Reducing Suicide

A NATIONAL IMPERATIVE

SK Goldsmith, TC Pellmar, AM Kleinman, WE Bunney, editors

Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide

Board on Neuroscience and Behavioral Health

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Reducing Suicide: A National Imperative Reducing Suicide A NATIONAL IMPERATIVE SK Goldsmith, TC Pellmar, AM Kleinman, WE Bunney, editors Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide Board on Neuroscience and Behavioral Health INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Reducing Suicide: A National Imperative THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the Centers for Disease Control and Prevention, the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, the Substance Abuse and Mental Health Services Administration, and the Veterans Administration. The views presented in this report are those of the Institute of Medicine Committee on Pathophysiology and Prevention of Adolescent and Adult Suicide and are not necessarily those of the funding agencies. Library of Congress Cataloging-in-Publication Data Reducing suicide : a national imperative / S.K. Goldsmith … [et al.], editors ; Committee on Pathophysiology & Prevention of Adolescent & Adult Suicide, Board on Neuroscience and Behavioral Health, Institute of Medicine. p. ;cm. Includes bibliographical references and index. ISBN 0-309-08321-4 (pbk.) 1. Suicide—United States. 2. Suicide—United States—Prevention. 3. Suicidal behavior—Treatment—United States. 4. Suicidal behavior—Risk factors—United States. [DNLM: 1. Suicide—prevention & control—United States. 2. Psychotherapy—United States. 3. Risk Factors—United States. 4. Social Support—United States. 5. Suicide—psychology—United States. ] I. Goldsmith, Sara K. II. Institute of Medicine (U.S.). Committee on Pathophysiology & Prevention of Adolescent & Adult Suicide. HV6548.U5 R43 2002 362.28’7’0973—dc21 2002012032 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Printed in the United States of America. Copyright 2002 by the National Academy of Sciences. All rights reserved. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Reducing Suicide: A National Imperative “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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Reducing Suicide: A National Imperative THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Reducing Suicide: A National Imperative COMMITTEE ON PATHOPHYSIOLOGY AND PREVENTION OF ADOLESCENT AND ADULT SUICIDE WILLIAM E. BUNNEY, JR., M.D. (Co-Chair), University of California, Irvine, California ARTHUR M. KLEINMAN, M.D. (Co-Chair), Harvard University, Cambridge, Massachusetts CARL C. BELL, M.D., Community Mental Health Council and University of Illinois, Chicago, Illinois DAVID A. BRENT, M.D., Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania LEONA EGGERT, PH.D., FAAN, University of Washington, Seattle, Washington JAN FAWCETT, M.D., Rush Institute for Mental Well-Being, Chicago, Illinois ROBERT D. GIBBONS, PH.D., University of Illinois, Chicago, Illinois KAY REDFIELD JAMISON, PH.D., The Johns Hopkins University School of Medicine, Baltimore, Maryland JILL E. KORBIN, PH.D., Case Western Reserve University, Cleveland, Ohio J. JOHN MANN, M.D., New York State Psychiatric Institute and Columbia University, New York, New York PHILIP A. MAY, PH.D., University of New Mexico, Albuquerque, New Mexico CHARLES F. REYNOLDS, III, M.D., Western Psychiatric Institute and Clinic, University of Pittsburgh, Pittsburgh, Pennsylvania MING T. TSUANG, M.D., PH.D., Harvard Medical School, Boston, Massachusetts RICHARD G. FRANK, PH.D. (Liaison to the Board on Neuroscience and Behavioral Health), Harvard Medical School, Boston, Massachusetts Staff TERRY C. PELLMAR, PH.D., Board Director, NBH SARA K. GOLDSMITH, PH.D., Study Director (until April 2002) SANDRA P. AU, Research Associate (until June 2001) DARIA K. BOENINGER, Research Assistant (since July 2001, until March 2002) ALLISON M. PANZER, Senior Project Assistant LORA K. TAYLOR, Administrative Assistant (until July 2001) CATHERINE A. PAIGE, Administrative Assistant (since October 2001) JENNIFER CANGCO, Financial Associate (until August 2001) ROSA POMMIER, Financial Associate (since December 2001) MIRIAM DAVIS, PH.D., Consultant BERNICE A. PESCOSOLIDO, PH.D., Consultant

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Reducing Suicide: A National Imperative BOARD ON NEUROSCIENCE AND BEHAVIORAL HEALTH KENNETH B. WELLS (Chair), Neuropsychiatric Institute, University of California, Los Angeles, California NANCY E. ADLER, University of California, San Francisco, California PAUL S. APPELBAUM, University of Massachusetts Medical School, Worcester, Massachusetts WILLIAM E. BUNNEY, University of California, Irvine, California HOWARD FIELDS, University of California, San Francisco RICHARD G. FRANK, Harvard Medical School, Boston, Massachusetts SID GILMAN, University of Michigan, Ann Arbor HERBERT D. KLEBER, Columbia University and New York State Psychiatric Institute, New York, New York BEVERLY B. LONG, World Federation for Mental Health, Atlanta, Georgia KAREN MATTHEWS, University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania BRUCE MCEWEN, The Rockefeller University, New York, New York KATHLEEN R. MERIKANGAS, Yale University, New Haven, Connecticut DAVID REISS, George Washington University Medical Center, Washington, D.C. RHONDA J. ROBINSON-BEALE, Blue Cross/Blue Shield, Detroit, Michigan CHARLES F. ZORUMSKI, Washington University School of Medicine, St. Louis, Missouri Staff TERRY C. PELLMAR, Director MICHAEL ABRAMS, Program Officer ADRIENNE STITH BUTLER, Program Officer MILAP NOWRANGI, Research Assistant BRIAN MCQUILLAN, Senior Project Assistant ALLISON M. PANZER, Senior Project Assistant CATHERINE A. PAIGE, Administrative Assistant

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Reducing Suicide: A National Imperative Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Daniel Blazer, Duke University Medical Center Gregory Fricchione, The Carter Center Douglas G. Jacobs, Harvard Medical School David Lester, Richard Stockton College Marsha M. Linehan, University of Washington Anthony J. Marsella, University of Hawaii David O. Meltzer, The University of Chicago, Pritzker School of Medicine Charles O’Brien, University of Pennsylvania Lee N. Robins, Washington University School of Medicine David Satcher, Morehouse School of Medicine Richard D. Todd, Washington University School of Medicine

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Reducing Suicide: A National Imperative Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Joseph Coyle, Harvard Medical School and Henry W. Riecken, University of Pennsylvania. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Reducing Suicide: A National Imperative Preface When Kevin Carter, a celebrated South African photo-journalist who was in his 30’s and only months before had won the highly prestigious Pulitzer Prize, killed himself several years ago, it was at first assumed that his suicide was linked to the consequences in trauma, moral desolation, and guilt that he experienced in filming some of Africa’s great human tragedies: wars and famines. Indeed his suicide note indicates as much. Soon afterward it was learned that he had been abusing drugs and suffered from bipolar disorder. Later still, it surfaced that he had experienced a wrenching divorce and was deeply upset about the separation from his young daughter. As this case shows, suicide can be a complex process. If ever a condition begged for an integrated understanding that takes into account biological, clinical, subjective, and social factors, this is it. It is for this reason that global data on suicide loom large and usefully balance findings from the United States that are the primary focus of this report. For example, although American psychiatrists have found that 90 percent of suicides in our country appear to be associated with a mental illness, data from China suggest that probably less than half of suicides there have such a correlation. In China, unlike most countries, more women than men kill themselves. Eastern European societies experience suicide rates 4 to 6 times higher than in the United States. Whereas in Hungary there has long been a very high rate of suicide, in other countries formerly part of the Soviet Union, the elevated rates correlate with a period of deep and disruptive social change. Suicide may have a basis in depression or substance abuse, but it simultaneously may relate to social factors like community breakdown, loss of key social relations, economic

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Reducing Suicide: A National Imperative depression, or political violence. Indeed, it may be that emotional states like hopelessness and impulsiveness link these different levels of human experience. It is important not to lose this sense of complexity if we are to fashion intervention programs that can prevent suicide. This report reflects different perspectives and levels of analysis. It embodies tensions between medical and social analyses of suicide that date back at least 100 years. Given the uncertain status of the science, it is not always possible or even useful to try to resolve these distinctive points of view. But we have tried to place all the relevant materials before the reader; even where the tensions can not be resolved by efforts at integration of analytic approaches, we have tried to present the uncertainties and contradictions. That way we feel we have done justice to the science and to the resonantly human characteristics of this crucial subject. Indeed, it is inconceivable that policy and programs will be up to the challenge unless they engage the different sides of suicide. Suicide is a medical issue; but it is also an economic, social relational, moral, and as September 11’s tragic global spectacle of suicide terrorist attack made clear, a political issue as well. Suicide prevention, in turn, holds medical, social, psychological, economic, moral and political significance. Our Committee of medical and social scientists grappled as best it could with this complex reality and has written a report that suggests that this is precisely what policy makers need to do to advance the science and improve health and social responses. I wish to acknowledge the crucial role played by the Committee’s staff in assembling this report from the Committee’s diverse perspectives. Arthur Kleinman, M.D. *** Suicide represents a major national and international public health problem with about 30,000 deaths in the United States and 1,000,000 deaths in the world each year and every year. The estimated cost to this nation in lost income alone is 11.8 billion dollars per year. There has been in the past and is currently a dramatic mismatch in terms of the federal dollars devoted to the understanding and prevention of suicide contrasted with other diseases of less public health impact. Research tools and opportunities currently exist to attack the problem of suicide. Recent successful programs for the prevention of suicide demand further testing. This report recommends a comprehensive approach to suicide and the development of a network of research laboratories for the study of suicide. There is every reason to expect that a national consensus to declare

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Reducing Suicide: A National Imperative war on suicide and to fund research and prevention at a level commensurate with the severity of the problem will be successful and will lead to highly significant discoveries as have the wars on cancer, Alzheimer’s disease, and AIDS. Suicide is the eleventh leading cause of death for all ages in the United States and the third leading cause of death among adolescents. A great deal of local and national funding and effort has been devoted to the problem of homicide in contrast to suicide. However, suicides in this country outnumber homicides by a third. During the period of the Vietnam War, four times the number of Americans died by suicide than died in combat. Two hundred thousand more people died of suicide than died of AIDS in the past 20 years. These mortality figures do not capture the intense suffering of the suicidal patient. One patient stated the night before she committed suicide: “The pain is all consuming, overwhelming. The pain has become excruciating, constant and endless.” A great deal has been learned about the risk factors contributing to suicide, biological changes that are associated with suicide, links between childhood trauma and suicide, and the impact of social and cultural influences, medical and psychosocial interventions. But a fundamental understanding of the suicide process remains unknown, and national prevention efforts have not been successful. The establishment of 60 centers throughout the United States to fight a war on cancer, and 28 Alzheimer disease centers, to fight a war on Alzheimer’s disease, provide highly successful models for the committee recommendation to develop a network of eight population-based research laboratories for war on suicide and investigation of the suicidal process. In 2000, the National Institute of Mental Health, the National Institute of Drug Abuse, the Veterans Administration, the National Institute on Alcohol Abuse and Alcoholism, Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention asked the Institute of Medicine to assess the science base of suicide etiology, evaluate the current status of primary and secondary prevention including risk and protective factors, develop strategies for studying suicide and comment on gaps in knowledge, research opportunities and strategies for prevention. The Institute of Medicine formed a Committee on the Pathophysiology and Prevention of Adolescent and Adult Suicide. In conducting this study, the 13-member committee met six times during 2001. The Committee was informed by two hosted workshops, Suicide Prevention and Risk Factors for Suicide, the deliberations of which have been subsequently published. The meeting agendas are in Appendix C of this report. At these workshops the committee was informed by a number of presentations by experts in the field. These included: Aaron T. Beck, C. Hendricks Brown, Gregory Brown, William Byerley, Katherine

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Reducing Suicide: A National Imperative Comtois, David Goldston, Madelyn Gould, David Hemenway, John Kalafat, Ronald Maris, Eve Mosscicki, Ghanshayam Pandey, Robert Post, Herbert C. Schulberg, Edwin Shneidman, and Martin Teicher. Additional experts in the field of suicide made presentations to the Committee: Paul Appelbaum, Alan Berman, Robert Gebbia, Scott Kim, Bernice Pescosolido, and Leonardo Tondo. Several representatives from government agencies provided their perspectives: Steven M. Berkowitz, Alexander Crosby, Robert DeMartino, David Litts, Jacques Normand, Jane Pearson, and Deidra Roach. Still others prepared background papers or provided analyses and data: Robert Anderson, Lois Fingerhut, David Jobes, Thomas Joiner, Jeremy Pettit, Ramani Pilla, Morton Silverman, and Shirley Zimmerman. The names and affiliations of these expert consultants are listed in Appendix B. Subsequently, individual committee members prepared draft chapters. Analysis and data collection, development, and writing of the final study report required an extensive staff effort. The Study Director, Sara K. Goldsmith, organized our discussions and prepared drafts of important components of the report. She was assisted by Sandra P. Au, Research Associate, Daria K. Boeninger, Research Assistant, Allison M. Panzer, Senior Project Assistant, and Miriam Davis, Consultant. The Director of the Board of Neuroscience and Behavioral Health, Terry C. Pellmar, prepared the initial project proposal and provided outstanding oversight of the entire effort and participated in writing and organizing the final draft. We thank each of the individuals and organizations for their assistance and advice over the course of this effort to analyze and attack the crisis of suicide in this nation. William E. Bunney, M.D.

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Reducing Suicide: A National Imperative Contents     EXECUTIVE SUMMARY   1     Risk and Protective Factors,   2     Treatment,   4     Prevention,   6     Additional Challenges in Suicide Research,   7     Next Steps,   8 1   INTRODUCTION   17     Personal Suffering,   17     The Federal Response,   19     Statement of Task,   20     Suicide Through History,   21     Suicide as an Interdisciplinary Effort,   25     Definitions,   27     Organization of the Report,   28     References,   29 2   MAGNITUDE OF THE PROBLEM   33     Geographic Trends,   34     Populations at Risk,   39     Limitations of Data,   55     Cost to Society,   55     Findings,   57     References,   58

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Reducing Suicide: A National Imperative 3   PSYCHIATRIC AND PSYCHOLOGICAL FACTORS   69     Psychiatric/Substance Use Disorders and Suicide Risk,   70     Psychological Dimensions of Suicide Risk,   89     Findings,   99     References,   100 4   BIOLOGICAL FACTORS   119     The Physiological Stress System,   120     Neurochemistry,   122     Genetic Factors,   130     Findings,   140     References,   142 5   CHILDHOOD TRAUMA   157     Scope and Definitions,   158     Childhood Trauma as a Risk Factor for Suicidality,   164     Childhood Sexual Abuse and Population Attributable Risk for Suicide,   167     Modifying Factors,   168     Biopsychosocial Effects of Childhood Trauma,   170     Childhood Trauma as a Risk Factor for Psychopathology,   177     Pathways to Suicidality,   179     Prevention/Intervention,   182     Findings,   183     References,   184 6   SOCIETY AND CULTURE   193     Framework: A Social Safety Net,   194     Society and Culture in Suicide,   196     Challenges,   212     Findings,   215     References,   216 7   MEDICAL AND PSYCHOTHERAPEUTIC INTERVENTIONS   229     Assessment,   229     Psychoactive Medications,   233     Electroconvulsive Therapy,   242     Psychotherapies,   244     Inpatient and Follow-Up Care for Suicidality,   250     Cultural Considerations and Faith-Based Interventions,   256     Findings,   257     References,   259

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Reducing Suicide: A National Imperative 8   PROGRAMS FOR SUICIDE PREVENTION   273     Framework for Prevention,   274     Universal Preventions,   275     Selective Prevention,   297     Indicated Prevention,   300     Integrated Approaches to Prevention,   302     Assessing the Effectiveness of Prevention Approaches,   313     Findings,   316     References,   318 9   BARRIERS TO EFFECTIVE TREATMENT AND INTERVENTION   331     General Barriers to Treatment,   332     Clinician Barriers to Treatment,   339     Patient Barriers to Treatment,   349     Barriers to Treatment for High-Risk Groups,   351     Global Barriers,   360     Findings,   361     References,   362 10   BARRIERS TO RESEARCH AND PROMISING APPROACHES   375     Methodology,   376     Surveillance of Suicide and Suicide Attempts,   379     Ethics and Safety,   389     Research Design and Analysis Issues,   393     Centers,   406     Findings,   411     References,   412 11   FINDINGS AND RECOMMENDATIONS   423     Enhancing the Infrastructure,   423     Enhancing the Database on Suicide,   431     Enhancing Identification of Those at Risk for Suicide,   434     Enhancing Prevention and Interventions,   436     APPENDIXES         A Statistical Details   441     B Consultants   469     C Workshop Agendas   472     INDEX   475

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