[Iskander] Hello I'm Dr. John Iskander.
Welcome to CDC, Beyond The Data.
I'm here today with Dr. Alex Crosby,
chief of the Surveillance Branch with CDC's Division
of Violence Prevention.
[Crosby] Glad to be here.
[Iskander] Dr. Crosby we heard at today's session
about suicide prevention.
Suicide of course is a profound personal tragedy but to take
up a public health approach, we need to know something
about trends at the population level.
What can you tell us about those trends?
[Crosby] Suicide that many people don't know it is the
tenth leading cause of death in the United States.
So it's responsible for over 40,000 deaths and one
of the other things is that since about 2006,
suicide rates have been going up.
Primarily going up among working age adults, those 35 to 64,
but you also see some increases among adolescents
and young adults, those age 15 to 24 too.
[Iskander] Now, are there other groups that have been found
to be at higher risk for suicide?
You know specific populations of interest?
[Crosby] Definitely.
Historically when researchers have looked at the issue
of suicide that they found that American Indians
and Alaska natives especially in that population 15 to 34 years
of age have some of the highest suicide rates
of any ethnic group.
Also, when you look at other at-risk populations,
you see that those who have been victims of violence.
For instance those who've been victims of child abuse
and neglect, have higher rates of suicidal behavior.
Also nonfatal suicidal behavior when they've looked
at sexual orientation, those who have identified as gay, lesbian
or bisexual report many more suicide attempts than those
that report heterosexual.
So there definitely are some populations for which we need
to be paying attention because their risk seems
to be a little bit greater than the general population.
[Iskander] So really a very broad,
broad range of groups potentially at higher risk
for suicide, and as you say, for suicidal behavior.
I think many in our audience probably are familiar with some
of the traditional risk factors
such as mental health conditions, but we learned today
that there is a broader group of risk factors.
What can you tell us about those
and how have we learned some of this information?
[Crosby] One of the ways, and there's been a lot of research
that has looked at a broader variety of things
that can contribute or are associated
with suicidal behavior.
One of the ways is what's called the social ecological model.
All that does is it tries to look
at what are the individual level risk and protective factors,
what are those that exist at the family and peer level as kind
of a next layer, then at the community level,
and then at the societal level.
Often times when folks have tried to look at suicide,
they focus very much at the individual level,
and very much focused on mental illness.
As more research has been done, they have found that,
for instance, there are risk factors
at the family and peer level.
For example, those within families
where family is highly dysfunctional.
Maybe there's a parent with substance abuse or a parent
that has been lost due to death or due to incarceration.
But those children are at higher risk.
In addition, at the community level,
you know we've seen things like there's differences
in geography even in the United States
where we see higher suicide rates
in the Rocky Mountains states.
Higher suicide rates there and in addition we've look to things
like social isolation.
Those that don't have a strong network of friends and family
at greater risk for suicide and it's one of the areas
in which we've looked at the converse
which is the protective factor and found that social connection
or a stronger social support network is actually protective
against suicide.
So there are various things that, as research has expanded
and tried to look at more of a public health approach rather
than just solely a mental illness approach
that we find more about risk factors that allows us
to do more in terms of our approaches and then also some
of the prevention activities.
[Iskander] So I will just mention briefly for our audience
that in fact one of today's presenters was
from the Colorado Department of Public Health and Environment
and they showcased some very innovative strategies
that they're working on.
So as you point out risk,
research has identified not only broader risk factors,
but some protective factors as well.
So I think one of the questions in many people's minds is,
is suicide preventable?
And, if so, what works to prevent suicide?
[Crosby] There have definitely been some programs
that have shown that they can prevent suicide.
You know there are several examples.
One example is the program that was implemented
by the US Air Force back in the mid-90s.
They were able to demonstrate by focusing
on several different things in regards
to treating the Air Force as a family, or as a community,
but they developed a community level intervention there,
and what they did is they were able
to decrease suicides by 70%.
Now one of the things that they found is that maintenance
and staying faithful to that particular program became
an issue.
That after they had seen that drop by 70% some
of the diligence to that program waned
and suicide rates started going back up again and then they had
to come back and do it again.
But definitely it demonstrated
that you can prevent some suicides,
you know, it dropped by 70%.
There has been some work that has been done
with the Garrett Lee Smith Memorial Act funded primarily
through the substance abuse
and mental health services administration that has shown
that gatekeeper kind of programs where you train people
in the community to be on the lookout for folks
that might be at risk.
Kind of a recognition and a referral type of program
that within those first 12 months they show some
statistically significant decreases in suicidal behavior.
What happens is again, you know some of the affect wanes as some
of the training goes away.
And you may say, you know, there's a similar comparison
to when people go and get CPR training.
They tell you, you got to come back every couple years to kind
of refresh your skills, make sure that you're aware
of any new techniques, any new things
and you forget some of what you've done.
But it's the same kind of thing with some of these programs too,
that they show some initial decreases, initial prevention,
but then you got to maintain those programs and keep them up
and make sure that people are aware.
You know as people move in and out of communities and things
like that happen, that you got to make sure that those kind
of programs you continue to keep them fresh in people's minds.
[Iskander] So as with many things
in public health we really need to be
on guard against complacency.
I think it's very encouraging
that the examples you just gave spanned everything
from interventions that occur on college campuses
to interventions within branches of the Armed Forces.
So, given some of these promising interventions,
what does the future of suicide prevention look like to you?
[Crosby] I think there's a very bright future
for suicide prevention.
I think that it definitely faces challenges.
You know this is an area
in which there definitely limited resources
and that's across public health.
That oftentimes there are challenges in getting resources
for particular programs because there's competing interests,
you know, where there may be a disease or health condition here
that needs some attention, you've got other ones
that also need some attention.
So there's definitely some of the challenges of resources.
What's been shown, and I think this is part
of what the research is doing,
is much more evaluation now is going on of programs.
Scientific rigorous evaluation, where we can really look
at outcomes and be able
to demonstrate this program is really showing a decrease
or it's able to show that this program doesn't work
and so we're able to you know modify or do some other changes
to that particular thing.
So, I think a strength that is now happening is much more
outcome evaluation of programs.
I think we're also improving our surveillance systems.
You know many states had to rely primarily on deaths
and death certificate data
which have very limited information regarding
circumstances and where the prevention activity might focus.
But as we've expanded things
like the national violent death reporting system
that puts together several different data sources,
has information about circumstances on it,
there are programs and states that been able to react
to that information, be able to say, oh, we need actually focus
on a different population, or here's a risk factor.
For instance, we found in some states that,
intimate partner problems are one
of the leading precipitating events for suicidal behavior.
Well they were able to focus some of their efforts
in that area. And so
there are definitely some things that we've seen looking
at nonfatal suicidal behavior that as we expand some
of our surveillance systems we're able to identify those
that have made suicide attempts
because the research has also shown us that that is one
of the groups that is at greatest risk of dying
by suicide, those who have made previous attempts.
So now how can we intervene with those that have made attempts
and then how can we prevent those attempts
from happening in the first place?
[Iskander] So as one our speakers noted today there is
grounds for optimism for the future of suicide prevention.
So I'd like to close by coming back to the idea
that this is really both an individual level,
a very personal problem that many people
and many clinicians are struggling with as well
as public health people who may to get more involved.
Are there some resources, both at the clinical
or personal level and at the public health level
that people can, where they can seek out more information?
[Crosby] Absolutely.
Clinicians can oftentimes look to some
of the larger organizations.
Whether that's American Academy of Pediatrics, American College
of Family Practitioners, that there's information there
that helps train or resources available for those clinicians
to be able to better identify their patients that might be
at risk of suicidal behaviors.
So, there definitely are resources for clinicians
in terms of community organizations or those
in the public that are trying to look for resources,
there's the National Action Alliance for Suicide Prevention.
Just a couple years ago
under Surgeon General Regina Benjamin we re-released an
updated version of the national strategy for suicide prevention.
Within that document there were a number
of different opportunities for community organizations,
for businesses, for public health departments, for schools,
for correctional institutions, for a number
of different places, or organizations or institutions
or disciplines to take action in regards to suicide prevention.
And here's something that's relevant
to the population that you might serve.
So there are definitely some resources available.
[Iskander] Thank you very much Dr. Crosby.
Please join us next time for CDC's Beyond The Data.
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