Dealing with Demons
Seen as a public health problem, suicide is preventable--at least that's an approach several states are starting to take.
In the mid-1990s, the United States Air Force was hit by a deadly epidemic: Every year between 1991 and 1996, about 60 airmen took their own lives, making suicide the second leading cause of death among the service's 350,000 members.
Eager to reduce the terrible toll, the service conducted "psychological autopsies" of the victims. These linked most of the suicides to problems airmen were having with the law, finances, intimate relationships, mental health, job performance and alcohol and drugs. The study also found most of the airmen were socially isolated and lacked the skills needed to cope with stress.
With these findings in hand, the service launched a counterattack. Top Air Force officials began urging airmen to seek assistance when they encountered personal difficulties, assuring them that doing so would not hurt their chances of promotion. The service also started training all its members in suicide risk-awareness and prevention, and it established "stress management" teams to help airmen and their families deal with potentially traumatic events.
These and other efforts worked. The suicide rate, which had been 14.1 per 100,000 active-duty service members from 1991 to 1996, fell to 9.1 per 100,000 from 1997 to 2002. Air Force officials attribute the improvement to the breadth of the program. "Suicide prevention," says one service manual, "is everyone's business."
The Air Force experience is getting a lot of attention these days in state capitols. At least 20 states have adopted suicide-prevention plans, most of them in the past few years, and many other states are working on the issue, too. Their efforts are driven by the belief that public health strategies, which involve looking for patterns that may point to the sources of disease and launching broad-based public information campaigns to encourage healthier living among the population at large, may hold the key to reducing suicide--just as they have been used to reduce heart attacks, strokes and lung cancer.
Public health campaigns to discourage smoking, bad diet or unsafe sexual practices have become a familiar and remarkably successful part of American life, but the use of such strategies against a psychological disorder represents a significant new departure. If successful, it could usher in one of the most fundamental shifts in thinking about the role of state mental health programs in decades-- one in which mental health agencies increasingly offer their services to the entire population rather than to the small group of people diagnosed as having severe mental illness.
"We have been missing opportunities to use public health promotion and prevention in the mental health sector," notes Alan Radke, who, as medical director for the adult mental health division of Hawaii's Department of Health, has been spearheading a broad review of prevention strategies for the National Association of State Mental Health Program Directors. "If we can demonstrate that the use of health promotion and prevention strategies works with suicide, from those learnings we can address any number of other conditions."
AN OUNCE OF PREVENTION
That's a big "if." The overall suicide rate has been stuck between 10 and 13 per 100,000 people annually for the past 50 years, and despite a handful of promising signs such as the Air Force program, there is no conclusive evidence that any strategy to reduce it will work. Indeed, suicide-prevention advocates sometimes seem to be acting more on faith than scientific proof. "When I started, I worried that this is too hard to fix and too big to understand," concedes Jerry Reed, executive director of the Suicide Prevention Action Network--USA, a lobby group that represents "suicide survivors," as family members of suicide victims call themselves. "But sometimes you have to act like a little bird, and hope when you leave the nest that you'll sprout wings before you hit the ground."
Although the prospects for success seem uncertain, advocates can offer some compelling reasons to tackle the problem. Suicide is the 11th leading cause of death in the United States, accounting for about 30,000 deaths a year. That's more than die from homicide (about 20,000 annually) or AIDS (14,000 a year). Moreover, researchers estimate that as many as 25 people attempt suicide for every one who actually kills himself. In 2002, some 250,000 people required medical treatment following suicide attempts, according to the Centers for Disease Control and Prevention. And surveys by the CDC show that 20 percent of teenagers have seriously considered killing themselves. (Much of the current push to combat suicide stems from a tripling of the rate among people aged 15 to 24 between 1950 and 1993, even though it has since leveled off.)
Suicide survivors have played a central role in planting the idea that suicide is a community problem, rather than a private, individual matter. That is no small step, because suicide has long carried a stigma. "It took me a couple of years before I could even talk about it," says Massachusetts state Senator Robert Antonioni, who lost a brother to suicide and has since persuaded the Massachusetts legislature to spend close to $1 million on suicide-prevention efforts over the past several years.
The important point, adds Kentucky state Senator Tom Buford, who steered a suicide-prevention bill through his state legislature this year partly in honor of his father who killed himself years ago, is that although "you feel you're living in sinful territory because somebody in your family committed suicide, after a while you see it's just an illness that needs to be treated."
Because the majority of people who are suicidal go undiagnosed until it's too late to treat the illness, researchers say the only effective strategy may be to stress prevention in messages aimed at the entire population. "By reducing the risk for a lot of people, you get more bang for your buck than concentrating on the few who are at high risk," explains Kerry Knox, an assistant professor of preventive medicine at the University of Rochester.
The idea that broad strategies work more effectively than narrow ones against a hidden enemy is a fundamental tenet of public health. Epidemiologists liken society's approach to suicide today to its understanding of cardiovascular disease 30 years ago. Then, strokes, heart attacks and high blood pressure were treated largely on a case- by-case basis. The results were far from satisfactory because, as with suicide, these afflictions often went undetected until victims suffered crippling or fatal symptoms. But research in the 1970s and '80s showed that public information campaigns designed to promote low- cholesterol diets, exercise and screening for high blood pressure among the population at large were an effective way to prevent cardiovascular disease--even though many of the people who hear such warnings probably face little risk.
At first blush, suicide seems different because it isn't a medical disease. But the latest research suggests that it may not be so different. Like cardiovascular disease, it apparently results from both biological and environmental causes. People who commit suicide or attempt it have abnormalities in the prefrontal cortex area of their brains, which controls "inhibitory" functioning. Because of this biological condition, "they are less able to restrain themselves and more likely to have strong feelings," observes J. John Mann, chief of neuroscience at the New York State Psychiatric Institute. "When they get depressed, they get more depressed than most people." He concludes that suicide may be the product of "stress-diathesis"--that is, a confluence of "stressors" arising from the environment and a "diathesis," or predisposition for suicidal behavior.
Knox and Mann both serve on a suicide-prevention working group convened by the New York State Office of Mental Health (the Psychiatric Institute, considered one of the foremost research institutions in its field, is part of the state agency). Although they come from a public health and a neurobiological background, respectively, they agree that, as Mann puts it, "You need a combination of strategies to have an impact on the suicide rate." While he believes the day isn't far off when doctors will be able to detect people who have suicidal proclivities by reading their brain scans, the technology will be of little value unless people are willing to seek help for themselves or recognize when people they know need it. "You need to educate the public to understand there are such things as psychiatric illnesses, and that they can lead to suicide," he says. "That requires the involvement of government."
THE CPR METHOD
Most states have started their suicide-prevention efforts with broad- based educational campaigns. This spring, for instance, New York State issued "SPEAK," which stands for Suicide Prevention Education Awareness Kits--packets of materials that explain the connections between depression and suicide and encourage help-seeking among teens, men, women and older people. Some states also offer advice to the news media on how to report on suicide. Guidelines adopted by Maine, for instance, seek to minimize the danger of "suicide contagion" by encouraging the press to refrain from describing how a person killed himself, glorifying a suicide and using such phrases as "successful suicide."
Some states have gone beyond educational programs to concentrate on strengthening the bonds that make for more supportive communities. In Alaska, where religious disillusionment and social breakdown are believed to lie behind high suicide rates among some native peoples, the state provides funds for village elders to teach children about their heritage. "This builds pride and relationships, so that if a kid gets in trouble later, he'll have somebody to turn to," explains Susan Soule, Alaska's program coordinator for suicide prevention and rural human services.
In the lower 48, suicide-prevention programs seek to accomplish the same objective by training "gatekeepers"--clergy, doctors, teachers, social workers and others--who might come into contact with people who are suicidal. Paul Quinnett, president and chief executive of the QPR Institute in Spokane, Washington, believes that doctors, psychologists and social workers should be required to receive suicide-prevention training as a condition of being licensed. QPR, a deliberate take-off on the familiar emergency treatment CPR, stands for "Question, Persuade and Refer," a simple methodology for detecting people at risk of suicide and helping them get professional assistance.
North Dakota has provided its own version of suicide-prevention training to 28,000 people since 2000 on a budget of just $75,000 a year. The program seeks official gatekeepers as well as informal leaders--people who tend to pull communities together by force of personality rather than official position. "We go into schools and ask, 'Who is the person who makes things happen?'" says Mark Lomurray, the state's suicide-prevention project leader. "That's who we train." While Lomurray can't prove a causal connection, he notes that the number of suicide deaths in North Dakota has fallen by almost half since the program began.
A BROAD REACH
It is too early to say if all the efforts surrounding suicide prevention will pay off, but if they do, state mental health programs may well need more money. "Right now, we do a good job identifying people who are suicidal, and we can refer them for services if there's a crisis," notes Cheryl DiCara, director of Maine's Youth Suicide Prevention Program. But for people who are troubled and haven't reached the crisis point, she says, "there's not a lot we can do."
Prevention advocates say that public health strategies may save money in the long run by reducing the need for acute care. But that implies new methods of serving people who don't need institutionalization. New York State offers some clues about where this more expansive orientation might lead. Traditionally, the Office of Mental Health has focused exclusively on helping people with severe mental disorders. After the September 2001 terrorist attacks, however, the department, with funding from the Federal Emergency Management Agency, began offering post-trauma counseling to the entire population of New York City and 10 surrounding counties. In two years, more than a million people availed themselves of these free counseling and educational services.
"We're reaching out to a much broader constituency than we ever did previously," notes Sharon Carpinello, New York's mental health commissioner. She expects the agency to become involved in a variety of new public health endeavors. In addition to suicide prevention, the agency is developing a disaster preparedness and "resiliency" campaign for the entire state and a separate campaign aimed at combating eating disorders in young women.
John Allen, who serves as the office's liaison with outside groups, says the new public health focus has brought enormous changes to his job. In the past, he mainly worked with a few small groups that represented patients in mental hospitals. But the post-9/11 project took him into the mainstream. One of his most important partnerships was with the New York State Thruway Authority, which helped the office distribute brochures to commuters. And the suicide-prevention program is bringing him into contact with major employers, local civic organizations and chambers of commerce.
As the department increasingly operates in a bigger arena, some prevention advocates hope it will start asserting itself on matters that previously have been beyond its ability to influence--including proposals to require insurance companies to offer the same coverage for mental illness treatments as they provide for medical care. The idea, of course, is very controversial because of the possible costs, but it's nothing compared with another issue that some prevention advocates have in their sights: gun control.
At the moment, there is no consensus even among suicide experts that stricter gun control would reduce the suicide rate over the long run. The best evidence is that making the leading instrument of suicide less available might have an impact for a while but that the improvement might dissipate over time as people switch to alternative methods to kill themselves. But the simple fact that the idea is even being discussed is a measure of how optimistic the mental health community is about the potential of public health strategies.
"I think we have to stay away from the more controversial strategies until society changes a little bit, but I don't feel totally hopeless," says Madelyn Gould, a research scientist at the New York State Psychiatric Institute who has participated in the state's suicide-prevention working group. "After all, who would have thought a couple of decades ago that anti-smoking campaigns would be so successful that today you can't even smoke anymore in bars in New York City?"