.S. jurisdiction would need to undertake a critical race and cultural analysis of its death certification process. Research practices, which rely on these data to interpret suicide trends within and between populations, would also benefit from

4 Black Lives Matter was founded in 2013 in response to the acquittal of Trayvon Martin’s murderer. It is a global movement and organization whose mission is to “eradicate white supremacy and build local power to intervene in violence inflicted on Black communities by the state and vigilantes.” https://blacklivesmatter.com/about/

26 such an analysis. It is time for suicide research institutions to exhaust all efforts to obtain diverse samples, fund participatory action research, and support publication pathways for researchers of color.

Chapter 3: Literature Review

This literature review presents the evidence of socio-environmental risk and protective factors for suicide that are relevant to urban planners.

While most suicide scholars agree that socio-environmental factors impact individual and area-level suicidality, this research’s depth and precision come with several practical and ethical barriers:

1. The individuals most affected by any risk factor - those who have died by suicide -

are unable to tell us their stories firsthand. Psychological autopsies may be

illuminative, but they are imperfect and time-intensive (Hjelmeland et al., 2012; Tait,

2015).

2. Researchers must consider the potential harm their studies pose to their subjects,

particularly if testing interventions. The research ethics of suicide are not always

clear-cut, and institutional review board processes can disrupt, delay, or end research

studies or trials entirely (Andriessen et al., 2019).

3. Suicide data are largely confidential and sensitive, making them hard to access and

interpret, a challenge discussed in detail in Chapter 5. Additionally, researchers with

the same data can have vastly different results depending on their analytic approach,

sample size and population, and the risk factor(s) they choose to examine or exclude.

4. Suicide prevention research in the United States is relatively underfunded by the

federal government, making grant opportunities highly competitive (American

Foundation for Suicide Prevention, 2020).

5. Suicide is incredibly nuanced and therefore difficult to study. To understand suicide

in a given time, place, and population, multiple disciplines, datasets, and analytic

approaches are needed. Of the hundreds of studies included in systematic, meta-

analytic, and narrative reviews, most use different approaches and methodologies to

study the relationship between various socio-environmental factors and suicide

(Milner et al., 2013). Additionally, quantitative research, which is particularly

insufficient at explaining suicide because it lacks socio-cultural depth, comprises the

majority of evidence. A recent review of the three major international suicide

publications over a four year period revealed that entries were overwhelming

quantitative, epidemiological, and North American-focused (Hjelmeland, 2016).

Still, a large amount of literature does exist that explores the spatial and socioeconomic

patterns of suicide from around the world. Research on the impact of urban environments, and

especially urban design, on mental health is more prevalent. However, systematic reviews of

studies that investigate the relationship between mental health and specific urban features often

turn up inconclusive due to the varying populations, settings, and indicators used between

studies. This author found no literature explicitly investigating the relationship between suicide

and urban planning.

This literature review groups risk and protective factors for suicide into three domains:

the planned and built environment, the natural and geographic environment, and the social and economic environment. While some risk factors exist practically and theoretically within multiple domains (e.g., green space, particularly in urban areas, can be both natural and built), I

have placed them in domains that most reflect their evidence-base.

The Planned and Built Environment

Trends in urbanization. There are large regional and urban-rural variations in suicide

rates globally, with the highest rates occurring in rural areas (Hedegaard et al., 2020; Helbich et

al., 2017; Pettrone & Curtin, 2020). Trends by level of urbanization are an important starting

place for planners to begin to unpack and investigate suicide’s spatial patterning.

While both urban and rural suicide rates have increased since 2000, rural rates have

increased more quickly and to a greater degree (Pettrone & Curtin, 2020). These trends are

temporally patterned and vary substantially by gender, age, and race (Singh & Siahpush, 2002).

While the evidence of this rural-urban divide is relatively sound, some variations exist due to the

many ways that researchers define and measure urbanicity. Planning-based typologies and data

sources also vary, making the selection of which urban-rural indicators to use in such an analysis

less standardized (Helbich et al., 2017; Chung et al., 2007). For instance, researchers at the

Center for Disease Control studied suicide rates by level of county urbanization over a six year

period defined by six classification levels ranging from large central metro to non-core (i.e., non-

metro):

Figure 1. Age-adjusted suicide rates, by county urbanization level: United States, 1999 and 2017. Source: Center for Disease Control, Morbidity and Mortality Weekly Report (2017).

The urbanicity classification system used by the Center for Disease Control resulted in

more nuanced findings than other studies (Kegler et al., 2017). Regardless of the type and

number of indicators selected to define urban and rural areas (e.g., population density, proportion

of built-up areas, transportation access), many studies confirm higher rural suicide rates

worldwide, including in Australia, China, England, Iran, Ireland, and New Zealand (Chung et al.,

2008; Helbich et al., 2017; Levin et al., 2005; Middleton et al., 2003; O’Farrell et al., 2016;

Pearce et al., 2007).

There are several explanations for the widening gap in suicide rates between rural and

urban areas. The type and availability of means greatly influence whether someone lives or dies

in a suicide attempt. In Sri Lanka, for instance, large variations in suicide rates between 1955 and

2011 were predominantly due to availability of pesticides in rural areas (Knipe et al., 2017). In

the United States, more people die by suicide with a firearm than all other methods combined,

making guns the most lethal and most common method of suicide (Pettrone & Curtin, 2020).

Nearly half of all U.S. adults live in households with firearms (Parker et al., 2017). Given that rural-dwelling U.S. adults are nearly three times more likely to own guns (and more of them)

than their urban counterparts, it comes as no surprise that suicide deaths in rural areas are

outpacing those in urban ones. In fact, household firearm ownership is strongly associated with

suicide rates, whereas prevalence of household antidepressant prescriptions, an indicator that

some might assume would be correlated with suicide, are not (Opoliner et al., 2014).

Additionally, white men, who comprise the largest share of suicide deaths nationwide, also own

the most guns (Parker et al., 2017).

Means is one of the most significant determinants in suicide rates, but it is not the only

determinant. Variations in urban-rural rates are associated with a variety of other types of

31 demographic and socioeconomic disparities that often geographically coalesce. High rates of poverty and rurality, for instance, have been shown to correlate with high rates of suicide

(Button, 2020). These disparities, such as the availability of health and social services, level of community social cohesion or fragmentation, and access to economic opportunities, are explored later in this literature review.

Spatial patterning. Spatial patterning (i.e., geographic trends, concentrations, and clustering) of suicide happens between and within rural and urban areas and is not only associated with means or socioeconomic status. Both rural and urban areas have experienced profound social and demographic changes over the past century, particularly in the last five decades. Between 1970 and 1990, compared with rural areas, U.S. urban areas experienced five times the population growth, a more substantial increase in births over deaths, lower divorce rates, and lower unemployment rates (Singh and Siahpush, 2002). Migration patterns between rural and urban areas disrupted social networks and community cohesion, two significant protective factors for suicide.

Urban density is a commonly used indicator in comprehensive plans. It allows planners to understand and measure population shifts over time in order to inform development. Population density, when used as an explicit measure of social isolation, can have profound implications on human health and wellness. Several studies show that areas with higher population densities have lower overall suicide rates (Hempstead, 2006; Helbich et al., 2017, Wang et al., 2013). One study found that municipalities in New Jersey that lost population between 1990 and 2000 and had high proportions of single-person households also had higher suicide rates (Hempstead, 2006).

While suicide rates generally are higher in rural areas, some studies have shown that suicide clusters are often more common in urban areas (Torok et al., 2017). Taken together, these

findings suggest that while “complex social networks” are protective against suicide, dense,

crowded areas within urban environments may be less so.

Studies on the geographic patterning of self-injury are beginning to emerge, though the topic remains thoroughly under-researched (Lersch, 2020; Vaz, 2019; Vaz, 2020). One study investigated the spatial patterning of 911 calls related to suicides in progress (more serious) and suicide threats (less serious) in Detroit, Michigan over a three year period. Researchers found that calls were not randomly distributed, but rather clustered in patches of hot spots throughout the city. Suicide in progress calls covered a slightly larger total area, as well as more unique areas, than suicide threat calls. Additionally, hotspots were associated with several perceived risk factors (e.g., blight complaints, demolitions, gun shops, liquor stores, burglaries) to varying degrees (Lersche et al., 2020).

In Toronto, researchers investigated the relationship between land use characteristics and suicide as well as between land use and self-harm (Vaz et al., 2020; Vaz et al., 2020). In the first study, self-harm patterns appear to significantly correlate with landscape characteristics, affecting men and women differently. For instance, suicides occurred most frequently in residential areas, likely coinciding where people live, followed by commercial and then industrial areas. However, men were more likely to attempt suicide at commercial properties than women, and women were more influenced by open space and land cover typologies. The study also found increased incidences of suicide and self-harm in areas with a high density of social housing and homeless shelters (Vaz, 2020).

Within cities, high rates tend to cluster in areas with high neighborhood-level poverty, particularly in Western cities (Button, 2020; Fontanella et al., 2018; Hsu et al., 2015; Lin et al.,

2019; Rehkoph & Buka, 2005) This holds true when comparing cities to one another: greater

suicide risk has been found in cities that have lower urbanization and less socioeconomic

development (Cheung et al., 2012; Denney et al, 2015).

Quality of the built environment. The literature is just beginning to emerge on the built

environment’s effect on suicide. However, many studies explore the direct and indirect

relationship between mental health and the urban built environment (Evans, 2003; Galea, 2005;

Gong, 2016; Guite, 2006; Hembree, 2005). These studies generally confirm that quality built

environments lead to positive mental health outcomes, although the direct (e.g., improved or worsened depression or anxiety) and indirect (e.g., improved or worsened social isolation or sense of control) impacts are wide-ranging and often hard to disentangle (Araya, 2006; Choi,

208; Evans, 2003; Fullilove, 1996; Larcombe et al., 2019). Due to the researchers’ varying methodological approaches and definitions of mental health, a recent overview of systematic reviews of the built environment’s effects on mental health found insufficient evidence to make any firm conclusions about this relationship (Nuñez-Gonzalez et al., 2019).

That said, results from individual studies are not without merit. Built neighborhood and planned features that are believed to contribute to population mental health include the presence

of functioning green neighborhoods, clean streetscapes that prioritize walking and social

interaction, affordable housing, quality (i.e., well-maintained, well-ventilated, energy efficient)

transportation infrastructure, and physical protections against noise and air pollution (Evans,

2003; Miles, 2011; Galea, 2005; Nuñez-Gonzalez et al., 2019). These features of the urban

environment, as well as land-use mix, industry activity, and traffic volume, influence individual

behavior, especially city-dwellers’ abilities to interact with and trust one another. They can

improve or derail concentration, social cohesion, and sleep ability, which have significant

associations with psychological distress (Nuñez-Gonzalez et al., 2019).

A person’s indoor environment also has an impact on their mental health. Researchers

conducted phone interviews with 1,355 New York City residents to assess the relationship

between depression and characteristics of the interior and exterior built environment. They found

that poor quality (e.g., non-functioning utilities, peeling paint, and structural fires) of internal and external residential environments is associated with a greater likelihood of depression (Galea,

2005).

Decades of research exist on the relationship between high-rise living, crowding, and

psychological distress. In 1975, sociologist Riaz Hassan found that residents who lived on the

highest floors of public housing complexes in Singapore experienced more stress and strain than

those living on lower floors (Hassan, 1977). A recent review of historic and contemporary

research between poor mental health outcomes and high-rise living found that this association

persists. Populations that live in high-rise apartments, particularly in low-income neighborhoods,

generally experience higher levels of psychological stress than the residents living below them.

However, this association does not hold for residents living in high-rise, luxury apartments in

affluent areas. In these cases, higher floors generally mean greater wealth, with ample room and

psychologically nurturing views of green and blue spaces (Larcombe et al., 2019).

A combination of neighborhood features is more likely the cause of mental health

outcomes than the type or form of individuals’ residential or surrounding buildings (Gonzalez et

al., 2020). A recently published article investigating the association of urban built environment

and socioeconomic factors with suicide in Hong Kong, a high-density city, found that

“unfavorable” built environments affects suicide attempts, but other factors (population density,

surrounding greenery, and marital status) were just as important. Thus, suicide prevention

35 strategies that target both the built and social environment are likely to be most successful (Wang et al., 2020).

Means accessibility. As this thesis earlier established, access to means is a key risk factor for suicide. The more lethal the means, the more likely a person will not survive an attempt. It is commonly believed that a person intent on dying by suicide will find a way to do so, regardless of any attempts to dissuade them. Critics of suicide barriers often assume that even if a barrier is built, which can be costly, individuals will simply find another method.

Two facts deflate this myth. First, impulsivity can play a role in suicide. In 2001, the

Center for Disease Control interviewed 150 people between the ages of 13 and 34 who had recently attempted suicide. One quarter of the interviewees reported that they had acted within five minutes of feeling the impulse to do so and another quarter had acted within five to 15 minutes (Kresnow et al., 2002). Several similar studies have been conducted that show the same results: suicide attempts often, though not always, happen impulsively and within 24 hours of an interpersonal conflict, in the midst of a crisis, or directly following an argument (Auerbach et al.,

2017; Simon et al., 2001; Zouk et al., 2006). This means that the method of suicide plays a critical role in whether or not someone survives a potentially impulsive act.

Second, individuals can become fixated on a particular method. Often, the means associated with certain methods, such as jumping, are culturally significant sites that are highly lethal and relatively accessible (Beautrais, 2007; Saeheim et al., 2017). The Golden Gate Bridge has attracted suicides since the moment it opened for exactly these reasons (Bateson, 2012).

Suicides off the Golden Gate Bridge have occurred at a rate of approximately 30 per year, due in large part to the bridge’s high lethality rate, combined with the appeal of surveying the landscape’s sublime view one last time (Whitmer, 2012). Individuals who survived suicide

attempts by jumping off San Francisco’s Golden Gate Bridge say they were drawn to the

bridge’s mysticism and the promise of an easy death (Friend, 2003).

In other words, how easily and how often certain suicide means are used are shaped by

our environments. In rural, agricultural communities, charcoal and pesticides are commonly used

means of suicide, given how widely accessible they are. Conversely, suicide by jumping is more

common in places where the majority of the population live in high-rise apartment complexes,

such as China, Hong Kong, New York City, and Singapore (World Health Organization, 2014).

In New York City, suicide due to jumping from a high place is eight times the proportion

nationwide (Protacio & Norman, 2016). This staggering statistic underscores the literature that

the means of suicide is just as important a consideration in prevention policies as the reasons for

suicide. As such, city planners, designers, and builders are clearly needed in determining how

best to mitigate suicide risk on high structures.

There is ample evidence showing that restricting access to suicide jump sites via physical barriers is particularly effective at preventing suicide by jumping (Cox et al., 2013). Suicides by

jumping occur at higher rates in places that have extensive high-rise housing, though suicides at

sites such as bridges, cliffs, and viaducts often receive more attention due to their iconic nature

(Beautrais, 2007). As a result, installations and evaluations of physical suicide barriers have

predominantly occurred at natural or iconic sites.

Regarding common suicide jump locations, researchers have investigated two important

and potentially interrelated effects: whether the number of suicides at a specific site decreased

post-installation of a suicide barrier and whether there was a concomitant increase in suicides by other means in the same area (Chi-Kin Law et al, 2014). Two studies in Europe showed that barriers significantly reduced the number of suicides caused by jumping from particular bridges,

without contributing to an increase in attempts from other structures (Bennewith et al., 2007;

Reisch et al., 2007). Similar long-term studies showed the same results on the Bloor Viaduct in

Toronto, Canada and on 36 bridges in Norway between 1999 and 2010 (Sinyor et al., 2017;

Saeheim et al., 2017). In light of these results, researchers conducted a meta-analysis of the

effectiveness of structural interventions at popular locations and a systematic review of

interventions to reduce suicides at popular locations and found that structural interventions

categorically averted suicides at popular locations without substitution effects (Cox et al., 2013;

Pirkis et al., 2013). As incidences of suicides decrease due to physical barriers, they do not

increase at other locations.

The Natural and Geographic Environment

Naturally-occurring phenomena influence patterns of individual wellness, suicide, and self-harm (Bratman et al., 2019; Chang et al., 2018). This section provides an overview of the evidence of the association of certain natural phenomena with suicide, namely, climate, altitude, air quality, and green and blue space.

Climate. Atmospheric conditions over time affect population health outcomes (Burke et

al., 2018; Watts et al., 2018). While decades of studies exist on the relationship between climate,

temperature, and seasonality with suicide, the evidence is at times contradictory due to the

varying methods, locations, and co-variables included in each analysis. However, the research is

becoming more nuanced, making clearer takeaways possible.

Experts and laypersons alike have long considered seasonality the primary climate-

related influencer on suicide trends (Burke, 2018; Dixon, 2009; Oka, 2015; White, 2015). A

closer look reveals a more complex association. Although suicide rates generally peak in spring

and summer, most people believe that suicides increase during winter months and around

38 holidays. These and other myths have been perpetuated by the suicide research community and upheld by the media (Annenburg Public Policy Center, 2019; CDC, 2013). Even sunlight, which has a well-established evidence-base charting its positive effect on mental health, can act as both a risk and protective factor for suicide (Bjorksten et al., 2005; Lambert et al., 2003; Vyssoki et al., 2015; White et al., 2015).

Researchers have only recently begun to disentangle seasonality in efforts to pinpoint which specific elements contribute to trends over time and across geographic areas (Dixon,

2016). This disentangling proved useful, as it revealed that temperature has a much greater impact on suicidality than season (Burke et al., 2018; Dixon & Kalkstein, 2016; Foundtoulakis et al., 2016; Kim et al., 2019; Lee et al., 2006; Yang et al., 2011; Gao et al., 2019). Generally, increasing ambient temperatures coincide with increasing suicide rates in many countries worldwide (Kim et al., 2019). A one-degree Celsius increase in temperature is significantly associated with a one percent increase in the incidence of suicide, regardless of regional variations (Burke et al., 2018; Dixon & Kalkstein, 2016; Gao et al., 2019).

Decades of longitudinal data on the effect of ambient temperature on suicide rates show that ignoring climate change could result in 9,000 to 40,000 additional suicides in the United

States and Mexico alone by 2050 (Burke et al., 2018). Yet, mainstream narratives about the danger that climate change poses to cities and population health rarely, if ever, include suicide.

Understanding the type of mortality caused by rising temperatures is especially important for planners, as mitigation of climate change and urban heat island effect sit firmly within their wheelhouse.

Altitude. Several studies show that suicide rates tend to be greater in higher altitude areas

(Betz et al., 2011; Cheng et al., 2002; Haws et al., 2009; Kegler et al., 2017; Kim et al., 2011;

Kious et al., 2018; Reno et al., 2017; Steelesmith et al., 2017). Though this is true in many places worldwide, the altitude-suicide relationship is especially pronounced in the United States, where large variations in mean altitude exist across the country (Kios et al., 2018; Reno et al., 2018).

Suicide rates in U.S. counties double as elevation increases from 2,000 feet to 4,000 feet and are highest at 9,000 feet (Love, 2019).

Figure 2. Age-adjusted suicide death rates by state, 2018. Source: Center for Disease Control, National Center for Health Statistics.

There is no shortage of explanations for why suicide rates cluster in high altitude, intermountain regions. Residents in high altitude communities are more socially isolated from one another, less connected to resources and social services, and more likely to own firearms

(Center for Disease Control, 2020; Kious et al., 2018). Recent studies that control for sociodemographic factors such as population density, poverty, divorce rates, religion, and access to mental health care have found that altitude may be independently associated with suicide

(Kios et al., 2018; Reno et al., 2018). However, these studies differ in methodological approach,

40 including how the researchers measure and define altitude, and population sizes are small and wide ranging.

One of the evolving explanations to higher rates at higher altitudes is physiological.

While the suicide-altitude link appears to be stronger than the depression-altitude link, some studies have shown that living in a high-altitude region can affect other mental health conditions, cognitive disorders, and substance use disorders (Kios et al., 2018; MHA, 2020). One possible explanation, which needs further research, is the impact that low oxygen levels have on brain functionality (i.e., hypoxia), specifically its ability to metabolize serotonin (Kanekar et al., 2015;

Kios et al., 2018; Reno et al., 2018). That depression can potentially be made worse by oxygen deprivation is necessary for understanding the full scope of geographically-driven suicide trends.

Socioeconomic and demographic features alone may not be able to explain the large rural-urban variations in suicide rates. Awareness of the many facets of altitude is one example of the nuance needed to develop a comprehensive regional planning approach to suicide prevention.

Air Quality. Studies have also shown that air pollution decreases happiness and life satisfaction, increases annoyance, reduces work productivity, impairs cognitive functioning, and exacerbates mental health conditions such as anxiety and depression. It fluctuates stock markets and worker productivity. It can also trigger individual and collective worry about the future and influence citizens’ opinions of the government (Lu, 2019). Only in the past ten years have researchers begun to explore the link between air pollution and suicide, but enough evidence has emerged to validate the association (Seltenrich, 2018).

An investigation into how air quality affects area-level suicide rates requires many data points, specificity regarding exposure (i.e., short- or long-term), and the ability to control for geographical differences and socioeconomic co-effects. Several studies have attempted

investigations to varying degrees and found that higher levels of air pollutants (e.g., particulate

matter, carbon monoxide, nitrogen dioxide, and sulfur dioxide) are generally associated with

increased risk of suicide and suicide attempts in several geographic locations worldwide,

including the United States (Bakian et al., 2014; Braithwaite et al., 2019; Kim et al., 2018; Lu,

2019). The first U.S. based study found that suicide risk in Salt Lake County, Utah increased in

the spring and fall when both acute and cumulative PM2.5 exposure was high (Bakian et al.,

2014). A recent and comprehensive systematic review and meta-analysis revealed an association

between short-term PM10 exposure and suicide and between long-term PM2.5 exposure and

depression risk (Braithwaite et al., 2019). While these studies have confirmed the air pollution-

suicide association, the “why” remains under-investigated.

Green and Blue Space. Human wellness is inextricably linked to the green spaces (e.g.,

parks, trees, grass, forests, gardens) and blue spaces (e.g., oceans, rivers, lakes) that surround us

(Barton, 2009; Bratman et al., 2019; Britton et al., 2020; Collins et al., 2020; Galea, 2005;

Gascon, 2015; Guite, 2006; Helbich et al., 2018; Lee et al., 2015; McCay, 2019; South, 2018;

Wood et al., 2017). The psychosocial benefits of engaging with green and blue spaces are plentiful, but they vary depending on the type, quantity, and quality of each space and the purpose of one’s interaction with them. (Gascon, 2015; Miles, 2011; Robert et al., 2016). These natural environments promote social cohesion, encourage physical activity and play, provide respite from noise and heat, and can restore wellness and cognitive functioning (Gascon et al.,

2015).

Few studies have assessed if and how the presence of green and blue spaces affect area- level suicide rates. Researchers in the Netherlands recently conducted the first and only cross- sectional, ecological study on whether these spaces could protect against suicide for people

living close to them (Helbich et al., 2018). They found that municipalities with large or moderate

proportions of green space had lower incidences of suicide, but that blue spaces bore little to no

effect on rates. However, different measures of distance, exposure, and type of space yielded

slightly different results. While this study and its findings are significant, more research is

needed to understand what specifically about green space protects against suicide.

The Social and Economic Environment

Economic insecurity. Studies from around the world reveal a clear association between

suicide and economic insecurity. Globally, suicide rates tend to coincide more frequently with

socioeconomic disadvantage, however non-Western cities have shown both lower and higher

rates in low-income areas (Bando, 2012; Fontanella et al., 2018; Hsu et al., 2015). Population

level suicide increases are particularly noticeable following economic recessions and periods of

decreased economic activity, a trend in the United States dating back to the Great Depression

(Granados et al., 2009). At least 20,000 additional suicides are associated with the 1997 and

2008 economic recessions throughout Asia, Europe, and North America (Chang et al., 2013;

Oyesanya, 2015).

Both the experience and anticipation of financial stress directly and indirectly elevate suicide risk (Classen et al., 2012; Kaufman, 2020; Kposowa, 2001; Milner et al., 2013; Reeves,

2014). A recent study found that, in the United States, a $1 increase in the minimum wage significantly decreased suicide rates among adults with a high school education or less, particularly during periods of high unemployment (Kaufman, 2020). Job loss, reduced income, and long periods of unemployment often coincide with additional strains that heighten suicide risk, such as vehicle loss, medical complications, or justice system involvement. The link

between suicide and financial stress has been found among different socioeconomic groups

(Wasserman, 2007).

Financial stress on its own can disrupt a person’s sense of wellbeing. In New York City,

adults with lower household income have a higher prevalence of serious psychological distress

(Tuskeviciute et al., 2019). Financial stress leading specifically to indebtedness and housing

insecurity have been associated with depression, anxiety, and suicide risk in many areas

worldwide (Desmond, 2015; Fowler et al., 2015; Mateo-Rodriguez et al., 2019; Rojas & Stenber,

2015). Studies in both Sweden and the United States following the 2008 global financial crisis

showed an increase in suicides among individuals who experienced home evictions and

foreclosures (Fowler et al., 2015; Rojas & Stenber, 2015). Of the 22,000 Swedish households

studied, individuals who were evicted by their landlord were four times more likely to complete

suicide than those who did not, even after controlling for several sociodemographic factors. In

Spain during this same time, suicide risk associated with evictions increased, especially when

banks adopted a threatening attitude towards homeowners (Mateo-Rodriguez et al., 2019).

Connectedness. The benefits of connectedness through strong social networks are well-

established (Araya, 2006; Barton, 2009; Fullilove, 1996). For individuals and communities, a

sense of belonging and affiliation to place is important to overall wellbeing (Choi, 2018; Miles,

2011). A socially cohesive society works toward the well-being of all its members by fighting exclusion and marginalization, promoting fairness and trust, and fostering an atmosphere of belongingness.5

The association between suicide rates and the levels of connectedness between people and society has been continually affirmed since the publication of Durkheim’s On Suicide. That

5 https://www.oecd.org/dev/inclusivesocietiesanddevelopment/social-cohesion.htm

suicides rates are lower in large cities may point to the benefit of living and interacting in large

and complex social networks (Melo et al., 2014). Connectedness, or the degree to which

individuals and groups are socially close, interrelated, or share resources, leads to increased

positive relationships and lower levels of loneliness and isolation (CDC, 2011). The ability to

have and sustain close, positive relationships is strongly protective against suicide (Kleiman &

Liu, 2014). Many studies emphasize the dominant role that social connections play in suicide prevention, showing that area level measures of social integration and disadvantage directly influence whether an individual thinks about, attempts, or completes suicide (Denney et al.,

2015; Reger et al., 2020; Van Orden et al., 2010). Suicide has been associated with divorce, separation, widowhood, and loss (Milner et al., 2013).

The loss or displacement of a person’s physical or social home (i.e., one’s sense of place and belonging) can greatly affect their mental health. Neighborhood residential instability, and the concomitant feelings it engenders within residents, are significantly associated with depression, anxiety, post-traumatic stress, and other psychosocial stress (Evans, 2003; Fullilove,

1996; Gharib, 2017; Lim, 2017; Miles, 2011). Dr. Mindy Fullilove has studied and written extensively about the psychiatric and other health implications of displacement as a result of systemic racism and institutional power dynamics in community settings (Fullilove, 1996).

Within her analyses, Fullilove aims to describe how place and health are fundamentally defined through a “psychology of place:”

The psychology of place is based on the assumption that individuals strive for a sense of

belonging to a place. This sense of belonging arises from the operation of three

psychological processes: familiarity, attachment, and identity. Displacement ruptures

these emotion connections. The ensuring disorientation, nostalgia, and alienation may

undermine the sense of belonging, in particular, and mental health, in general…The idea

that longing for home can produce illness is quite foreign to modern psychiatric thinking

(Fullilove, 1996).

Fullilove’s ideas about the mental health implications of displacement have become more

mainstreamed in public health action. In 2017, epidemiologists at the NYC Department of Health and Mental Hygiene assessed the association between displacement and healthcare access and mental health among the original residents of gentrifying neighborhoods in New York City (Lim,

2017). Of the 12,882 residents included in the study’s cohort, 23% were considered to have been displaced. These individuals experienced more mental health related hospitalizations than those who were not displaced (Lim, 2017). The study’s researchers concluded that gentrification, a key external driver of displacement, led to increased housing burden, displacement to non- gentrifying areas, and, ultimately, psychological distress. This study adds to an emerging literature base that highlights the association between mental health and displacement via colonization, gentrification, demolitions, natural disasters, and related factors (Choi, 2018; Gong,

2016; Nolen, 2017).

COVID-19 has caused or exacerbated economic stress, social isolation, and health and

mortality inequities across the United States (Reger et al., 2020). Researchers at Stanford

University and Iowa State University have estimated that more than 49,000 additional suicides

could be seen in the United States as a result of COVID-19’s impact on employment and social

isolation (Weems et al., 2020). Suicide prevention policies, funding, and interventions are

needed now in New York City, especially ones focused on influencing systems. Increases in

suicide rates due to COVID-19 may be likely, but they do not have to be inevitable.

Chapter 4: Existing Conditions

Global and National Suicide Trends

By official counts, suicides are greater than all forms of interpersonal and intergroup

violent deaths worldwide and is the only leading cause of premature mortality in the United

States for which rates are not declining (Burke et al., 2018; Cutcliffe et al., 2017).

According to the latest World Health Organization6 and Center for Disease Control data:

• Nearly 800,000 people die by suicide every year. • The global age-standardized suicide rate is 10.5 per 100,000 people. • While the majority of suicide deaths occur in low-and-middle-income countries where 84% of the world’s population reside, high-income countries tend to have higher suicide rates. o Suicide rates in the African, European, and South-East Asian regions are higher than the global average • Suicide remains the second leading cause of death in 15 to 29-year-olds worldwide.

6 Given that suicide is often considered a taboo subject and, in some cases, illegal, suicide is likely underreported in all places irrespective of cultural context or epidemiological proficiency. Out of 183 WHO Member States, only 80 report having good-quality vital registration data that can be used to estimate suicide rates (WHO, 2020).

• The United States age-standardized suicide rate is 14.2 per 100,000 people, which is comparable to the global average.7 • Only 38 countries report having national strategies for suicide prevention.

In the United States, suicide is currently the tenth leading cause of death and is in large

part responsible for the nation’s recent decline in life expectancy (Arias, Kochanek, Murphy, Xu,

2018). U.S. suicide rates have increased by 35% since 1999, making suicide more than twice as common than homicide in every state (Hedegaard et al., 2020; Morgan et al., 2018). Mental health and life satisfaction have been declining over the past two decades, especially among U.S. adults in low socioeconomic households (Goldman, 2018). The mental health of young people is

no better. Between 2007 and 2017, the suicide rate among 10 to 24-year-olds increased by 56%

and tripled among 10 to 14-year-olds (Curtin & Heron, 2019). While the suicide rate for young

people is lower in New York City than the rest of the country, disparities in mental health and

attempted suicides are prevalent. Suicide attempts among NYC high schoolers increased from

eight percent to 11% between 2007 and 2017 and more youth are feeling sadder than they did ten

years ago (NYC DOHMH EpiQuery – Youth Risk Behavior Survey, 2007, 2017).

Middle-aged white men are commonly cited as the nation’s prevailing high risk group, as

they comprise the largest share of suicides. U.S. male adults are nearly four times more likely to

die by suicide than U.S. female adults, though that gap is beginning to narrow (Hedegaard et al.,

2020; Tang et al, 2018). The large number of white U.S. suicides compared to other racial and

ethnic groups is less alarming when one considers that the U.S. population is 76.3% white

(United States Census Bureau, 2020). Middle-aged white men may represent the most suicide

deaths in the United States, but rates among other groups are growing faster.

Suicide rates are on the rise in all U.S. racial and ethnic groups for which reliable rates

7 Lithuania has the highest age-standardized suicide rate at 47.5 suicide deaths per 100,000 population; Barbados has the lowest rate at 0.3.

are known:

In 2017, non-Hispanic American Indian and Alaska Native (AIAN) individuals had the highest

suicide rates for both females and males aged 15 to 44 (Curtin & Hedegaard, 2020). While

overall U.S. suicide rates have increased by 35% since 1999, rates among AIAN females and

males have, respectively, increased by 139% and 71% (National Indian Council on Aging,

2019). The age-adjusted suicide rate for AIAN populations is nearly double the national rate

(22.1 versus 14.2 per 100,000 people), and AIAN females had the highest recent percent increase

than any other U.S. population. Contrary to most other populations where suicide rates peak in

middle-age, AIAN suicide rates peak during young adulthood (Suicide Prevention Resource

Center, 2020). Living in close communities where suicides occur can heighten the risk of cluster

suicides, especially among young people (Substance Abuse and Mental Health Services

Administration, 2018).

Where data is available, suicide rates are often significantly disparate between Indigenous

and non-Indigenous populations worldwide. Forced segregation, land loss, population loss, and

the intergenerational trauma of colonization precipitated by centuries of white supremacy

continue to erode protective factors for suicide in Indigenous and other communities of color

(King et al., 2009; Leenaars, 2006; Pollock et al., 2018). The suicide rates among U.S. AIAN

Suicide rates among young Black boys are also on the rise. Since 2007, the national

suicide rate for Black youth has nearly doubled while decreasing significantly for white youth,

giving the impression of rate stability (Asti et al., 2015; Emergency Taskforce, 2019). In 2019,

the Congressional Black Caucus convened the Emergency Taskforce on Black Youth Suicide and Mental Health in response to emerging research on the increase in suicide rates in Black children and youth (Lindsey et al., 2019). The Taskforce’s report, Ring the Alarm: The Crisis of

Black Youth Suicide in America, revealed that suicide attempts by Black boys and girls rose by

73% between 1991 and 2017. Not only were Black youth under 13 twice as likely to die by suicide compared to white youth, they also engaged with more lethal means. The Taskforce report highlighted that although several Black researchers are interested in further studying this topic, they are less likely than their white peers to be awarded research funding by the National

Institute of Health (Emergency Taskforce, 2019).

Lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) youth also

experience additional stressors that contribute to suicide risk. Queerness in the United States and

globally is often discriminated against and, in some places, illegal. In New York City, nearly a

tenth of NYC high school students reported having attempted suicide sometime within 2016.

That percentage skyrocketed to 32% for youth who reported having also been bullied on school

grounds and who identified as lesbian, gay, or bisexual. In 2017, transgender youth in New York

City were much more likely to report a suicide attempt than cisgender youth (32% versus 9%)

(Yoon et al., 2019).

Focusing prevention efforts on reducing white male suicides would achieve a national

reduction in overall rates. Ample attention has been given to interventions for this group, such as reducing access to lethal means and workforce programs. Construction, for instance, has the highest suicide rate across all industries (Peterson et al., 2018). Its workforce is 97% male,

56.9% white, and 63% middle-age. Many veterans, who have a higher suicide risk than non-

Veterans, choose construction as a career. Construction work is challenging and can lead to long

hours, sleep deprivation, chronic pain, and seasonal layoffs (Construction Financial Management

Association, 2020). These workers absolutely deserve suicide prevention programs tailored to them. However, populations beyond white, middle age males in the United States share an at

times heavier burden of societal risk factors. These data underscore the need for a health equity

approach to suicide prevention, where the most burden receives the same, if not more, attention

as the most deaths.

New York City Suicide Trends

New York City’s age-adjusted suicide rate is more than half the national rate, yet still on

the rise (6.5 versus 14.2).

Figure 5. NYC total reported suicide deaths, 2000-2017. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self-Harm (Suicide), 2017.

Demographically, NYC suicide trends are generally consistent with national trends. Most suicides occur disproportionately among middle-aged, white males preceded by various health, job, financial, or legal stressors (Radcliffe et al., 2019). Yet, out of 11 boys aged 10 to 17 who died by suicide in 2016, five were Latinos (Tang et al., 2019). In general, Latinx and Black NYC residents have a higher percentage of premature deaths compared to white and Asian/Pacific

Islander NYC residents (Brahmbhatt et al., 2019).

Contrary to national trends, the NYC male suicide rate has decreased since 2013, but is still twice the rate of females (Tang et al., 2018, 2019). Suicide rates among females rose between 2006 and 2015. This increase was especially prevalent among white and Asian/Pacific

Islander (API) females but noticeable among Latinas and Black females. According to the Center for Disease Control and the New York City Department of Health and Mental Hygiene, Latina adolescents report higher levels of sadness, hopelessness, and suicide attempts than their female peers of other racial and ethnic groups, locally and nationally.

Geographically, NYC suicide trends over time are difficult to interpret at anything less than the borough level. Suicides take time to certify by a death examiner, so the data are not available to analysts or the public in real time. When available, due to the small numbers at a hyper-local level and sensitive nature of suicide data, described in Chapter 4, neighborhood rates can appear random from one year to the next. Furthermore, external events can influence areas level suicide rates through contagion or cluster effects, such as when high profile celebrities die by suicide (Fink et al., 2018; Gould, 2001). Multiple years and confidential data points are thus needed to tell the full story of suicide in New York City, to which only a few entities have access.

Some area level trends have been revealed. Between 2000 and 2014, suicide rates increased in Manhattan and Queens, but remained otherwise stable (Protacio & Norman, 2016).

Figure 7. NYC age-adjusted suicide rates by community district of residence, multiple years. Source: New York City Department of Health and Mental Hygiene, EpiQuery Mortality Data, Intentional Self- Harm (Suicide), interactive mapping tool. # data are suppressed due to imprecise and unreliable estimates.

Certain community board districts appear to have continually higher rates than the citywide

average. This is particularly noticeable over the years in northern Queens. Some districts have

experienced double, or nearly double, the citywide rate, such as Bronx community board district

eight (Fieldston, Kingsbridge, Marble Hill, North Riverdale, Riverdale, and Spuyten Duyvil) in

2007, 2012, and 2017.

The administrator of NYC suicide death data, the NYC Department of Health and Mental

Hygiene, has published several valuable reports on suicide trends. But epidemiologists and urban

planners are bound to ask different questions of the data. None of the DOHMH published

reports, for instance, account for population changes over time, housing affordability,

displacement, air pollution, or the built environment. A deeper look at NYC suicide data

collection and analytic processes are described in Chapter 5.

The Evolution and Current State of Suicide Research and Prevention Efforts

Public Health Model

Many studies on suicide, and efforts to address it, emerged throughout the 20th century

(Marsh et al., 2016; Marsh, 2010). Progress in research and treatment strategies, coupled with successful advocacy campaigns, provided motives for more focused and resourced attention on prevention in the United States. In 1958, the nation’s first suicide prevention center opened in

Los Angeles, California in a condemned building on the Los Angeles County General Hospital grounds (Shneidman, 1965). In 1967, the National Institute for Mental Health, a federal mental health research agency, established the Center for Studies of Suicide Prevention. Sixteen years later, the Center for Disease Control established a violence prevention unit with a specific focus on understanding and preventing youth suicide, which was on the rise (Office of the Surgeon

General, 2012). The field of suicidology and the number of organizations dedicated to it has only

grown since then.

Yet, U.S. suicide rates have failed to decrease over time, largely due to the subject’s lingering stigma and multi-layered contributing factors, challenges with accurately capturing and standardizing data, and the frequent shifting of resources to higher mortality causes. For instance, while the suicide rates in New York City have increased annually by an average of 2.3 % since

2008, the total recorded number of suicides in 2017 was 479, representing the sixth highest cause of premature death in the city at the time of this writing, and thus deserving of investigation.

When suicide does receive attention, efforts to track, analyze, and respond to it generally

conform to the public health model of disease prevention. Such a model uses a population-based

approach, which prioritizes the monitoring of suicide on a large scale (it focuses on rates and

groups of populations rather than individual incidences of suicide in a given geographic region

over time). Based on continuous surveillance and systematic data collection and analysis of death

data, local public health officials are to interpret and report trends, identify risk and protective

factors, select appropriate interventions, and implement the interventions through a

comprehensive suicide prevention plan (CDC, 2012; WHO, 2014). The mental health divisions

of local public health agencies are usually responsible for monitoring and preventing suicide in

their respective jurisdictions, consistent with the dominant framing of suicide as a psychological

problem.

Many resources exist to help municipalities monitor suicide and develop prevention

plans. The Suicide Prevention Resource Center, the nation’s only federally supported suicide

resource center, acts as a convenient single point of access to the most up to date guidance on

suicide prevention. While the Suicide Prevention Resource Center offers a wide range of

emerging research, best practices, training opportunities, leadership guidance, and culturally

appropriate interventions, navigating these resources can be overwhelming. Dr. Jerry Reed,

Senior Vice President for Practice Leadership at the Education Development Center, which

operates the Suicide Prevention Resource Center, recommends that local authorities at a

minimum consult two essential documents: The CDC’s Technical Package of Policy, Programs,

and Practices for Preventing Suicide and the National Action Alliance for Suicide Prevention’s

Transforming Communities – Key Elements for the Implementation of Comprehensive

Community-Based Suicide Prevention. These documents provide just enough information to help public health agencies and other authorities establish an infrastructure and framework for tacking suicide at both a population and community-based level.

Even if local authorities do not list suicide prevention as a stated priority, they need to at least know suicide’s well-established risk and protective factors. A public health approach groups risk factors for any health outcome into individual, interpersonal, community, and societal level categories. Doing so allows authorities to implement universal or targeted interventions, informed by a five-tiered conceptual framework for public health action (Frieden,

2010). At the base of the pyramid are interventions directed toward socioeconomic factors, such as clean water or economic policies (i.e., ones with high population impact). At the top of the pyramid are interventions directed toward individuals, such as clinical care, counseling, and education. Suicide risk factors and their related protective factors follow this same formula.

Well-established suicide risk and protective factors for general populations include (Stone et al.,

2017)

• Individual level

Risk factors: Previous suicide attempt, history of mental illness, history of substance

misuse, feelings of hopelessness, feelings of isolation, and other health conditions

(physical disability, illness, or other biological determinants). Research has established a

strong link between suicide and depression, though most people living with mental illness

do not die by suicide and having a mental illness alone is not a risk factor for suicide

(Bradvik, 2018).

Protective factors: Clinical care and treatment, crisis hotlines, and hospital follow-up

programs.

• Interpersonal level

Risk factors: High-conflict relationships, exposure to violence, discrimination, bullying,

lack of social support, stress related to work or finances, a recent loss (relational, social,

or financial), and a loss of a friend or family member to suicide.

Protective factors: Economic supports, psychosocial education, and skills development

training.

• Community level

Risk factors: Barriers to accessing healthcare and social fragmentation.

Protective factors: Strategies to reduce provider shortages, mental health insurance, and

connectedness programs.

• Societal level

Risk factors: Stigma associated with help-seeking behavior, mental illness, and suicide,

media misrepresentation of suicide and unsafe reporting practices, and availability of

lethal means.

Protective factors: Means restriction, gatekeeper trainings, and media reporting

guidelines.

These risk and protective factors are compulsory components of local research agendas and prevention plans, for good reasons. However, the Center for Disease Control’s Preventing

Suicide: A Technical Package of Policy, Programs, and Practices and the National Action

Alliance for Suicide Prevention’s Transforming Communities: Key Elements for the

Implementation of Comprehensive Community-Based Suicide Prevention guidelines, along with other well-cited guidance documents, exclude many of the risk factors described in this thesis’s literature review.

The well-established risk factors of suicide are well-established for a reason: they have obtained evidence-based status through sustained attention, resource-allocation, and research prioritization over extended periods of time. In reality, risk factors vary in type and severity across communities and populations. It is possible to develop, through interdisciplinary collaboration, interventions that address the political-institutional mechanisms responsible for creating, worsening, or ignoring structural risk factors.

Chapter 5: Qualitative Research Analysis

Description of Qualitative Analysis

I spoke with and interviewed experts in the fields of suicide prevention, public health, urban

planning, urban design, engineering psychology, architecture, geography, and law about the

opportunities and challenges for interdisciplinary alignment around suicide prevention. Each conversation informed various aspects of this thesis. I selected four primary interviews for full

qualitative analysis based on their professional expertise, level of knowledge of the subject, and

willingness to participate:

• Scott Gabree, PhD, Engineering Research Psychologist at the Volpe National

Transportation Systems Center

• Elizabeth Hamby, Director of Take Care New York (TCNY) at the New York City

Department of Health and Mental Hygiene

• Jerry Reed, PhD, Senior Vice President for Practice Leadership at Education

Development Center

• Catherine Stayton, Dr.PH, MPH, Director of the Injury and Violence Prevention Program

at the New York City Department of Health and Mental Hygiene

Their biographies, which the reader would benefit from reviewing prior to reading this

chapter, are listed in Appendix B. Interviewees represent local and national government and

research institutions, though their opinions as expressed are their own. I was unable to interview

representatives from community based or advocacy organizations, which is a key limitation to

this study. That said, I was able to delve more deeply into the role of institutional actors in

suicide prevention and how political structures can aid or abate progress.

Several themes emerged across the interviews related to data, community health and engagement, and interdisciplinary collaboration. These themes are described through four key findings:

1. Suicide prevention’s focus on individual risk, combined with widespread

misunderstanding of what constitutes mental health, are ever-present and thwarting

progress.

2. Considerable challenges and opportunities exist with respect to suicide data transparency,

education, usage, and partnership.

3. Community planners and physical planners have unique roles to play in suicide

prevention, provided they commit to health equity work.

4. Interdisciplinary collaboration between mental health experts, urban planners, community

groups, and suicide survivors is needed to slow rising suicide rates across the United

States.

Some sub-findings exist, which are indicated in italics in their respective sections.

Presentation of Qualitative Analysis

1. Suicide prevention’s focus on individual risk, combined with widespread

misunderstanding of what constitutes mental health, are ever-present and thwarting

progress.

Although suicidology has evolved beyond its pathological beginnings, prevention efforts remain predominantly individual and mental-healthcare focused. This thesis presents a strong case that emerging research from other disciplines deserves consideration by suicide prevention strategists. Dr. Jerry Reed, one of the nation’s leading suicide prevention experts, agrees that the field is ready for a broader framework:

A psychologist or a psychiatrist, and I think the [suicidology] field, in general, has

viewed suicide as an issue between a patient and a therapist. I'm a social worker. I see

suicide as an issue between an individual and his or her environment, which may include

their mental health, but it's not exclusively mental health. So for me, environment

matters. That's why I subscribe to a public health approach [to suicide prevention]. My

perspective is that there are risk and protective factors related to environment that, if

addressed, could save lives (J. Reed, personal communication, October 16, 2020).

Despite their public health framing, suicide prevention interventions that focus on

individuals outpace those that target structural or societal change. This is partly due to the

research bias that has allowed individually-based interventions to amass evidence over time (i.e.,

what has been proven to work will get promoted the most). Additionally, public health agencies

that monitor and respond to suicides within their jurisdictions often filter most of their work

through a chronic disease prevention lens. This individual behavior change approach is “at odds

with the whole-person health and healthy community framework” that the New York City

Department of Health and Mental Hygiene (DOHMH), for example, is striving to achieve (E.

Hamby, personal communication, October 21, 2020).

The result of overfocusing on individual behavior rather than structural change in suicide

has coincided with an increase in suicide rates. Catherine Stayton, Director of the Injury and

Violence Prevention Program at the DOHMH, describes the missing link in prevention efforts:

Everywhere, there is a [suicide] trend line that defies a biomedical story because we've

thrown a toolkit of medications at depression and up it goes. We have worked our fingers

to the bone on destigmatizing mental health issues and treatment and up it goes. So,

we’re missing a link when you take a step back and think population level, which is very

distinct from thinking clinically and individually about the risk for suicidal ideation and

behavior. If you go back to rudimentary epidemiology, which involves person, place, and

time, it’s looking to me like one of the missing links is place context (C. Stayton,

personal communication, November 24, 2020).

Suicide prevention’s emphasis on individual interventions not only ignores place context, it also does not appear to be working. Any social science professional will agree that people are inextricably bound to and informed by their environments. This statement is true in urban planning as much as it is in public health. Taking a step back and observing suicide from a population health perspective (i.e., person, place, and time) may help disciplines come together to better understand the scope of the problem. According to Stayton, many public health success stories have followed this approach, from tobacco cessation campaigns to Mothers Against

Drunk Driving. Efforts to reduce access to lethal means of suicide and increase social connectivity also follow this approach, which has regional and temporal significance:

When you're rural and not connected is when risk seems to increase, and we do know the

literature is really robust on rural suicide being higher than urban suicide, though this

didn't used to be the case. It was when people left the rural areas and went to the urban

areas to look for opportunities that they lost connection and so rates were higher in urban

areas. You no longer knew people and you came from a small rural community where

you had that. So, the first wave of people to the urban centers was actually contributing to

an increase in suicide. Now that we have adapted to urban settings, an accommodation

that has been valuable, I think, to suicide, it’s rural communities that have higher rates.

This is because of the loss of connection, the changed social environment, and the

degradation of rural families that have left people without a lot of hope or opportunities

(J. Reed, personal communication, October 16, 2020).

Urban development’s effect on regional suicide rates is a clear example of urban planning’s influence on suicide. When Reed was writing his dissertation, his research indicated that 60%-70% of the regional variation in suicide rates had to do with three things: (1) homes that owned a gun, (2) people per square mile, and (3) the divorce rate of the state. Prevention strategies often tackle lethal means and interpersonal relationships, but they rarely, if ever, meaningfully consider population density. The problem, according to Stayton, is that while experts have taken a public health approach to suicide prevention, it has “stayed in the lane of mental health as public health,” ultimately limiting its potential partnership base. Suicide has become an extension of individual mental health risk, rather than a multifactorial health outcome requiring multifactorial analysis (C. Stayton, personal communication, November 24, 2020).

Public health is as siloed from public mental health as urban planning is from both fields.

This theoretical and practical segregation leads to disconnected priorities and funding streams, impacting neighborhood conditions throughout the city. Communities within these neighborhoods often do not separate physical health, mental health, and the planned environment in the same way professionals do. Elizabeth Hamby, Director of Take Care New York,

DOHMH’s blueprint for community health, puts it this way:

One of the things that's important for us as professionals to keep in mind, particularly in

public health, is that while we really like to keep physical health and mental health

separate, for communities it's the same. Communities would tell us over and over and

over again that they need more support when it comes to mental health. A lot of times

they would talk about things related to services, but also there were crises in their

communities related to trauma, grief and loss, and their overall sense of well-being (E.

Hamby, personal communication, November 10, 2020).

Trauma, grief, loss, and compromised wellbeing have associations with overall community health and area-level suicide rates and incidences. Suicide prevention strategies that treat an

individual as separate from community, rather than an extension of it, are doomed to fail.

Guidance documents, like the CDC’s Preventing Suicide: A Technical Package of Policies,

Programs, and Practices, do a fine job of telling the socio-environmental story of suicide, but do

not go far enough upstream in their proposed solutions.

Finally, mental health’s central role in suicide prevention presents both challenges and

opportunities. On the one hand, potential allies may find it difficult to comprehend suicide

outside of its mental health narrative, which is a useful and not insignificant framework. On the

other hand, over-associating mental health with suicide will continue to delay progress towards

structural change. The rail industry’s trajectory of incorporating suicide into its overall injury

prevention work provides an example of this tension:

I have dealt with people [in the rail industry] believing that there's nothing you can do [to

prevent suicides]. They think, what the heck do you expect us to do about this? We’re rail

professionals, not mental health experts. That was locked in as the full mentality of the

rail industry for decades. But it's irresponsible to ignore a third of the deaths that

happened on the rail system. It wasn't until the last ten years or so that we finally started

to have conversations and find allies who were in agreement that we should be doing

something different. So [the mentality] is slowly starting to change, but I think in every

rail organization across the country there are individuals who still wonder, why are we

involved in a mental health thing? I'm here to move trains and to get people from point A

to point B. If somebody is fully aware of the dangers and places himself in front of the

train, there's nothing that I can do to prevent that (S. Gabree, personal communication,

October 9, 2020).

Mental health should not be taken out of the suicide prevention equation. But urban planners must do a better job of understanding, explaining, and fixing the role that systems play in community mental health outcomes. Neighborhood structural conditions, and the political forces that control them, contribute significantly to a person’s sense of wellness. Sometimes wellness is defined and charted clinically (e.g., through depression rates or psychiatric hospitalizations), but many times it is not. Too often, suicide is also defined and charted clinically. Ultimately, suicide and wellness are about livability, which planners shape through their work. A more upstream approach to addressing matters of livability, one targeting political structures and policies, is needed to reduce suicide rates.

2. Considerable challenges and opportunities exist with respect to data transparency,

education, usage, and partnership.

Precise suicide data are hard to access and easy to misinterpret. If varied public and private stakeholders are to share the responsibility of reducing suicide rates, as this thesis proposes later, then transparency, education, and partnership around the data are fundamental. This process is much easier said than done and begins with an understanding of how suicide deaths are officially determined and analyzed.

In New York City, the owner and assimilator of all cause of death information is the

DOHMH Division of Epidemiology, specifically its Office of Vital Records and sister office,

Vital Statistics. The DOHMH Office of Vital Records receives death information from the Office of the Chief Medical Examiner of the City of New York, which undertakes a regimented

66 investigative process to determine the cause and manner of all deaths in the city. Stayton, who collaborates extensively with the Office of the Chief Medical Examiner on NYC injury-related deaths, shared that suicide is the highest manner of death certification to achieve because the

Office of the Chief Medical Examiner must confirm that the cause of death was a deliberate intent to self-harm (C. Stayton, personal communication, November 24, 2020). According to

Stayton, deliberate intent is provable, but can take time:

My understanding is [suicide certification] happens quite readily when there are things

like notes at a scene or a deep record attached to the decedent that tracks to suicidal

behavior and ideation. And then I think there are some kinetic, physiological, and

anatomical signals at autopsy when there’s been a self-directed injury. But that is the

science of the medical and legal investigative workforce at the Office of the Chief

Medical Examiner. And I have come to have extraordinary faith, absolute intrigue, and

high, high, high regard for how that office makes those assignments.

The science of the Office of the Chief Medical examiner may be sound, but this thesis has demonstrated that some socio-environmental risk factors for suicide are neither widely recognized nor easily traceable. Signs of suicide deaths, such as notes or mental health records, are less typical than they are dominant. Mental health records, for instance, are dependent upon access to services, which are inequitably distributed. Furthermore, signs of suicide deaths may depend on cultural norms of which medical examiners may not be aware.

Because the bar for suicide certification is so high, suicides take longer to certify than other manners of death. If that bar is not reachable, says Stayton, then “it is not uncommon for the Office of the Chief Medical Examiner to designate the death undetermined and it will never make the books as a suicide. It might have some signals of one, but it won’t get classified as

67 such” (C. Stayton, personal communication, November 24, 2020). Given the challenges associated with investigating and classifying potential suicide deaths, some U.S. jurisdictions have created “suicide fatality review” teams. Suicide fatality review teams act as partners to medical examiners, supplementing their investigations with community reviews and other strategies to find systemic patterns. In 2019, New York State received a grant to establish its first suicide fatality review team serving four counties (Erie, Onondaga, Suffolk, Westchester). At this time, New York City does not have a suicide fatality review team or analogous review process in place (Bernstein, 2020).

Under-classification of suicide deaths has real-time implications for urban planning. In the rail industry, a subspeciality of transportation planning:

Rail data are intentionally hard to get because of the law. If there is an incident, and a

[rail company] hasn’t heard back from the coroner yet, they can’t say it’s a suicide. So,

they are going to put it in their system as a trespass until it gets updated. The challenge,

though, is that the newest data are always going to be trespass heavy and suicide under-

counted because they’re waiting for medical examiner reports to come back. We’ve tried

so many different ways to [work with rail companies to capture suicide data] without

changing the law, because it can take six months to get a determination. But then that’s in

the system as a trespass event for six months (S. Gabree, personal communication,

October 9, 2020).

Proactively addressing potential suicide deaths while allowing the death certification process to unfold is a challenging task. There are economic and emotional costs to suicide fatalities in the public realm that require attention in their immediate aftermath. Rail and subway suicides cause significant service delays and are consequently costly. They can have a profound emotional

68 impact on rail employees, especially train operators, at times leading to post-traumatic stress disorder (Sawada et al., 2017). Suicide prevention and injury prevention activities often, but do not always, overlap. As such, strategies to mitigate rail or public realm (e.g., bridge and building) suicides cannot simply be paused until deaths are officially certified.

In New York City, once suicide deaths are officially certified the data are then passed on to the DOHMH where data scientists develop research agendas, analyze the data, and disseminate information based on their analyses (C. Stayton, personal communication,

November 24, 2020). Often, analysts consult other datasets that highlight nuances within the topic they are studying. For example, the NYC Youth Risk Behavior Survey surveys NYC public high school students on a variety of health-related behaviors, including how often they feel sad or if they have ever thought about or attempted suicide. While the NYC Youth Risk Behavior

Survey is self-administered and collected every two years, and therefore less reliable than other datasets, it provides essential context to the mental health behaviors of New York City’s young people. Multiple datasets can complicate or delay an analysis, but they are usually needed to paint a fuller picture of a problem, especially for urban planners.

Members of the NYC public can access and interpret DOHMH-vetted suicide information in several ways: (1) review the agency’s suicide-related publications, (2) download and analyze primary suicide data from its EpiQuery database, or (3) submit a formal request to the DOHMH to conduct or partner on a more advanced analysis (C. Stayton, personal communication, November 24, 2020). DOHMH publications are meticulously crafted, thanks to the high level of expertise of the agency’s epidemiologists and provide a good starting place. In the past three years, the DOHMH has released four suicide death publications, focusing on trends related to gender, race, methods/means, and location (of decedent residence). While these

documents are tremendously useful, they are limited in scope, presenting person and place information without context. Their content can be confusing to laypeople and may appear contradictory from one publication to the next, depending on the years included in the study and type of analysis conducted. Furthermore, the authors stop short of explaining their findings, which can lead to speculation or misinterpretation of the data.

For example, a DOHMH Epi Data Brief published in 2016, Suicides in New York City,

2000 to 2014,8 presents a choropleth map of United Hospital Fund neighborhoods color-coded

by four categories of Federal Poverty Level. The base map is overlaid with the count of suicides

in each neighborhood. The authors’ takeaway is that between 2012 and 2014, neighborhoods

where 10%-20% of residents, or the map’s second wealthiest category, had an income below the

Federal Poverty Level had the highest rate of suicide; neighborhoods where less than 10% of residents had an income below the Federal Poverty Level had the lowest rate. This information,

however interesting, appears inconclusive without an understanding of each neighborhood’s

population, demographic profile, and built or other characteristics.

Simply put, the DOHMH suicide publications are not the most accessible documents,

even for someone well versed in public health analysis. More importantly, presenting the data

without a strategy to engage communities in interpreting them, or a plan to identify

neighborhood-level risk factors, misses an opportunity to educate the public and partner on

solutions. According to Stayton, it is important that people know that suicide data beyond these

reports can and should be accessed:

The [suicide] data have high protections around them, but they are there. We've gotten

much better at creating access points, but death data is highly protected, and it is

8 https://www1.nyc.gov/assets/doh/downloads/pdf/epi/databrief75.pdf

important to honor those protections. Stewards of the data can only go so deep. It is up to

the researchers that have envelope-pushing questions to knock on doors loudly to get

access to the data. And sure, there are protocols and processes, and it can take a while and

government is famous for bureaucratic processes that are not swift. So, it starts to feel

like it's an obstructed process, but it's not. It's just regulated. And you’ve got to have the

will, the tenacity, and a profoundly purposeful and focused question to make sense out of

the data. Discoveries happen when you start to see other potential patterns. But you really

need some messengers and champions helping stakeholders know that (C. Stayton,

personal communication, November 24, 2020).

These publications, therefore, offer a starting point for understanding baseline NYC

suicide trends. Community members, planners, and other stakeholders are needed to interpret or

ask questions of the trends. Communities impacted by suicide deserve robust investigations into

the ground-level, socio-environmental risk factors that may have contributed to their area’s suicide rate, uptick, or cluster in a given point of time. The DOHMH should not be held

singularly accountable when geographic or sociodemographic clusters emerge. Because of the

protected nature of suicide data, it would be sensible for relevant City agencies to partner on

understanding and addressing suicide, with the DOHMH as the data lead. Otherwise, data

requests by individual researchers with an interest in this topic could take months, if not years.

Profoundly purposeful questions, after all, can generate profound change. For example,

the United States Federal Railroad Administration had been requesting that railroads remove

suicides from reporting until June of 2011 (S. Gabree, personal communication, October 9,

2020). Reform happened only through persistent questioning and advocacy:

We have no knowledge of any [railroad] suicide event prior to June of 2011. So that

speaks to the “there's nothing we can do about it” mentality that the railroad industry had

until about ten years ago. People pushed hard for rule changes in part because engineers,

members of railroad unions, couldn’t work for six months because they couldn't get over

the experience [of seeing someone die by suicide] while the [Federal Railroad

Administration] claimed that event never happened. That was not cool to them, so the

Federal Railroad Administration needed to find a way to record [suicide-related

incidents] so they can understand what's going on (S. Gabree, personal communication,

October 9, 2020).

If suicide was not difficult to categorize or discuss, the Federal Railroad Administration would

not have excluded rail suicide events from its database for so long. The fact that suicide is one of

the top two causes of train-related deaths in the United States is only known because of the

Federal Railroad Administration systematically began to track and prevent them (S. Gabree,

personal communication, October 9, 2020). These efforts are beginning to pay off. Since 2011,

the Federal Railroad Administration and United States Volpe Center have developed six key

research areas to understand suicides, published countermeasure research, and co-formed the

Global Railway Alliance for Suicide Prevention,9 an international working group on rail suicide

mitigation efforts.

The imperative to responsibly share data and collaborate on research agendas also

extends to suicide attempts and self-injuries. Calls to 911 can provide valuable information on where people self-injure throughout the city, which could illuminate specific environmental risk or protective factors for suicide. Dr. Eric Vaz, a geographer and the Graduate Program Director

9 https://www.volpe.dot.gov/rail-suicide-prevention/grasp

for the Master of Spatial Analysis at Reyerson University, has conducted research on the land

use patterns and environmental characteristics of suicide and self-harm in Toronto, Canada.

Vaz’s research demonstrates a strong link between gender differentiation, land use cover, and self-harm. It further shows that the more fragmented a land use structure is, the more it welcomes or promotes suicide ideation. Cohesiveness of landscape structure, according to Vaz, is a dominant part of self-harm ideation (E. Vaz, personal communication, October 1, 2020).

Vaz’s work is revelatory, showing the depth of analysis that can be done when researchers outside of the public health or clinical professions ask profoundly purposeful questions. However, for Vaz, navigating the bureaucratic intricacies of accessing and investigating suicide data was time consuming and discouraging. It took him close to five years to obtain and analyze the data and another several months for peer review. By the time he was finished, Toronto had already developed and published a suicide prevention plan and Vaz had moved onto less hindered topics (E. Vaz, personal communication, October 1, 2020).

Suicide data must remain protected. However, stewards of the data, as Stayton pointed out, can only go so deep with their analyses. Urban planners are trained to ask certain contextual questions that epidemiologists are not. A progressive suicide research partnership between the two fields would only result in richer data analyses.

3. Community planners and physical planners have unique roles to play in suicide

prevention, provided they commit to health equity work.

Participatory community planning

Although most planners would acknowledge their profession’s ability to develop or disrupt healthy environments, they may be surprised to learn that their unique skills can add value to suicide prevention efforts. Inequities of all kinds show up in New York City’s housing

73 policies, economic development plans, distribution of parks and green space, and public transportation priorities. These inequities affect individual and collective wellness, as well as suicide rates, from one census tract to the next. Health inequities follow similar geographic patterns across the city, affirming the adage that zip codes matter more than genetic codes with respect to health outcomes (Graham, 2016; Weinstein et al, 2017). In other words, where you live influences not just how you live, but also how you die.

Advocates, civic institutions, Community Boards, and neighborhood organizations have always sought to influence public and private urban development practices, which frequently reinforce health disparities. According to Hamby, these, and other stakeholders, including NYC agencies, often lack the necessary information and coordination required to prioritize health equity in their planning processes. A withholding of information by those who have it should not always be construed as intentional. As noted in the previous section, health data can be reasonably confidential and easy to misinterpret. Discerning the relative importance of the varied contributors to suicide, let alone specific spikes in area-level rates from one year to the next, takes vigorous detective work. General health, with its multi-contributing factors and cultural nuances, is just as intricate.

When I came to the health department to work on urban planning projects, I was getting

to know all these epidemiologists and longtime public health professionals and becoming

deeply familiar with the conversation about health equity. I sat one of these

epidemiologists down one day and said, okay, so what does create health? And she

laughed because, well, there's not an easy answer to that. It's a lot of different things. It's

where you live. It's how old you are. It's your life experience. It's systems, structures, and

policies. But I realized that question was a generative question. So, when we go out and

we talk to communities about health in the context of neighborhood planning, that

question is our starting point (E. Hamby, personal communication, October 21, 2020).

Community planners understand the benefits and tradeoffs of different methods for community engagement. They are expected to know and navigate the interests and inner

workings of varied public and private stakeholders. They are skilled at finding, assembling, and

communicating numerous data points down to the census tract level. Simply put, planners can be incredibly useful in rallying partners with different urban development pursuits around a common goal.

That said, a collaboration of planners, community stakeholders, and health experts cannot

expect a comprehensive answer to “What creates health?” in a few visioning sessions. As Hamby

notes, this question is a starting point. When planners are presented with a health-related

challenge, one thing Hamby helps them ask is “Why?” at least five times in different ways to get

to root causes. Only then can planners support communities in undoing the structural inequities

that created or contributed to the challenge to begin with. This process to understand what

creates health must be one that is co-generative rather than extractive. Planners are uniquely

positioned to either assist with or thwart authentic community engagement around all manners of

topics, including health.

All of this is contingent upon the NYC Department of City Planning and adjacent agencies incorporating clear and comprehensive health goals into their initiatives. The neighborhood planning process, an outgrowth of Mayor de Blasio’s affordable housing plan, is one recent example. An attempt to balance neighborhood rezonings with community engagement, neighborhood planning has been taking place in key areas across the city (NYC

HPD, 2020). The process gathers City representatives, local residents, elected officials, and

neighborhood organizations in each area to learn from one another, create a shared vision, and

generate and integrate a plan into the formal zoning review process (NYC DCP, 2020). Although

elements of community health are often articulated in neighborhood planning vision sessions,

mental health remains elusive. Two Bronx Department of City Planning planners noted that while “social cohesion,” an important component of mental health, is frequently discussed in vision sessions, it can be loosely defined (personal communication, October 30, 2020). Concepts such as social cohesion10, collective efficacy, and social capital are widely studied and

referenced, but they are defined and manifest differently from one community to the next. How

one measures and incorporates something like social cohesion into a local plan can also vary.

Without a clear method for defining and measuring social cohesion, an extension of community

wellness, it is no surprise that planners and community members are looking for guidance.

Hamby offers one that might be considered:

DOHMH measures social cohesion through I think a four question sequence in the

Community Health Survey. That’s our best measure right now. If you talk to people,

almost everyone will agree that’s inadequate. But social cohesion is really hard to

measure and define because it includes everything from civic participation, whether it’s

voting or volunteering, to your sense of trust and safety in your community, to your sense

of your community’s ability to effectuate change. It’s nuanced. An interesting future

opportunity would be to think through an eco-social model of social cohesion. Meaning,

what kind of physical, institutional, and personal factors exist in an ecosystem that we

can observe through ongoing conversations rather than look for a single indicator or

index to assess it (E. Hamby, personal communication, October 21, 2020)?

10 DOHMH defines social cohesion as shared values and trust among neighbors (Take Care New York, 2020).

Co-generating an eco-social or similar model of social cohesion can dovetail with efforts to improve suicide research and help planners operationalize mental health planning in practice. But bringing stakeholders together to define and envision healthy, inclusive communities only works if governments are held accountable to the outcome. When co- generated plans are ignored or foiled by political interests, participants in the planning process are likely to feel frustrated and helpless. Failed plans meant to improve community mental health could actually worsen it as a result of institutional betrayal (Smith & Freyd, 2014).

The fatal flaw of several of the de Blasio administration’s neighborhood plans, according to Hamby, was that decisions ultimately came down to one City Council Member who had political points to earn or leverage. For many community members, not being able to see the outcome of their participation in a meaningful way undermined the very process meant to elevate their voices. Community engagement and government accountability begin and end with the narrative that communities want to explore. Good health equity planning requires government planners and health officials to listen to communities, if not follow their lead:

Ten years ago, teen pregnancy data in the Bronx was off the charts. A total outlier from

the rest of the city and a huge issue. So, our colleagues went into the community saying

that our data are telling us that we have a real problem with teen pregnancy. And the

community stakeholders said okay, we hear you about the teen pregnancy, but what are

you going to do about the rats? And there's no causal pathway between rats and teen

pregnancy, but there's a larger context of a sense of neglect by government, by systems,

that is an important part of both of those. And I think with something as specific as

suicide, it's not necessarily likely that every person you meet has had a personal

experience with suicide. But there are larger issues that are related to [suicide] risk and

protective factors that maybe they do have a direct experience with, and I think you can

build from there (E. Hamby, personal communication, October 21, 2020).

While it is true that not everyone has had a personal experience with the topic, many have

(Cerel et al., 2018). Public health and urban planning professionals do need to understand root

causes of health inequities and take communities’ leads in prioritizing them. The topic of suicide,

however, does not always need to be introduced through related issues. A strong partnership

between planners, epidemiologists, community leaders, and other stakeholders is needed to drive

the strategy for understanding suicide and its related forces. Such strategies will and should look

different from one community to the next, whether it is tackling suicide head-on or through other

pathways.

Physical planning and placemaking

Urban planners can contribute to suicide prevention in concrete ways beyond

participatory community planning. New York City, for example, presents individuals in crisis

with innumerable jump sites that are often easily accessible. Where participatory community

planning can focus on root causes and solutions to unlivable situations, physical planning and

placemaking can help, for instance, restrict access to lethal means. Stayton and her fellow

researchers approach suicide from an injury-prevention standpoint. In 2012, they published a

report on self-inflicted injuries in New York City, noting the influence of environmental factors

on NYC suicide rates and methods. One of the report’s recommendations was for policymakers to allow barriers in NYC buildings to prevent fatal jumps.

Given that the proportion of suicide deaths in New York City due to jumping from a high place is eight times the proportion nationwide, environmental modifications on buildings and bridges seems a worthwhile local intervention. However, specific building typologies or cluster

locations attached to suicide incidences did not emerge from DOHMH’s 2012 research. Certain

analytic challenges exist, such as whether a suicide occurred from a window or a roof, which can

be hard to determine if there are no witnesses or a note left at the scene (C. Stayton, personal

communication, November 24, 2020). Furthermore, a suicide from a bridge could be misclassified as a drowning (Gray et al., 2014).

Nonetheless, these challenges and previous findings should not deter researchers from

picking up where Stayton and her team left off. In fact, an interdisciplinary team of researchers,

equipped with a decade of new data, is precisely what is needed to bring potential patterns to

light. Acts of suicide can be impulsive or occur in moments of crisis and attempters are often

young or under the influence of substances. Structural interventions merely provide extra

protection for individuals who are in vulnerable states or apprehensive about death. If certain environmental modifications or building codes can safeguard against injuries, including suicide, it is incumbent upon planners, builders, and developers to take them into consideration:

If you ask me, the urgency of the increasing [suicide rate] trend line [coincides with the]

sensibility of creating a universal protective response when there are hotspots. One can

envision this as somewhat equitable in that it's about the structures that are risky for

everybody and putting barriers that will protect everybody. Now, I need to acknowledge

that with place-based interventions not everybody is in every space. So, it's privileging or

protecting only those that are in those spaces and using the spaces. But the theory would

go that everyone is equally protected when you put environmental modifications to work.

It is my understanding of them that they are protecting everyone in a particular space (C.

Stayton, personal communication, November 24, 2020).

Environmental modifications for suicide prevention work, but there are opportunity costs and benefits to them. Bridge and subway suicides are often sensationalized in the media, garnering a wide range of attention from local residents, advocates, and elected officials.

Residents of San Francisco, for example, have engaged in an intensely contentious and at times hostile debate over a suicide barrier on the Golden Gate Bridge for over 70 years (Caulkins,

2015; Friend, 2003). The desire to preserve the architectural integrity of the Golden Gate Bridge have clashed with advocacy efforts to install on it a suicide barrier. But after decades of being the number one suicide destination in the world, residents of San Francisco elected to change the bridge’s legacy and invest in a suicide barrier.

Unlike in San Francisco, bridge and subway suicides are thinly spread throughout New

York City and barriers can be prohibitively expensive. In these cases, a partnership between

City, State, and federal actors may be most strategic. Take rail and transit suicides, for instance:

Rail suicide in the United States is about half a percent of all suicides. If we look at just

subway systems, there's something like between 60 and 85 or so a year. But I think more

than half of those are in New York City. In terms of the number of transit suicides that

happen in New York City compared to all [NYC] suicides, I'm sure transit is a low

percentage of all incidences. In terms of where transit suicides occur, New York City is

the highest by a lot. So, there's a perspective for if you're trying to prevent transit suicide,

then you put your resources into New York City. If you're trying to prevent suicide in

New York City, you probably don't put your resources into the subway system (S.

Gabree, personal communication, October 9, 2020).

On this information alone, it would be unwise to develop a suicide prevention plan for New York

City without transportation planners at the table. Not only can they examine the benefits and

80 burdens of transit suicide prevention strategies, transportation planners can also guide discussions about transit equity and accessibility, which impact mental health broadly.

A standout model for regional suicide prevention planning, according to Reed, is the

Colorado-National Collaborative for Suicide Prevention (Collaborative). Although the

Collaborative has not yet engaged urban planners in its work, it does see built environment strategies, such as green spaces, walkable neighborhoods, and shared facilities, as key elements in suicide prevention planning. Sarah Brummett, Director of the Office of Suicide Prevention at the Colorado Department of Public Health & Environment, believes prevention work is more about creating communities that are worth living in rather than keeping people alive (S.

Brummett, personal communication, October 21, 2020). As a result, Brummett and the

Collaborative focus on how to create shared, safe, and inclusive spaces that foster meaningful connections across communities. This intentional focus on pro-social infrastructure, from improving transportation to promoting shared use facilities, is innovative in the suicide prevention world. Additionally, the Collaborative developed a comprehensive framework for prevention that includes indicators and strategies for promoting economic stability, quality daycare, affordable housing, lethal means restriction, and equitable access to healthcare.

Brummet believes urban planners can absolutely play a role in suicide prevention, especially in a place like New York City where zoning dictates space utilization. For suicide prevention to work, a diverse group of stakeholders should be looking at multiple datasets collaboratively. The value of linking land use patterns with data such as hospital visits, community garden locations, and alcohol outlet density cannot be underestimated (S. Brummett, personal communication,

October 21, 2020).

Urban planners are clearly needed at the suicide prevention table. They have practical knowledge, skills, and connections to a host of actors and industries that can think creatively about prevention on multiple levels. The next finding will reinforce this point and present both challenges and opportunities for collaboration.

4. Interdisciplinary collaboration between mental health experts, urban planners,

community groups, and suicide survivors is needed to slow rising suicide rates across

the United States.

The Value of Interdisciplinary Action

Cities offer an abundance of protective factors for suicide and everyone has a role to play in nourishing these protections. Given the broad range of risk and protective factors associated with suicide, reducing suicide rates in any location comes down to interdisciplinary collaboration. Reed believes professional siloing has been stunting progress:

I've been in the [suicide prevention] field for 30 years and I think the biggest mistake we

make is we talk to ourselves too much. We don't talk to the lawyers, we don't talk to the

faith leaders, we don’t talk to the urban planners. We really don't talk to the primary care

practitioners. We talk to ourselves and therefore things stay the same. I've kind of come

out of that box. I really think the solutions are going to be horizontal, not vertical (J.

Reed, personal communication, October 9, 2020).

Limiting knowledge generation about suicide to the suicidology field is not lowering suicide rates. The science and evidence behind modern prevention strategies are strong but come from flawed beginnings. Furthermore, efforts to reduce rates remain relatively top-down. It is time to redefine suicide as a political-institutional problem related to livability, not just a collection of individual level risk factors (Button, 2020). This is only achievable through bottom-up and

82 horizontal collaboration between multiple disciplines and people with lived experience with suicide.

Now that every state has a suicide prevention coordinator, the collaborative potential is ripe. The real shift for jurisdictions will be in following county and community level trends and developing local, culturally appropriate interventions. Once a system for identifying and monitoring suicide has been established, then jurisdictions should develop solutions in partnership with representative stakeholders:

It shouldn't just be a group of mental health people. With suicide, if we've learned

anything it’s that everybody plays a role, not just the social worker or the psychiatrist.

The faith community, for instance, has an incredible opportunity to reach out to people in

their congregations. The urban planners can make sure we build safe environments.

Maybe we don't build high rise housing anymore. Even though I know space in New

York City is a premium, there may be real reasons to think of different models and

policies for housing. If older adults are dying at a higher rate in an area, do you have the

local senior center director at the table? Do you have media representatives at the table?

Everybody has to come together and identify what role they would play in trying to

address the burden (J. Reed, personal communication, October 16, 2020).

In New York City, many examples exist of agencies, neighborhood based organizations, coalitions, and communities engaging with one another around health equity and other issues.

What does not exist, according to Hamby, is a place where agencies can make collective decisions about the city as a whole, based on these engagements:

We have these big vision documents like PlaNYC and OneNYC that provide a kind of

overarching framework. Then we have agency-led projects like Take Care New York,

Where We Live NYC, and the neighborhood studies. But the promise of having a place

for people to really come together [has not come to fruition]. Given the controversy of

what happened with the neighborhood studies, I don't see that work continuing and it

concerns me because I think that ultimately what's needed is a kind of stone soup process

[of decision-making] (E. Hamby, personal communication, October 21, 2020).

Essentially, these big vision documents give the impression of coordinated citywide responses to complex problems, but actual decision-making happens outside of their articulated strategies.

This hurts communities as well as City agencies, which are often reflective of the people these agencies serve. City employees who engage with and want to do right by communities, are habitually at the mercy of political whims outside of their control. It can feel glacial and at times impossible for City employees to collaborate with one another outside of the established hierarchy.

Political Will

The inability for City agencies to make decisions with communities, or even with each other, impairs urban development. But collective decision-making is hard, especially when agencies have budgets and priorities separate from ones articulated in citywide initiatives. On a daily and practical basis, inter- and intra-agency siloing is common, for better or worse. Stayton has noticed that in order to bring multiple disciplines together in New York City, a political will has to be there:

Political priorities send resources [to an issue]. It's certainly my lived experience with

Vision Zero, for instance, which got DOHMH to create a portal page that shows cyclist

injury, cycling infrastructure, and self-reported cycling behaviors all in one story. And I

don't think we would have done that if it wasn't required by City Hall to sit with multiple

agency colleagues once a week for the past three years to figure it out. Vision Zero

created that statement of will. And, man, was the collaboration exquisite. It had been

happening in little percolations and partnerships, but not at that level. I feel like in public

service, maybe in academia too, somebody has to have announced a priority. And I mean

someone who has the podium and who may win some kind of award for being at that

podium. There has to be a voice on [an issue] to galvanize it (C. Stayton, personal

communication, November 24, 2020).

Interdisciplinary action is hindered by the individual missions and strategic plans of each

City agency. Although they often confront many of the same structural problems (e.g., poverty,

housing affordability, food insecurity, environmental injustice), the enormity of New York City

and diversity of its population spreads agencies thin. Agencies tend to work on separate sections

of the same puzzle and are frequently given new puzzles to prioritize when crises emerge.

Without political leadership and braided funding at the highest level, City agencies have little

power or autonomy to work in consistent partnership around a common goal.

Mayor de Blasio and former Health Commissioner, Dr. Oxiris Barbot, have both been

public about their own suicide losses, but a political voice galvanizing suicide prevention has

been noticeably absent in New York City (Billups, 2019; Hernández, 2013). New York City has

never implemented a coordinated strategy to address suicide or suicide-related behavior, either at a citywide or local level (S. Giliotti, personal communication, November 13, 2020). New York

City’s first and only comprehensive mental health plan, ThriveNYC, has 54 initiatives worth 850 million dollars, none of which aim to reduce the City’s suicide rate (ThriveNYC, 2016).

Vision Zero, New York City’s plan to end traffic fatalities, provides an example of what

can be done when political priorities are carried out through interagency collaboration. Vision

Zero operates from the belief that the city’s 200 traffic deaths each year are not accidents and are unacceptable. Through its 240 engineering, education, enforcement, and legislation initiatives,

New York City has truly galvanized behind reducing traffic-related injuries and deaths. Vision

Zero has reduced speeding by over 60% in school zones and lowered traffic fatalities by a third since before the program began (NYC, 2020). When asked if the city could galvanize action behind suicide or if something broader, such as mental health or injury prevention, would be more strategic, Stayton replied:

I think the answer is it could and should be suicide. I think we might be entering a space

where societally we are able to talk about it and the epidemiology is really requiring us

to. There was an era where there were more homicides than suicides. Now, we're in a

completely flipped arrangement where we have almost double the suicides we have

homicides, although homicides have started to inch up. I believe there is shared space in

grief and loss, particularly around suicide, which I think touches just about every

powerful person you can imagine. Not to exploit that, but just to humanize it and

motivate. And I think that potentially creates some opportunity (C. Stayton, personal

communication, November 24, 2020).

The rising suicide rates in New York City and impending long-term negative mental health effects of COVID-19 have created such an opportunity. From a political priority standpoint, annual suicides in New York City currently more than double traffic-related fatalities. This thesis has shown that suicides, resulting from a myriad of biopsychosocial and environmental factors, are just as unacceptable as traffic fatalities. Suicides may be self-inflicted fatalities, but they are fatalities, nonetheless. More importantly, they often result from structural and preventable inequities and should not be judged any differently than other manners of death.

Where, then, is suicide’s Vision Zero?

Interdisciplinary collaboration around suicide, a complex and stigmatized issue, will take time. In the rail industry, Gabree said that the uptake has felt glacial. Convincing the industry that suicide is a battle worth fighting was not easy because they did not see it as their responsibility. The trick was in figuring out how to say, “You’re not solely responsible, but you can be a part of the solution.” Communicating what different partners could bring to the table if they would just come together moved the dial a bit. “Sometimes getting new ideas into their minds over the years is good. You see them come back five years later saying, hey, remember when we talked about suicide prevention? I think maybe we should be doing something about it”

(S. Gabree, personal communication, October 9, 2020).

Suicide, like all matters of livability, cannot be understood or addressed through any one discipline. This qualitative analysis demonstrates the opportunities for intersectional alignment around suicide specifically and health equity broadly. It confirms scholar Jason Corburn’s research that in order for urban planning and public health to realign, a coordinated framework, articulated strategy for addressing health inequities, dynamic approach to place, and participatory democracy are needed (Corburn, 2004). Realignment is a challenging, but necessary and achievable goal. New York City is ready for such a challenge.

Chapter 6: Recommended Future Directions

Suicide is a social justice issue that requires an interdisciplinary, health equity approach to understand and prevent. A new framework is needed that measures suicide risk by environments, not individuals. Not only is such a framework based on evidence, but it is also more empathetic and fairer towards people with lived experience with suicide. Given the broad range of socio-environmental, political, and other structural factors that contribute to suicide risk, planners have a clear role to play in shaping this new framework.

Fundamentally, it is the job of planners to cultivate physical and social environments that protect inhabitants and minimize ones that harm them. Rates of suicide and self-harm can be traced to urban development practices, land use patterns, poverty concentration, and air pollution, among other externalities. Suicide prevention requires the involvement of planners with skills and knowledge in areas such as environmental justice, physical design, and community participatory planning.

New York City stakeholders - City Hall, specifically - can take immediate steps towards interdisciplinary alignment around suicide prevention. Some recommendations for immediate steps, which focus largely on government activities and are therefore not exhaustive, include:

1. Establish and charge an interagency coalition with developing a citywide suicide prevention strategy.

Recommended lead: NYC Department of Health and Mental Hygiene; Recommended partners: NYC Department of City Planning, NYC Department of Design and Construction, NYC Department of Environmental Protection, NYC Department of Housing Preservation and Development, NYC Department of Parks and Recreation, NYC Department of Small Business Services, NYC Department of Social Services, NYC Department of Transportation, Economic Development Corporation, NYC Fire Department, Health and Hospitals Corporation, Mayor’s Office of Immigrant Affairs, Metropolitan Transit Authority, New York City Housing Authority, and other agencies as determined by NYC’s suicide data and research.

An interagency suicide prevention coalition can:

a. Develop an interdisciplinary framework for collaborating and approaching the subject

and problem of suicide. For example, Jason Corburn proposes ecosocial

epidemiology11 and environmental justice as two useful paradigms for attempting to

explain and address health disparities across perspectives.

b. Articulate a strategy for interagency collaboration based on social determinants of

health, such as Health Equity in All Policies (Wernham & Teutsch, 2015).

c. Undertake a review of case studies and precedents to help inform local planning and

concrete action for mental health and suicide prevention. Below are some examples:

i. The Cabinet of Japan passed the Basic Act for Suicide Prevention (Basic Act)

law in 2006 to combat its steadily high suicide rate (MHLW, 2020; Sawada et

al., 2017; WHO, 2015). The Basic Act, which is complimented by a special

fund and the General Principles of Suicide Prevention Policy, obligates all

Japanese municipalities (i.e., cities, towns, and villages), in addition to

prefecture governments, to establish local suicide prevention plans (MHLW,

2020; Umeda, 2016; WHO, 2020). The General Principles of Suicide

Prevention Policy outlines an overarching philosophy for suicide prevention,

high level goals and objectives, policies for moving the work forward in a

coordinated manner (including practices for evaluation and data

management), and methods for promoting practical initiatives at the

community level. With these systems of funding and oversight in place, the

11 In Reconnecting Urban Planning and Public Health, Corburn describes ecosocial epidemiology as “embodiment, or how throughout our lives we literally incorporate, biologically, the material and social world in which we live” (Corburn, 2004).

government aims to reduce Japan’s overall suicide rate from 18.5 to 13 per

100,000 by 2025 (SPRC, 2017).

ii. The Massachusetts Coalition for Suicide Prevention12 and the Colorado-

National Collaborative for Suicide Prevention13 are two successful

multistakeholder groups with clearly defined prevention goals and priorities.

In 2019, the Massachusetts Coalition for Suicide Prevention published

Widening the Lens,14 a racial toolkit for exploring the role of social justice in

suicide prevention.

iii. Gloucester, England is believed to be the first city to introduce a suicide

prevention measure in a comprehensive plan (BBC News, 2019). As part of

the Gloucester 2031 City Plan, developers must construct suicide risk

mitigation measures on new buildings and structures above 12 metres in

height.15

d. Develop a progressive and explicitly anti-racist research agenda and data sharing and

management plan to better understand suicide trends at a hyper-local level.

e. Create contextual and environmental suicide risk indices at various scales (census

block, neighborhood, community district, borough, citywide) to measure risk based

on systems and structures.

f. Coordinate resources to respond to suicide clusters in real time.

g. Ensure that COVID-19 recovery efforts include suicide prevention activities.

12 https://www.masspreventssuicide.org/ 13 https://allianceforsuicideprevention.org/wp-content/uploads/2020/07/CNC-One-Pager.pdf 14 https://www.masspreventssuicide.org/wp-content/uploads/2019/09/WideningTheLensToolkit.pdf 15 https://tinyurl.com/yy8a66x5

h. Develop interdisciplinary interventions that meaningfully tackle structural risk

factors, improve imminent suicide risk protocols (e.g., develop alternatives to police

intervention in active suicide attempts), and work with communities (neighborhoods,

schools, faith-based institutions, etc.) in the aftermath of suicides.

i. Collaborate with community based and advocacy organizations working to address

suicide, either explicitly or implicitly, with a focus on supporting and funding efforts

led by Black, Indigenous, People of Color (BIPOC) groups.

2. Ensure that all city planning processes include relevant measures to promote mental

health and, where possible, protect against suicide.

Recommended lead: NYC Department of City Planning; Recommended partners: Department of Design and Construction, NYC Department of Environmental Protection, NYC Department of Health and Mental Hygiene, NYC Department of Housing Preservation and Development, NYC Department of Parks and Recreation, NYC Department of Transportation, Economic Development Corporation, Metropolitan Transit Authority, and other agencies as relevant to each unique planning process.

At this time, most city planning processes fail to recognize the effect of urban planning on individual and community mental health. Efforts are underway to update some processes, such as the Citywide Environmental Quality Review Technical Manual, to better include health, but major renovations are needed across the board.

The NYC Department of City Planning and adjacent agencies can:

a. Participate in the NYC interagency coalition for suicide prevention.

b. Invest in local experimental research and pilot programs that aim to understand,

measure, and treat urban planning’s effect on mental health and suicidality. As the

literature review of this thesis shows, results of studies that measure such effects vary

based on researchers’ (1) key terms and definitions and (2) measures of access,

quality, dosage, and use-purpose of particular spaces.

i. Encourage ongoing community based participatory action research and citizen

science in experimentation.

c. Ensure that design interventions are guided by data, not politics. This is especially

important in the consideration of suicide barriers on public structures. Barriers,

though highly effective, are costly and take time to construct. They should be

prioritized based on a number of factors including, but not limited to, feasibility,

environmental impact, actual occurrences of suicide attempts or deaths (compared to

other sites), and projected lives saved.

d. Embed racial impact studies within planning processes, such as the Uniform Land

Use Review Procedure, that contribute to neighborhood change, especially before

rezonings are approved.16

e. Elevate biodiversity planning in urban environments. Nature has proven to positively

influence mental health (Bratton et al., 2019). While equitable access to quality green

space is important to human wellness, planning departments must think bigger and

bolder when it comes to planning for mental health. In his 2021 thesis, Urban

Planning in the Anthropocene: A Case for Citywide Biodiversity Policy, fellow Pratt

Institute Graduate Center for Planning and the Environment student, Duane Martinez,

demonstrates that the drastic alteration of the planet’s life systems as a result of

human activity calls into question the relationship between urban planning,

biodiversity, and ecosystem services. He argues that biodiversity loss in cities

threatens the opportunity for urban humans to connect with nature and potentially

benefit from the relationship. Planning efforts to improve mental health and reduce

16 This recommendation was wisely suggested by fellow Pratt Institute Graduate Center for Planning and the Environment student, April Hurley.

risk factors for suicide would be wise to consider the recommendations outlined in

Duane Martinez’s thesis.

Conclusion

Cities, by their very nature, protect against suicide. They offer complex social relationships, access to life-affirming resources, and an abundance of economic and cultural prospects. When functioning well and fairly, they are bastions of hope, diversity, and opportunity.

Too often, the protective factors that cities embody are inequitably distributed, creating concentrated pockets of risk. These compound risks can create or maintain unlivable situations.

Systems and structures that allow these risks to endure, and that contribute to an area’s suicide rate, should be the principle target of suicide prevention interventions.

Cities must affirm, not jeopardize life. New York City has an opportunity to pioneer a new approach to suicide prevention that focuses on systemic change, livability, and socio- environmental mediation. Urban planners have a key role to play in advocating for and progressing such an approach.

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Appendix A. Timeline of the Urban Planning and Public Health Relationship

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Appendix B. Interviewee Biographies

Dr. Scott Gabree is the manager of the research program for grade crossing safety and trespass prevention in the Human Factors Division at the Volpe National Transportation Systems Center in Cambridge, MA. The trespass prevention program is focused on understanding trespass and suicide incidents on the U.S. rail system and what rail carriers may be able to do, in coordination with other groups, to help reduce the frequency and impact of these events. Dr. Gabree received his B.A. in Psychology from Miami University (OH) in 2004 and his Ph.D. in experimental psychology (with a focus on visual/color perception) from Northeastern University in 2009.

Elizabeth Hamby is the Director of Take Care New York at the New York City Department of Health and Mental Hygiene in the Office of the First Deputy Commissioner/Chief Equity Officer. Take Care New York is the City's Health Equity Blueprint. It provides information, fosters collaboration, and catalyzes action among all parts of government and society to advance health equity. Ms. Hamby is an artist and a professional amateur, with skills in community-based social practice and design, placekeeping, and cross-disciplinary trespassing.

Dr. Jerry Reed is Senior Vice President for Practice Leadership at Education Development Center, Inc., (EDC). Dr. Reed recently co-led the committee that updated the U.S. National Strategy for Suicide Prevention and he serves as an Executive Committee member of the National Action Alliance for Suicide Prevention. Dr. Reed also serves on the National Advisory Board of the Kennedy-Satcher Center for Mental Health Parity and is an active member of the American Association of Suicidology, the American Public Health Association and the International Association for Suicide Prevention and serves on the Executive Committee of the National Action Alliance for Suicide Prevention. Dr. Reed received a Ph.D. in Health-Related Sciences with an emphasis in Gerontology from the Virginia Commonwealth University in Richmond in 2007 and his MSW degree from University of Maryland at Baltimore in 1982 with an emphasis in Aging Administration. He served in the United States Navy during the period 1974-1978.

Dr. Catherine Stayton is the Director of the Injury and Violence Prevention Program at the New York City (NYC) Department of Health and Mental Hygiene and is on faculty at the Mailman School of Public Health at Columbia University. The DOHMH Injury and Violence Prevention Program monitors fatal and non-fatal injury and violence in New York City over time and place, identifies populations at risk, disseminates data, and provides technical assistance on prevention policies and programming on a broad range of injury topics, including suicide and self-inflicted injuries. In 2014, she launched New York City’s contribution to the Center for Disease Control and Prevention’s National Violent Death Reporting System and became the Health Department’s point of contact for Vision Zero. Dr. Stayton is DOHMH’s intimate partner violence surveillance, research, intervention and prevention programming and policy, and outreach point person. Dr. Stayton received her DrPH from Columbia University Mailman School of Public Health in 2002 and her MPH from New York University in 1994.

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