between 1950 and 1984 failed to show a straightforward relationship between detoxification and suicide rates. Suicide among men by this method began to decline along with detoxification until 1979, at which point it began to rise again. A decline in female suicides by this method began in 1975 (Clarke and Lester, 1986).

Railway Suicides

The rate of railway suicide (e.g., jumping in front of a train) also is related to access. In New York, the rate of railway or subway suicide is proportional to the amount of track in a given borough (Marzuk et al., 1992). However, among cities internationally, there are marked variations in the suicide rate per passenger. Rates are extremely low in Singapore, Tokyo, Budapest, and Hong Kong but much higher in London, Barcelona, Rio de Janeiro, and Paris (O’Donnell et al., 1994).

Because the case fatality rate is high (estimated at 55 percent) and prediction is difficult, injury control methods have been suggested to reduce fatality. Suggestions include physical separation of passengers from the train bed, improved surveillance of passengers by station staff, liaison to hospital staff in stations with a high density of chronic mental patients, availability of emergency hotline telephones, redesign of bumper of train (including the addition of an airbag), increasing the distance between the train and the train bed, and a slower speed of approach to the station (Beskow et al., 1994; Clarke and Poyner, 1994). In addition to design issues, curbing media publicity about railway suicides may diminish the likelihood of imitation (Schmidtke and Hafner, 1988; Sonneck et al., 1994, see earlier section).

Hotlines and Crisis Centers

Research on the effectiveness of hotlines and crisis centers in reducing suicide is scarce, and what does exist is inconsistent. Yet the high prevalence of such services and their high usage warrants research so that the most effective services can be provided. There are over 350 Befrienders International Centers, associated with The Samaritans, in over 40 countries (see Scott, 2000), and there are over 1000 teen suicide hotlines alone in the United States as of 1992 (CDC, 1992). Hotlines and crisis intervention services include a broad scope of services including anonymous or non-anonymous phone counseling for suicidal individuals and/or their family and friends, face-to-face counseling, and referrals by professionals, paraprofessionals, and/or volunteers with various training. These services can intervene during an acute suicidal crisis and connect individuals to additional mental health services that they might not otherwise



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