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Ann Marie T. Sullivan, M.D., Commissioner
Governor Andrew M. Cuomo

The Challenge of Suicide Prevention

Gary L. Spielmann, M.A., M.S.
Director of Project Management & Chair
Suicide Prevention Working Group
New York State Office of Mental Health

Suicide is consistently the leading cause of violent death in New York, the United States, and the world. New York lives lost to suicide (1,292 in 2002) exceed the number of homicide victims by 32%. New York lost more lives to suicide than 44 other states did; only California, Texas, Florida, Pennsylvania and Ohio lost more. (CDC: 2004) The economic impact of suicide, and depression which often precedes it, is between $3.4 and $4.0 billion annually in New York. (J. Clinical Psychiatry: 2003)

Suicide has been called a "silent epidemic": "silent" because many who attempt suicide are adept at not disclosing their psychic pain to others, and because "others" don't often inquire about someone's state of mind. Suicide is "epidemic" because of its prevalence. The President's New Freedom Commission on Mental Health (2003) characterized suicide as a far more common health problem than people realize. For every two homicides in this country, there are three suicides. For every person who dies from HIV/AIDS, two people die by suicide. Besides the 30,000 Americans who lose their lives to suicide each year, some 650,000 will receive emergency treatment for it. (IOM: 2002) These numbers undoubtedly represents a substantial under-reporting of suicide attempts and completions, because of the taboo that attaches to both. For every death, there are scores of family and friends whose lives are devastated emotionally, socially and economically.

One in every 25 lives lost to suicide in this country is a resident of New York. The typical suicide death in New York is a middle-aged white male who resides alone, upstate, suffers from depression, and uses a firearm to end his life. Suicide in New York is the 3rd leading cause of death among those aged 15-24; 4th for those aged 10-14; 5th for those aged 25-34; 6th for those aged 35-44; and 9th for those aged 45-54 (CDC, 2001). While males die by suicide four times as often as females, females make more attempts. From 2000-2002, more than 24,000 persons were treated at hospitals for self-inflicted injuries. Most of them were females. A firearm was the most common agent of suicide (36%), followed by suffocation/asphyxia (26%), poisoning (17%), and falls (8%) (CDC: 2001)

New York's suicide rate peaked in 1994 and declined steadily until 1999 where it has stabilized. (Figure 1)

The ten-year history (1993-2002) of suicide among New York adolescents and young adults, age 15-19, shows that suicide is less common among this group than for the general population. Geographically and historically, the patterns are similar to those for adults. (Figure 2)

Bar chart of Suicide death rates per 100,000 population in New York, 1993-2002*

Bar chart of Suicide death rates per 100,000 population in New York, 1993-2002*
* Source: New York State Department of Health (2004)

Demographic Factors

In 2000, 80% of suicides were males, of whom 85% were white, 10% were African-American, and 8% were Hispanic. White males between 25 and 54 years of age comprised 40% of all suicides recorded in New York. Among whites, males comprised 68% of suicides, while among African-Americans and Hispanics, males comprised 78% of all suicides. There were no suicides in 2000 recorded for African-American females 65 years and older. Similarly, there were no recorded suicides for Hispanic females older than 75 and between 25 and 34 years of age. Finally, suicide among the very young (<15 years) is rare. Eleven suicides were recorded for this age group in 2000 (8 males; 3 females). Starting at age 15, however, this rate begins to climb. Elders, especially white males, have the highest rates. (NYSDOH: 2003)

Geographic Distribution

Suicide is a statewide public health problem with regional variations as shown in the following:

Figure 3. Prevalence by Region (General Population)

Region* Deaths, 2000-2002 Population Suicide Rate**
Western NY 389 1,584,652 8.0
Finger Lakes 323 1,264,272 8.4
Central NY 395 1,427,114 9.1
New York/Penn 63 302,970 6.7
Northeastern NY 393 1,455,242 8.7
Hudson Valley 440 2,205,473 6.6
New York City 1,319 8,062,027 5.4
Long Island 508 2,782,600 6.0
NY State Total: 3,830 19,084,350 6.6

Source: 2000-2002 Vital Statistics, Center for Community Health, New York State Department of Health (August 2004)
*Administrative regions of the New York State Department of Health

**Rate adjusted for the 2000 Census

One in 10 New York high school students made a suicide plan in 2001, and one in seven seriously considered attempting suicide. (CDC: 2004) 150,000 New York teenagers attempted suicide in 2000 and 82 died from it. (NYSDOH: 2003). Adolescent suicide is also a statewide problem, with a regional overlay.

Figure 4. Prevalence by Region (Adolescents and Young Adults, Ages 15-19)

Region* Deaths, 2000-2002 2000 Population Crude Rate**
Western NY 25 114,306 7.3
Finger Lakes 14 93,918 5.0
Central NY 30 116,347 8.6
New York/Penn 6 23,467 8.5
Northeastern NY 23 107,548 7.1
Hudson Valley 25 147,256 5.7
New York City 54 500,189 3.6
Long Island 32 174,204 6.1
NY State Totals 209 1,277,235 5.5

Source: 2000-2002 Vital Statistics, Center for Community Health, New York State Department of Health (August 2004)
* Administrative regions of the New York State Department of Health

The eleven counties* comprising the Central New York region experienced the highest rate of suicide deaths for both their general and adolescent/young adult populations from 2000-2002. Other regions with an above (statewide) average rate for adult suicides were in descending order: Northeastern New York, Finger Lakes, Western New York, and New York/Penn. For adolescents/young adults, New York/Penn, Western New York, Northeastern New York, Long Island, and Hudson Valley experienced suicide rates above the statewide average. New York City was the region with the lowest suicide rates across the lifespan.

While suicide is widely considered an infrequent event, it is well to remember that for every completed suicide, there are between 8 and 25 attempts. Data collected by the New York State Department of Health reveals the following geographic distribution of suicide attempts that required emergency room treatment:

Figure 5. Self-Inflicted Injury/Discharge Rate per 100,000 Population. 2000-2002. General Population.

Region Discharges, 2000-2002 2001 Population Rate
Western NY 2,300 1,584,652 8.0
Finger Lakes 1,961 1,264,272 8.4
Central NY 2,571 1,427,114 9.1
New York/Penn 403 302,970 6.7
Northeastern NY 2,433 1,455,242 8.7
Hudson Valley 2,493 2,205,473 6.6
New York City 8,584 8,062,027 5.4
Long Island 3,260 2,782,600 6.0
NY State Totals 24,005 19,084,350 6.6

Source: 2002 SPARCS Data as of August 2004 (NYSDOH)

Figure 6. Self-Inflicted Injury/Discharge Rate per 100,000 Population. 2000-2002. Adolescents/Young Adults, Ages 15-19.

Region Discharges, 2000-2002 2001 Population Rate
Western NY 295 114,306 86.0
Finger Lakes 295 93,918 104.7
Central NY 442 116,347 126.6
New York/Penn 64 23,467 90.9
Northeastern NY 374 107,548 115.9
Hudson Valley 413 147,256 93.5
New York City 1,168 500,189 77.8
Long Island 479 174,204 91.7
NY State Totals 3,530 1,277,235 92.2

Source: 2000-2002 SPARCS Data as of August 2004 (NYSDOH)

Figures 5 and 6 demonstrate that Central New York experienced more suicidal attempts requiring medical attention than any other region from 2000-2002. The attempt rate for adolescents is more than double that for the general population. Overall, persons living upstate exhibited more suicidal behavior than their counterparts downstate, especially residents of New York City.

Fatalism

Of all the challenges posed by a major public health threat, such as suicide, perhaps the most difficult of all is the widely-shared belief that we can do little to prevent or control it. So long as this belief is widely shared in the public mind, the task of focusing attention and resources on the problem is much more difficult. The stigma in our culture attached to both mental illness and suicide is intensified by fatalistic attitudes about both subjects. The sense of not being able to do much to predict, much less prevent suicidal behaviors, is the ultimate rationale for ignoring the subject. Silence, reinforced by stigma and shame, and suicide go hand-in-hand.

Federal efforts in the past ten years, combined with a citizens' movement, have contributed much to ending the belief that we are powerless at preventing suicide and life-threatening behaviors. Evidence abounds of progress in diagnosing and treating illnesses with medications and therapies, alone and in combination (IOM: 2002). The head of SAMHSA, the federal agency responsible for coordinating mental health services, has said there is a compelling need to educate both the media and public that for mental illnesses "help is available, treatment is effective, and recovery is possible." (SAMHSA: 2002)

There is also powerful evidence that some suicides are impulsive. A classic study of 515 persons prevented from jumping from the Golden Gate Bridge found that 94% of those had died from natural causes or were still alive 25 years later. The belief that Golden Gate Bridge attempters will inevitably "just go somewhere else" to kill themselves was clearly unsupported by the data. "Instead, the findings confirm previous observations that suicidal behavior is crisis-oriented and acute in nature. Accordingly, the justification for prevention and intervention…is warranted and the prognosis for suicide attempters is, on balance, relatively hopeful." (Seiden: 1978)

A major reason why suicides are not destiny for many would-be attempters is the range of improvements made in the diagnosis and treatment of mood disorders. John Mann, MD has argued that suicide is generally a complication of a psychiatric disorder (Mann: 2002) and that treatment of high-risk psychiatric patients should reduce suicide rates. Research has found depression to be the major psychiatric cause of suicide, and anti-depressants to be beneficial for treating major depressive disorders. (Mann: 2003) From 1985 to 1999, the national suicide rate fell 13.5%, with a greater decline among women, and antidepressant prescription rates increased over four-fold, mostly with SSRIs. (Grunebaum et al.: 2004) Problem-solving skills may help coping behavior and reduce suicide risk. (Mann: 2003) For clinicians, a history of suicide attempts and a family history of suicidal behavior are evidence of a predisposition to complete a suicide. (Mann: 2002).

More women are diagnosed with depression than men, but a higher percentage of them are more likely to be treated with antidepressnts than men. As a result, fewer women die by suicide than men. This is especially true for middle-age and elderly men. (Grunebaum et al.: 2004). Depression is treatable in 80 to 90 percent of cases, yet only 30 to 50 percent of depressed individuals are diagnosed as such by their primary care physicians. A majority remain "half-treated": prescribed antidepressants but without followup visits. (IOM: 2002; JAMA: 2003) This appears to be borne out by a recent survey of enrollees in New York's health insurance plans and HMO's. They ranked the quality of care received for depression lower than for any other health condition; their major complaint: the lack of followup visits to a provider after being started on a course of antidepressant medications (NY Health Accountability Foundation/IPRO; 2004)

Diseases of the central nervous system, such as epilepsy, AIDS, Huntington's Disease, head injuries and cerebrovascular accidents, carry a much higher relative risk for suicide. These disorders may trigger depression and suicidal ideation and may impair restraint or inhibition of the desire to act upon such thoughts. (Mann: 2003) A history of physical or sexual abuse during childhood, a history of head injury or neurological disorder, and cigarette smoking increase the risk of suicide. (Mann: 2002)

The affective state most associated with a suicide crisis is desperation - a state of anguish accompanied by an urgent need for relief. The fear of emotional disintegration - of lives unraveling, collapsing or falling apart - has been described as greater than the fear of death. For many desperate patients, death seems to be the only way to attain both relief and control. (Hendin et al.: 2004)

Since most persons with a psychiatric disorder never attempt suicide, those who die from suicide differ from the majority in some way. The search for this "difference" inspires much psychiatric research. (Mann: 2002) Improved treatment delivery for serious depression and related psychiatric disorders, particularly in males, will potentially further reduce the national suicide rate." (Grunebaum: 2004) "To this end, randomized controlled clinical trials of SSRIs and other new-generation, non-tricyclic antidepressants in suicidal depressed patients are needed to provide clearer estimates of the efficacy of these medications in the prevention of suicidal behavior." (Grunebaum et al.: 2004)

A final reason why OMH believes the challenge of preventing suicide can be met is the successful five-year experience the agency has had in implementing an assisted outpatient program (Kendra's Law). This Law established a process for identifying individuals with mental illness who, in view of their treatment history and circumstances, are likely to have difficulty living safely in the community without supervision. After five years, Kendra's Law has reduced harmful behaviors by its enrollees, including 55% fewer recipients engaged in suicide attempts or physical harm to themselves. (OMH: 2005)

In the words of Governor Pataki: "Kendra's Law has provided New Yorkers with mental illness access to the treatment they need in an effective manner that ensures their safety, as well as that of the public," Governor Pataki has said. "The vast majority of these individuals are already leading productive and fulfilling lives in their communities, but the results are clear - Kendra's Law works. That's why I am proposing that this extremely successful program be made permanent." (Press release: March 8, 2005)

Awareness

To combat the stigma that blocks progress toward the control of suicide requires raising the level of knowledge about mental illnesses, their treatment and the real prospects of recovery for those with a diagnosable disorder. This has been undertaken at both the federal and state level. Surgeon General Satcher's Call to Action to Prevent Suicide (1999) was a clarion call to "consider suicide as a significant public health problem and put into place national strategies to prevent the loss of life and the suffering suicide causes." Recent advances in neuroscience, psychiatry, epidemiology, and behavioral science further the goals of finding means to prevent suicidal behavior.

The Surgeon General's Call to Action began a re-evaluation of suicide as a public health problem, not just a private tragedy. It called for suicide to be studied systematically, and set forth a three-part public health strategy to combat suicide: Awareness, Intervention, and Methodology (AIM). Awareness signifies a commitment to broaden the public's awareness of suicide and its risk factors, including mental disorders. This task has been taken up at the state level.

The New York State Office of Mental Health (OMH) has recently broadened its scope beyond its traditional mission of meeting the mental health needs of individuals with serious psychiatric disorders. OMH has adopted strategies frequently used in the medical field, and is actively working to promote public mental health through education and advocacy. Commissioner Sharon E. Carpinello, RN, Ph.D. has noted that OMH is now actively working to increase public awareness and understanding of the nature and impact of mental illness; effective treatments and services; useful preventive and coping strategies; and how to get help when needed." (Carpinello: 2004)

Keenly aware of the connection between mental illness, especially mood disorders, and suicide, Commissioner Carpinello has noted that "Research has shown that suicide prevention and early intervention efforts are successful at saving lives, and by encouraging and assisting people to learn when, where and how to speak up, suicides can be prevented. Research also has shown that many suicides may be prevented if attention is devoted to identifying and intervening with those at risk." (Carpinello: 2004)

To this end, in May 2004, OMH launched a statewide public education and awareness campaign that uses a public mental health model to help people become more familiar with the risks and warning signs of suicide. With a team of nationally recognized experts, clinicians and individuals whose lives have been touched by suicide, OMH gathered the most current scientific knowledge available about suicide risks and prevention, and produced Suicide Prevention Education and Awareness Kits (SPEAK) for statewide distribution. The kits include information about suicide, suicide prevention, risk factors, warning signs, and resources about how to seek help through crisis information and treatment resources that are accessible on a 24/7 basis in every county in New York. There is also information about specific populations and age groups, including men, women, older adults, teens and college students. (OMH: 2005)

While the main goal of the SPEAK campaign is education and awareness to prevent suicide, it is hoped that SPEAK's broad-based public health approach will help to mitigate the stigma associated with seeking help for psychological distress. An important message of the SPEAK campaign is to ask for help when an individual or someone they care for needs it. SPEAK is available in multi-media (print, electronic, website) in both English and Spanish, with a Chinese version in production. Feature articles on SPEAK have appeared in Governing magazine, Mental Health Weekly and Behavioral Healthcare Tomorrow.

Suicidal Risk

A critical step in preventing suicide is to identify and understand the risk factors that contribute to it. A risk factor is anything that increases the likelihood that persons will harm themselves. Risk factors are not causes, but are contributors to unhealthy behavior and outcomes. (CDC: 2004) A population-based study confirms that not all individuals and regions are equally at risk .

Maintaining a favorable balance of protective vs. risk factors is key to preventing harmful behavior. Targeting efforts to those harboring actual risk should contribute to a rational allocation of resources and to achieving desired outcomes. Risk factors may be biological, psychological, or social in nature, and can exist in the individual, family and environment.

Risk Factors
The Department of Health and Human Services has identified the following risk factors for suicide:

Protective Factors

Protective factors buffer people from the risks associated with suicide. A number of protective factors have been identified:

Voluntary Screening for Risk

A significant challenge for suicide prevention is that 90% of those who attempt suicide suffer from a diagnosable psychiatric illness, alcohol or drug abuse. Yet only about 5% of those with a diagnosed psychiatric illness will actually die by suicide (IOM, 2002). Many more will die from health-related causes and accidents. While this suggests a "needle-in-the-haystack" search is uncalled for, this 5% comprises a large majority of the 30,000 suicide deaths that occur each year in this country. Such is the prevalence of mental illness in the general population.

Clearly, from a public-health perspective, we should make every effort to identify and treat those who have a diagnosable illness or addiction, mindful that only a fraction of this population will make a serious suicide attempt. Widespread implementation of mental health screening throughout New York State would greatly support this public-health approach of identifying and treating those who are at greatest risk for suicide. A secondary benefit of mental health treatment is to help the individual address other co-occurring health-related conditions, such as diabetes or hypertension, that may have even greater morbidity and mortality than their diagnosed mental illness.

A further challenge is posed by the finding of IOM suicide experts that while suicidality and depressive disorders are related, they respond to treatment somewhat differently. In an individual case, depressive symptoms can be reduced by medicines without reducing suicidality, and cognitive-behavioral therapy can reduce suicide without significant change in affective symptoms. Another finding to consider is that an individual who attempts, but does not complete, suicide, is actually at higher risk for eventual suicide than he/she was before the initial attempt. Apparently, once the threshold of self-destructive action is crossed, it is much easier for the would-be suicidal person to cross a second or third time. It is also a confirmation of the dictum that the best predictor of future behavior is past behavior.

Since 70% of those who complete suicide do so on the first attempt, we need to identify them and intervene before they act on their suicidal impulses. (Caine: 2003) We may have but one chance to save someone's life. For this purpose, a public health model of prevention is required. The psychological autopsy is a proven means of revealing the motives and intent behind suicides through probing interviews and reconstructed events involving a suicide's family, friends and acquaintances. This approach can help explain why a suicide occurred, but it offers no help to saving that person's life. This approach has, however, led to the development of mental health screening as a means of suicide prevention.

From psychological autopsy studies it became clear that suicide is not the unpredictable event it was once believed to be. 90% of those who died by suicide had a diagnosable mental illness at the time of their death and 63% were symptomatic for over a year before their death, representing a substantial missed opportunity for identification (Shaffer, 1996). The development of voluntary mental health screening that resulted from these psychological autopsy studies can and must be used to help prevent future loss of life. Fortunately, several reliable and valid screening programs have been developed for different population groups. It is probably true that no psychological test, clinical technique, screening form or biological marker is precise enough to accurately predict every suicidal act. Still, they can identify some, perhaps most.

A state plan to prevent suicides must embrace - and successfully integrate - two different approaches in order to identify a "target population" of would-be suicides and intervene before self-destruction occurs. The first has been termed the individual-based, or clinical approach to prevention. It stresses the neurobiological family and personal factors accumulated by individuals to help "explain" their motivation to engage in self-destructive behaviors. The public health perspective examines the correlates between an individual and the larger society to gauge the stresses and strains that can propel an individual into a downward spiral ending in death. This approach was pioneered by the French sociologist, Emile Durkheim in the 19th century, and is still very relevant today. (Durkheim: 1897)

Following the template of the National Strategy for Suicide Prevention, we need to combine both an individual and societal approaches into a statewide strategy. Specifically, we need to:

  1. integrate population-oriented public health prevention measures with currently available clinical and medical interventions designed to address the needs of groups of individuals bearing greater burdens of risk.
  2. move from building awareness of the need for suicide prevention to concerted actions that actually reduce the loss of life and remedy conditions that frequently foster it. And that means empowering local communities where those most "at risk" live.

Reaching individuals and groups with elevated risks for suicidal behavior will require concerted action at the community level. The question is: how can state and local governments effectively promote implementation of evidence-based or best-practice approaches to suicide prevention? A good place to start is by reviewing what is known about effective suicide prevention. The Institute of Medicine's Reducing Suicide (2002) concluded that the state of knowledge is such that we know what the key risk and protective factors are, as well as those interventions that can prevent suicidal behaviors. What is needed now is a coherent program of action and the means to implement it effectively. Above all, we need to generate a behavioral impact on people through the efforts of a coalition of private and public agencies, individuals and families living in the community.

From a statewide perspective, mental wellness and suicide prevention activity are "local". To be meaningful, behavioral change must originate in the community: in peoples' homes, work sites, corporations, and unions; in the courts and criminal justice system; in jails and prisons; in non-government organizations, community and faith-based agencies; and in government agencies at the grassroots. (Caine, ED and KL Knox: 2003) The essential goal of such efforts is to de-stigmatize help-seeking around suicidal thoughts and feelings.

A statewide plan has to be flexible enough to impact citizens living in rural settings, like the Adirondacks and Catskills, the densely populated New York metropolitan area and suburbs statewide . Yet a workable plan must also be consistent enough to guarantee availability of "evidence based" or "best practice" prevention services". We owe the public no less than "equal protection" across the lifespan regardless of geographic location. Current efforts at the local level are at best uneven across New York. (See Appendix to this chapter)

The National Strategy

Fortunately, the federal government has provided the states with a conceptual framework for designing a statewide plan across the lifespan of their citizens. The National Strategy for Suicide Prevention (NSSP) issued in 2001 was a massive effort, spanning several federal agencies, state governments, nonprofit organizations, communities, and other ancillary groups. Perhaps most significant is the Strategy's message of hope. As SAMHSA's administrator put it: "… suicides are preventable. We need to raise awareness that help is available, treatment is effective, and recovery is possible." (CG Curie: 2002) Pursuant to the NSSP, the Suicide Prevention Resource Center has just released its registry of evidence-based programs and practices (NREPP) in the field of suicide prevention. (SPRC: 2005)

Summary Recommendation #1:

The New York State plan should accept and further the goals of the National Strategy for Suicide Prevention (NSSP).

Result:

The National Strategy contains 11 goals.

Goals:

  1. Promote awareness that suicide is a public health problem that in many cases may be preventable.
  2. Develop broad-based support for suicide prevention.
  3. Develop and implement strategies to reduce stigma associated with being a consumer of mental health, substance abuse, and suicide prevention services.
  4. Develop and implement suicide prevention programs.
  5. Promote efforts to reduce access to lethal means and methods of self-harm.
  6. Implement training for recognition of at-risk behavior and delivery of effective treatment.
  7. Develop and promote effective clinical and professional practices.
  8. Improve access to and community linkages with mental health and substance abuse services.
  9. Improve reporting and portrayals of suicidal behavior, mental illness, and substance abuse in the entertainment and news media.
  10. Promote and support research on suicide and suicide prevention.
  11. Improve and expand surveillance systems.

Building on the Science Base

The National Academy of Science's Institute of Medicine examined the state of the science base surrounding suicide, gaps in our knowledge, strategies for prevention, and research designs for the study of suicide. The report identified several factors affecting the incidence of suicide: biological and genetic factors, psychological factors, substance abuse and mental illness, a history of child abuse, especially sexual abuse, social factors and cultural/spiritual influences. Exactly how these risk factors combine to shape behavior is not fully known. However, the IOM report, Reducing Suicide: A National Imperative (2002) believes that suicidality can be treated through pharmacology and psychotherapy. Primary health care is a critical setting for the detection of risk factors, such as depression and drug abuse.

Summary Recommendation #2:

The New York State suicide prevention plan should build upon the scientific findings of the IOM report. The report's recommendations should be carefully evaluated as to their potential benefits and costs to the citizens of our state. All elements of our state plan should be based on the best scientific evidence available and be modified as required by scientific progress.

The IOM report recommends the following:

  1. Develop a national network of suicide research population laboratories devoted to interdisciplinary research on suicide and suicide prevention across the life cycle. The University of Rochester's Center for the Study and Prevention of Suicide (CSPS) is a leading example of this type of facility.
  2. National monitoring of suicide and suicidality should be improved to:
    • encourage measures of suicidality in all large and/or long-term studies;
    • include suicide patients in clinical trials when appropriate safeguards are in place;
    • develop a national suicide attempt surveillance system;
    • support a surveillance system such as the National Violent Death Reporting System that includes data on mortality from suicide.
  3. Primary care providers are frequently the first and only medical contact for suicidal patients. A diagnostic interview tool is as accurate as many medical tests are, but physicians are reluctant to use it. Only 30 to 50 percent of depressed patients are diagnosed as such by their primary care physicians. Providers need help to better identify suicidal persons by:
    • improved use of screening tools to identify depression, substance abuse, child abuse, impulsivity and relationship stresses
    • referral by physicians of suicidal patients or those with multiple risk factors to mental health professionals;
    • professional in-service training of health care providers in suicide risk, detection and intervention;
    • modifying the curriculum of medical and nursing schools to include the study of suicidal behavior.
  4. Programs for suicide prevention should be developed, tested, expanded and implemented, including expanded partnerships among federal, state, and local agencies; expanded successful programs such as the US Air Force Suicide Prevention Program that integrates prevention at multiple levels: universal, selected, and indicated.

Universal prevention is one targeted to an entire population

Selected prevention is targeted to members of a population with higher than average risk factors.

Indicated prevention is targeted to members of a population with sub-syndromal symptoms of a disorder.

Programs that remove barriers to treatment, increase knowledge, attitudes and competencies in the community, and increase access to help and support should be implemented:

National Goals and Recommendations
The President's New Freedom Commission on Mental Health established six goals to guide national and state policy on this subject:

Summary Recommendation #3:
New York should adopt the recommendations of the President's New Freedom Commission on Mental Health (2003) in affirming the belief that there are a range of effective treatments, services and supports to facilitate recovery from mental illness. As improvements in the current delivery system occur, the art and science of suicide prevention will improve also. Indeed, suicide prevention can serve as an indicator of how much improvement public mental health systems have made, and how much more they need to improve.

The President's Commission report highlighted twelve model mental health programs worthy of being singled out. Two of these model programs whose goals include suicide prevention are the "United States Air Force Initiative to Prevent Suicide" and the "Columbia University TeenScreen Program".

In 1996, the Air Force's Chief of Staff was deeply troubled that one-quarter of Air Force deaths in the early 1990's were from suicide. The problem: Air Force personnel were reluctant to get help when they needed it. His response led to a preventive intervention program that has reduced suicides in the Air Force by 33%. Key to the success of that program is the strong message of support from the peak of the command structure and reduction in the stigma of acknowledging mental health problems. By changing the dynamics of how Air Force personnel addressed sensitive personal issues, by rewarding self-admission and penalizing problem-avoidance, the antecedents of suicide were effectively treated. Moreover, the intervention also reduced risk for other violent behaviors (accidental deaths, violent offenses, severe family violence). These results recommend this program as worthy of adaptation to other settings and organizations.

For more than a decade, Columbia University has developed a reliable and easy screening program for depression, suicide risk, and other mental disorders that pose a serious threat to the health, well-being, and academic success of our youth. This public health effort, called the TeenScreen Program, has an ultimate goal of ensuring that all youth are offered a mental health checkup before graduating, or otherwise leaving high school. At no charge, the Columbia University TeenScreen Program provides consultation, mental health screening materials, software, training, and tehnical assistance to schools and communities. TeenScreen identifies and refers for treatment those who are suffering from an untreated mental illness and are at risk for suicide, finding them before suicide becomes the tragic outcome.

This report and the plan it underpins combine two complementary strategies. The first is a public health approach to suicide prevention advanced by Dr. Eric Caine and his colleagues at the University of Rochester. Taken in combination with the neurobiological approach advanced by Dr. J. John Mann of Columbia University and the New York State Psychiatric Institute, a comprehensive prevention strategy is possible.

Dr. Mann has developed a stress-diathesis model to explain why certain individuals are moved to suicide, and others are not. In his view, mental illness, while prevalent in many of the suicidal population, is not sufficient to explain every suicide. (JJ Mann, MD: 2002) Rather he attributes suicidal behavior to the coincidence of stressors, such as depression, with a predisposition (diathesis) for suicidal behavior. These factors can be both genetic and environmental in origin. Neurobiological studies have identified brain-related abnormalities associated with impulsivity and aggression, specifically, low levels of serotonin in the brain. By combining the public health model advanced by Caine with the neurobiological model of Mann, we can address the full spectrum of suicide prevention: from pre-emergent symptoms in the general population to the acute state preceding a suicidal event among the high-risk population in New York.

References

Caine, ED, M.D. and Knox, KL, Ph.D., Preventing Suicide and Reducing the Burden of Suicidal Behaviors, University of Rochester Center for the Study and Prevention of Suicide (CSPS) , 2003

Carmel Hill Center for Early Diagnosis and Treatment of Mental Illness, Catch Them Before They Fall, New York: Division of Child and Adolescent Psychiatry, Columbia University, September 2003

Carpinello, Sharon E., RN, Ph.D. Going Proactive: Embracing Outreach and Prevention in the Public Mental Health Arena, Behavioral Healthcare Tomorrow, December 2004, 8-9

Centers for Disease Control and Prevention, Leading Causes for Mortality and Morbidity: New York, Summary Results, 2001

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Centers for Disease Control and Prevention, National Vital Statistics Reports, Vol.53, No.5, October 12, 2004, Table 29

Centers for Disease Control and Prevention, Ten Leading Causes of Death, New York, 2001, All Races, Both Sexes. Retrieved January 26, 2004

Centers for Disease Control and Prevention, Suicide Injury Deaths and Rates per 100,000. 2000, New York. WISQARS Injury Mortality Report. May 27, 2003

Centers for Disease Control and Prevention, Details of Leading Causes of Death, 2001 New York, Retrieved February 17, 2004

Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance, United States, 2001, Table 13. Retrieved February 18,2004

Conte, Christopher, Dealing with Demons, Governing, August 2004, 28-31

Durkheim, Emile, Suicide (Free Press: 1997). Originally published in 1897.

Goldsmith, SK, Pellmar, TC, Kleinman, AM, and Bunney, WE,(eds.) Reducing Suicide: A National Imperative. National Academies Press, 2002

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Appendix

State and National Suicide and Mental Health Resources

National Suicide Prevention LifeLine
1-800-273-8255

New York State suicide hotlines
http://suicidehotlines.com/newyork.html Leaving OMH site

Samaritans Suicide Prevention Center
518-689-4673 (Albany area)
212-673-3000 (New York City)
http://www.timesunion.com/communities/samaritans Leaving OMH site
(Albany website)
http://www.samaritansnyc.org Leaving OMH site
(New York City website)

Mental Health Association in New York State (MHANYS)
518-434-0439
http://mhanys.org Leaving OMH site

Mental Health Association of New York City (MHANYC)
212-254-0333
800-LIFENET (crisis line)
http://www.mhaofnyc.org/ Leaving OMH site

National Alliance for the Mentally Ill-New York State (NAMI-NYS)
518-462-2000
http://www.naminys.org Leaving OMH site

Teen Screen-Columbia University Program
http://www.teenscreen.org Leaving OMH site

Families Together in New York State
518-432-0333
888-326-8644 (information & referral line)
http://www.ftnys.org Leaving OMH site

Suicide Crisis Telephone Numbers for New York State by County

This list of suicide crisis phone numbers includes numbers for local county mental health clinics or the mental health units of hospitals, as these are the places best equipped to handle crisis calls in some counties.

Albany County

Allegany County

Bronx

Broome County

Cattaraugus County

Cayuga County

Chautauqua County

Chemung County

Chenango County

Clinton County

Columbia County

Cortland County

Delaware County

Dutchess County

Erie County

Essex County

Franklin County

Fulton County

Genesee County

Greene County

Hamilton County

Herkimer County

Jefferson County

Kings County

Lewis County

Livingston County

Madison County

Monroe County

Montgomery County

Nassau County

New York City

Niagara County

Oneida County

Onondaga County

Ontario County

Orange County

Orleans County

Oswego County

Otsego County

Putnam County

Queens

Rensselaer County

Richmond County

Rockland County

St. Lawrence County

Saratoga County

Schenectady County

Schoharie County

Schuyler County

Seneca County

Steuben County

Suffolk County

Sullivan County

Tioga County

Tompkins County

Ulster County

Warren County

Washington County

Wayne County

Westchester County

Wyoming County

Yates County

  • Lifeline (585) 275-5151 (800) 310-1160 TTY (585) 275-2700
  • Suicide Prevention and Crisis Service (607) 272-1616
  • Notes:

    * Source: New York State Department of Health (2004)
    * Cayuga, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence and Tompkins (Source: New York State Department of Health)