2005-2009 Statewide Comprehensive Plan for Mental Health Service Services
Chapter 8: Preventing Suicide

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Overview of OMH's Statewide Suicide Prevention Campaign

In May 2004, OMH launched SPEAK, 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.¹ Research has shown that suicide prevention and early intervention efforts are successful in saving lives, and by encouraging and assisting people to learn when, where, and how to speak up, suicides may be prevented.

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. SPEAK is designed to provide people with information to help them better understand suicide and give them ways to help prevent it. The kits include information about suicide, suicide prevention, risk factors, warning signs, and resources about how to seek help through crisis information and treatment sources that are accessible on a 24/7 basis in every New York State county. There is also information about specific populations and age groups (i.e. men, women, older adults and teens). Ongoing research findings are informing further development of SPEAK. For example, a booklet written specifically for parents of college students was added in response to a recent research finding that the percentages of students treated for depression and feeling suicidal doubled during 1989-2001.²

While the main goal of the SPEAK campaign is education and awareness to prevent suicide, it is hoped that SPEAK's broad-based public mental 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 you or someone you care for needs it.

Extensive use of both print and electronic media is an important element of the SPEAK campaign. In 2004, OMH launched multiple initiatives to raise the public's awareness and understanding of the need for suicide prevention and to combat stigma. More than 10,000 SPEAK kits have been distributed, with an additional 20,000 requests for specific booklets, posters, and resource guides in the process of being fulfilled. These booklets are written for specific populations at risk: those who are depressed, teenagers, older adults, women, men, and college students. Requests for kits have come from a cross section of community organizations and individuals: primary care physicians and nurses (89); not-for-profit agencies (12,155), State psychiatric hospitals' outpatient programs (1,122); voluntary and private hospitals and health maintenance organizations (1,921); school districts (all 1,692 schools in the State will receive kits via the State Education Department); local government agencies (1,273); State agencies with local programs (1,435); colleges and universities (375); professional associations (1,498); advocacy organizations and individuals (1,290); pastoral and faith community (196); out-of-state (130); individual requests (273); and corrections and law enforcement (3). These numbers do not reflect the potential of other State and Local agencies printing and distributing SPEAK kits on their own.

Beyond the printed word, more than 2,000 individuals have been instructed in person about SPEAK by OMH's Commissioner, Director of Project Management, and Health Promotion and Education staff. Audiences have included: NASMHPD, National Council on Suicide Prevention, medical staff at Jamaica Hospital Medical Center, NAMI-NYS, United Way of New York State and New York City, NYSUT Health Educators, MHA-NYC, New York Psychological Association, a statewide Trauma Symposium held in Brooklyn, visitors to the 2004 New York State Fair in Syracuse. In all, more than 37 SPEAK presentations were held in 2004 and more are planned during 2005. In June 2004, SPEAK was the featured subject of a Benita Zahn televised health program broadcast on Channel 13 (Albany), and additional suicide prevention public service announcements are planned for television and radio which target college students, adolescents, and the elderly.

SPEAK is also available on the OMH Web site in English and Spanish at http://www.omh.state.ny.us/omhweb/speak/. Feature articles on SPEAK have appeared in Governing magazine,³ Mental Health Weekly⁴ and Behavioral Healthcare Tomorrow.⁵

Suicide in New York

Suicide is the leading cause of violent death in New York State, the U.S., and the world. The number of New York State residents whose lives are lost to suicide (1,292 in 2002) exceeds the number of homicide victims by 32%. One in ten New York teenagers made plans to commit suicide in 2003, and one in seven seriously considered it. The economic impact of suicide in our State is estimated to be between $1.1 and $5.0 billion annually. The suicide rate in New York State peaked in 1994, declined steadily until 1999, and has remained constant since that time at 6.6 suicides per 100,000 population.⁶

In 2002, one in 25 suicides in the U.S. occurred in New York State, and the State had the sixth highest number of suicides in the nation after California, Florida, Texas, Pennsylvania, and Ohio. For each completed suicide in New York, there are 8-25 attempts, resulting in millions of dollars in health care expenditures, lost wages, disability payments, and lost productivity. From 2000-2002, 3,830 New York residents completed suicide, and more than 24,000 individuals were treated and discharged from New York hospitals as a result of self-inflicted injuries. Most of those treated were female. Most of those who died were male.

Geography, Race, Ethnicity, Sex and Age Factors

The incidence of suicide in New York mirrors a national trend of elevated attempts in rural areas, compared to urban or suburban areas. Besides geography, incidence is affected by race, ethnicity, sex and age factors. Among suicide deaths in New York State in 2000, 80% were male, 85% were White, 10% were Black, and 8% were Hispanic. Males comprised 68% of suicides among Whites and 78% among both Blacks and Hispanics. Overall, White males aged 25-54 accounted for nearly 40% of all New York suicides in 2000.

During this time period, there were no recorded suicides for Black females aged 65 and older or for Hispanic females between 25-34 years of age or older than 75. Finally, suicide among the very young (<15 years) is rare: 11 suicides were recorded for this age group (8 males, 3 females). Starting at age 15, however, the suicide rate begins to climb. Older individuals, especially White males, have elevated rates, as do Native Americans.

According to the federal Center for Disease Control (CDC, 2001), in New York State suicide is the third leading cause of death among those aged 15-24, fourth for those aged 10-14, fifth for those aged 25-34, sixth for those aged 35-44, and ninth for those aged 45-54.⁷. The typical suicide death in the State is a middle-aged White male, living alone upstate, who is suffering from depression and uses a firearm to end his life. For every death, the lives of families and friends are negatively impacted emotionally, socially, and economically.

More information about suicide in New York State is available on the Department of Health (DOH) Web site at http://www.health.state.ny.us/nysdoh/chac/ .

The National Perspective

There are two barriers to considering suicide as a public health problem: the traditional view that suicide is an isolated act, and the belief that most acts of suicide cannot be prevented. Recent national reports describe research advances in neuroscience, psychiatry, epidemiology, and behavioral science demonstrating that these beliefs are largely incorrect.

In 1999, The Surgeon General's Call to Action to Prevent Suicide 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 called Awareness, Intervention, and Methodology (AIM). Awareness signifies our commitment to broaden the public's awareness of suicide and its risk factors. Intervention recognizes that the burden of suicide prevention lies with everyone, not just the medical community. It calls for the development and enhancement of community-based suicide prevention programs that involve a cross-section of community members who can recognize the signs of suicidal intent and intervene. Methodology compels us to advance the science of suicide prevention.

The National Strategy for Suicide Prevention (NSSP), a collaborative effort of SAMHSA, CDC, and other federal agencies, represents the combined work of advocates, clinicians, researchers and suicide survivors around the nation. Its Summary of National Strategy for Suicide Prevention: Goals and Objectives for Action (2001) lays out a framework for action to prevent suicide and guides development of an array of services and programs. The NSSP has established twelve goals and encourages states to meet them through well-integrated plans and programs. More information about this national suicide prevention project is available on its Web site at http://www.mentalhealth.samhsa.gov/suicideprevention/strategy.asp .

In 2002 the Institute of Medicine of the National Academy of Sciences published their report, Reducing Suicide. Its panel of experts recommended a broad range of actions based on the best scientific evidence to date. The Final Report of the President's New Freedom Commission, Achieving the Promise (2003) concluded that "suicide is a serious public health challenge that has not received the attention and degree of a national priority it deserves. Many Americans are unaware of suicide's toll and its global impact." Accordingly, the Commission's first goal is to save lives throughout the nation by preventing suicides across the life span. The Commission has identified two model mental health programs whose goals include suicide prevention: the "United States Air Force Initiative to Prevent Suicide" ⁸ and the "Columbia University TeenScreen® Program." ⁹

In the early 1990s one-quarter of U.S. Air Force deaths resulted from suicide. In response, the U.S. Air Force Initiative to Prevent Suicide was implemented and it has since reduced suicides in the Air Force by 33%. Key to the program's success is the strong message of support from the top of the command structure and efforts to reduce the stigma of acknowledging mental health problems. By changing the dynamics of how Air Force personnel addressed sensitive personal issues and rewarding self-admission and penalizing problem-avoidance, factors leading to suicide were effectively treated. Moreover, the intervention also reduced risk for other violent behaviors (e.g., accidental deaths, violent offenses, and severe family violence).

Columbia University's TeenScreen® program is designed as an easy and reliable 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. The program's goal is to ensure 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 technical 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.

Beyond Awareness: Suicide Prevention in New York State

Suicides are a complication of psychiatric disorders. More than 90% of those attempting suicide have a diagnosable psychiatric illness,¹⁰ and the most common diagnoses are mood disorders including major depression, bipolar disorder, and dysthymia. Treatment of depression with psychotropic medications is usually effective, as are certain cognitive therapies. To effectively reduce the suicide rate, an integrated strategy involving multiple interventions is required. Access to evidence-based care and treatment for those who are depressed or suicidal across the life cycle is essential. Early identification of those who bear suicidal risk from depression, coupled with referral for treatment, will improve the prospects for saving lives.

A multi-layered strategy that combines focused attention on those who are imminently suicidal and many others who harbor risk factors predisposing them to self-harm, but are not yet in a suicidal state, offers the best hope of saving lives in New York. Given the close connection between mental disorders and suicidality, prevention must give special attention to diagnosing and treating persons with a psychiatric disorder.

From a statewide perspective, mental wellness and suicide prevention are "local." To be meaningful, behavioral change must originate in our communities in peoples' homes and workplaces; in the courts and criminal justice system; in jails and prisons; in non-governmental organizations, community and faith-based agencies; and in government agencies.¹¹ The essential goal of such grass roots efforts is to de-stigmatize help-seeking around suicidal thoughts and feelings.

Saving Lives in New York

A statewide, population-based effort at suicide prevention needs to be flexible enough to impact citizens living in rural settings as well as densely populated metropolitan areas and suburbs. For the past two years, OMH researchers have collaborated with members of the New York State Suicide Prevention Council to assess the current state of suicide in New York and to offer real world solutions to saving lives at risk.¹² The result is a 450 page study containing recommendations based on the 'best science' of suicide prevention. The study identified several approaches to suicide prevention including promoting personal resilience, adopting guidelines for media coverage of suicidal events, broader mental health screening, availability of warm lines and hot lines statewide, and restrictions on access to lethal means by suicidal persons. The burden of suicide throughout the life course is explained by specialists in each of the following populations: adolescents, college students, families, suicide survivors, new mothers, men in the middle years, cultural, ethnic and racial groups, recipients of mental health services, the dually diagnosed, and older adults.

The study's findings and recommendations will be available in the near future.

OMH Suicide Research and Intervention

The enigma that is suicide is the research problem that a group of neuroscientists and child psychiatrists in OMH have made their life's work. The goal is to elucidate the triggers for suicide and then develop interventions to prevent it. OMH researchers are on their way to satisfying that goal.

Neuroscientists in OMH have embraced modern technologies and applied them successfully in deciphering the brain. Child psychiatrists found that rigorous research techniques coupled with sensitivity when approaching teens at risk is the best approach to getting results.

Suicide and the Brain

A number of years ago, researchers began investigating the causes of suicide and found that while there are biological abnormalities in the brain involving neurotransmitters, such as serotonin, that underlie major depression and related mood disorders, there was a separate set of abnormalities in the brain related to the predisposition or vulnerability to commit suicide. By careful mapping of these abnormalities in the brain of individuals who have committed suicide, the researchers have been able to identify an area of the brain that is involved in impulse control. The input of the neurotransmitter serotonin to this area of the brain is clearly impaired in individuals who commit suicide. This impairment contributes to the clinical observation that these individuals tend to be more likely to act on powerful feelings and, in general, remain more impulsive throughout their lives. Unfortunately, when this impulsivity is coupled with depression and suicidal feelings, the individual is more likely to act on those feelings and commit suicide. OMH researchers have observed that the serotonin system that supplies that part of the brain seems to show a deficit and, by extension, have determined that there is a similar deficit in individuals who are impulsively aggressive. Thus, a breakdown or an impairment of this behavioral restraint system in the brain may predispose certain individuals to commit suicide when they feel very depressed and other individuals to commit aggressive acts when they feel angry.

With the availability of brain scanning techniques in very recent time, we have extended our research to try to determine whether individuals who are at risk for suicidal behavior manifest the same deficits in the serotonin system in the brain prior to suicide. Can these findings in postmortem brain studies be observed in living individuals before they commit suicide? To find out, researchers have employed a combination of PET (positron emission tomography) or PET scanning and MR imaging (magnetic resonance imaging) to study the brain of individuals who are suffering from depressions and to compare those who have a history of suicidal behavior to those who have never manifested any suicidal behavior. Preliminarily, these findings are beginning to demonstrate serotonin abnormalities that may be responsible for suicidal behavior and opening, for the first time, the possibility that these individuals can be intensively treated in order to prevent suicide. The introduction of such scanning techniques into clinical practice represents a very real possibility in terms of enhancing our ability to detect such high-risk individuals. At present, general clinical evaluation has proven an insufficient method to detect high-risk individuals, and may explain why suicides occur in individuals who have seen their doctor within the last month. Adding brain imaging approaches involving brain scans to detect these vulnerable individuals may increase the likelihood that more high-risk individuals will be detected before they die and permit the implementation of appropriate medication and psychotherapies. The increasing knowledge gained by such innovative research is a boon to those in the field as well as people whose lives have been personally touched by suicide.

Adolescent Suicide

OMH child researchers have helped to launch programs in schools nationwide, including New York, to address the absence of a mental health component to general health evaluations. Schools provide the ideal setting to introduce interventions to identify children potentially at risk for suicide and in need of treatment. The researchers developed the DISC (Diagnostic Interview Schedule for Children), the most widely tested and researched child psychiatric assessment tool available. The computerized and self-administered version of this instrument allows children, including those who are unable to read, a private interview that provides complete reporting and instant diagnosis based on DSM-IV, the manual of psychiatric disorders.

While these intervention measures are critical, a discussion of suicide must also include an examination of the contagion phenomenon. Known as the "copycat effect," teens are particularly vulnerable to suicide by notables or fellow students and are influenced by reports and portrayals of suicide in their schools or in the mass media. To reduce the contagion or copycat effect, the OMH researchers were recruited for a national panel to develop specific research-based recommendations for the media and for school personnel. The report includes facts about suicide and mental illness, recommendations for interviewing surviving relatives and friends as well as recommendations for language. This was a necessary step towards increasing awareness in the media and encouraging responsible reporting that may serve to educate the public.

Conclusion

Through public mental health promotion, research, and collaborative work with members of the New York State Suicide Prevention Council, New York State is talking important steps to lessen the burden of suicide for our citizens. Giving people the information they need to help themselves can lead to an overall reduction of risk factors that can lead to self-harm, and an increased quality of life for all. In addition, accurate information will go far in challenging the myths and unveiling the mysteries that so often surround mental illness and suicide.

Outreach efforts that are multidimensional and address the needs of the entire person have the greatest potential for positive impact. OMH will continue to successfully address meeting the needs of "every single one" by approaching public mental health efforts such as SPEAK in partnership with colleagues and counterparts in other governmental and community-based health, social or family service agencies. For example, the agency is developing a disaster preparedness and "resiliency" campaign for the entire State and a separate campaign, in partnership with the State Department of Health, is aimed at combating eating disorders in young women. By broadening its focus beyond treating mental illness only, and reaching into communities through public mental health promotion efforts, OMH has enhanced the potential to promote the mental health of all New Yorkers.

Notes

¹ The OMH press release announcing the statewide suicide prevention campaign is included in Appendix 8.
² Benson, S.A., Robertson, J.M., Tseng, W-C., Newton, F.B., & Benton, S.L. (2003). Changes in counseling center client problems across 13 years. Professional Psychology: Research & Practice, 34(1) 66-72.
³ Conte, Christopher, Dealing with Demons. Governing, August 2004, pp. 28-31.
⁴ New York spearheads its own suicide prevention, education initiative. Mental Health Weekly, July 26, 2004, vol.14, no.28, pp. 1-3.
⁵ Carpinello, S.E. (December 2004). Going proactive: Embracing outreach and prevention in the public mental health arena. Behavioral Healthcare Tomorrow, 13 (6): 8-9.
⁶ Source: 2000-2002 Vital Statistics, Center for Community Health, New York State Department of Health (August 2004). Rate adjusted for the 2000 Census.
⁷ Centers for Disease Control and Prevention, Leading Causes for Mortality and Morbidity: New York, Summary Results, 2001.
⁸ More information about the United States Air Force Initiative to Prevent Suicide is available on the Web at http://phs.os.dhhs.gov/ophs/BestPractice/usaf.htm
⁹ More information about the TeenScreen(r) program is available on the Web at www.teenscreen.org .
¹⁰ Mann, J.J. (2002). A current perspective of suicide and attempted suicide. Annals of Internal Medicine, 136: 302-311
¹¹ Knox, K.L., Conwell, Y., & Caine, E.D. (2004). If suicide is a public health problem, what are we doing to prevent it? American Journal of Public Health, 94(1): 37-45.
¹² See Appendix 9 for a New York State Suicide Prevention Council membership list.

Additional Sources of Information

"A Landmark Program Beyond Compare," Preventing Suicide: The National Journal, 3(2) February 2004, p. 3.

American Academy of Child & Adolescent Psychiatry, Children and Firearms, 1999.

Chaudron, L.H., & Caine, E.D. (2004). Suicide among women: a critical review. J Am Med Womens Assoc., 59(2):125-34.

Goldsmith, S.K., Pellmar, T.C., Kleinman, A.M., & Bunney, W.E. (eds.) Reducing Suicide: A National Imperative. (Washington, DC: The National Academies Press, 2002).

Moscicki, E.K., & Caine, E.D. (2004). Opportunities of life: preventing suicide in elderly patients. Arch Intern Med.,164(11):1171-2.

National Heart, Lung, and Blood Institute (NHLBI), The Framingham Study: Design, Rationale, and Objectives. Online at www.framingham.com/heart/ Retrieved on 10/21/04.

National Strategy for Suicide Prevention: Goals and Objectives for Action. (Washington, DC: DHHS, 2001).

President's New Freedom Commission on Mental Health Final Report. (2003). Achieving the Promise: Transforming Mental Health Care in America. (Washington, DC: DHHS).

The Surgeon General's Call to Action to Prevent Suicide (Washington, DC: DHHS, 1999).

National Suicide Prevention Hotline and Web Site The U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMHSA) has launched the National Suicide Prevention Lifeline 1-800-273-TALK. The national hotline is part of the National Suicide Prevention Initiative (NSPI)-a collaborative effort led by SAMHSA that incorporates the best practices and research findings in suicide prevention and intervention with the goal of reducing the incidence of suicide nationwide. In addition to the national hotline, a new Web site has been launched at http://www.suicidepreventionlifeline.org .

Comments or questions about the information on this page can be directed to the Office of Planning.