rate declined. Not only was the most common method of suicide (i.e., inhalation of cooking gas) less effective, but individuals did not resort to other means (Kreitman, 1976; Brown, 1979).

Much of the subsequent progress in suicide prevention research has been made in identifying risk factors for suicide, as this is one of the first steps toward prevention. Less progress has been made in the design and evaluation of programs to prevent suicides. The major challenge for research is the development and testing of new interventions to prevent suicide. The task ahead is formidable even for the most skillful researchers. Evaluation of prevention efforts has been fraught with methodological problems, including definitions of suicidal behavior, the validity and reliability of assessment instruments, the relative rarity of suicide, and the need for large samples and lengthy follow-up (Meehan et al., 1992; U.S. Preventive Services Task Force, 1996; NIMH, 1998). For example, although teen cluster suicides are seen as preventable, they have proved difficult to study because of definitional and methodological complexities.

Research on the prevention of suicide clearly warrants higher priority from the Department of Health and Human Services, which houses virtually all federal suicide prevention programs. The committee applauds the U.S. Surgeon General's recognition of inadequate attention to suicide and his initiation of various measures to prevent suicide, including the first National Suicide Prevention Conference in October 1998. Research must be expanded, as described in Chapter 8.

Violence Prevention

There can be no doubt that violence exacts a grievous toll on the nation's health (Chapter 2). The toll encompasses death, injuries, long-term disabilities, and strain on the trauma care system (Chapter 6). The homicide rate in 1995 was 8.6 per 100,000 population, a rate that overshadows that of all other industrialized nations (Fingerhut and Warner, 1997; Ventura et al., 1997). The impact is greatest on young people, especially minorities. Homicide is the foremost cause of death for African-American males ages 15–34 and the second most important cause of death for young people of all races ages 15–24 (NCIPC, 1996). The magnitude of nonfatal assaultive injuries—defined as physical harm occurring during the course of an assault, robbery, or rape between strangers, acquaintances, or family members—is much higher than that of homicides but is more difficult to capture because of problems in reporting, especially family violence. According to the National Crime Victimization Survey, assault injuries among those age 12 and older occurred at a rate of 12.7 per 1,000 people in 1994 (CDC, 1996; BJS, 1997).

The fields of criminal justice and public health bring different perspectives and strengths to bear on the violence problem. The criminal justice system—the police, courts, and corrections system—works to prevent violence primarily



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