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Testimony on Suicide Awareness and Prevention by David Satcher, M.D., Ph.D.
Assistant Secretary for Health and Surgeon General
Office of Public Health and Science
U.S. Department of Health and Human Services

Before the Senate Committee on Appropriations, Subcommittee on Labor, Health and Human Services, Education
February 8, 2000

Chairman Spector, Senator Reid , I am pleased to be here today to participate in this historic hearing, advancing the discussion of suicide prevention in America.

Suicide is a serious public health problem. It results in over 30,000 premature deaths each year. In 1997, the most recent year statistics are available, suicide was the eighth leading cause of mortality in the United States and the third leading cause of death among youth and young adults [10-24 year olds]. Men aged 75 years and older actually had the highest rate of suicide of any group. Indeed, suicide is a national problem that affects people of all ages, races and ethnic origins.

When we compare the incidence of suicide with that of homicide, most people are surprised to learn that suicide is by far the greater killer. In fact, for every two deaths by homicide in the U.S. there are three deaths due to suicide. And if a person dies by a firearm, that death is one-third more likely to have been a suicide than a homicide.

Because of the stigma too long associated with mental illness and suicide, we, as a nation, have been reluctant to talk openly about this threat to our health and well being. We owe a great debt of gratitude to concerned individuals, such as: Dr. Kay Redfield Jamison, author of Night Falls Fast; important groups such as SPAN, the Suicide Prevention Advocacy Network, and its founders Elsie and Jerry Weyrauch; you, Senator Reid, as a leader on this issue in the Senate; and to many others who have stepped forward to speak out about their own personal loss to suicide; and more importantly, to take action to prevent loss of life due to this terrible killer. I am extremely pleased that we are now engaging in an open national dialogue on the issue of suicide. The goal of the discussion, of course, is an outcome we all desire--measurable and significant decreases in deaths and suffering due to suicide and suicidal behavior--decreases which will be sustainable over the long term.

I trust that through this hearing today, we will all gain a greater understanding of the scope of suicide as a public health problem and garner significant, official, and broad support for the work of completing a National Suicide Prevention Strategy.

Why a National Suicide Prevention Strategy?

Our goal of developing a National Strategy is linked closely with international suicide prevention efforts. In 1996, the World Health Organization, recognizing that mental illness, including suicide, ranks second in the burden of disease in established market economies, urged member nations to address suicide [WHO document: Prevention of Suicide: Guidelines for the Formulation and Implementation of National Strategies.] In the past few years, Australia, Denmark, Finland, Norway, Sweden, New Zealand, and the UK have developed national suicide prevention strategies. The WHO has established its own suicide prevention task force to encourage national policies promoting suicide prevention around the world and to evaluate WHO efforts to reduce mortality associated with suicide. This progress in the international community has contributed momentum to the considerable efforts already underway in our own country.

We now understand that many suicides and intentional, self-inflicted injuries are indeed preventable. Just over six months ago, I issued a B. In that Call, I introduced a blueprint for addressing suicide represented by the acronym A-I-M, which stands for Awareness, Intervention, and Methodology.
  • "Awareness" signifies our commitment to broaden the public's awareness of suicide and its risk factors.

  • "Intervention" means we will enhance services and programs, both population-based and clinical care to reduce suicide.

  • And "Methodology" compels us to advance the science of suicide prevention.

Awareness, Intervention, Methodology-AIM-this framework for suicide prevention stems from work begun through a significant public-private partnership involving the Department of Health and Human Services, which brought together researchers, clinicians, survivors and advocates, and various federal and state agencies in Reno, Nevada, a little over a year ago. Empowered by that first-of-its-kind meeting, grassroots organizers--many of whom are suicide survivors--have joined with state public health officials and others in at least 20 states to begin planning state level prevention efforts. Many are now working with their state legislatures in the appropriations process for these programs.

I can think of no other issue with which I've been involved that has produced so large and so positive an outpouring of public support. Since issuing the Call to Action, countless people have spoken or written to me, sharing their grief from their own experiences with suicide and telling me how they are getting involved in the suicide prevention movement.

I think it is critically important for those of us working this issue at the Federal level to fully appreciate this passionate groundswell for suicide prevention. Today, we have a tremendous opportunity to provide national leadership that will guide this outpouring of energy to productive ends.

The AIM blueprint identifies 15 key recommendations that will do just that. Perhaps the most important of AIM's recommendations is the mandate to complete a comprehensive National Suicide Prevention Strategy. It is this comprehensive Strategy that will direct the Nation at the federal, regional, state, tribal, and community levels to a collaborative, comprehensive, coordinated response to suicide.

Our National Suicide Prevention Strategy will outline a conceptual framework and courses of action to guide, promote, and support culturally appropriate, integrated programs for suicide prevention among Americans.

I should stress that a National Strategy is not a federal-only or even a federally-driven project. To the contrary, a National Suicide Prevention Strategy must foster the myriad public-private partnerships necessary for effective suicide prevention in every community. We envision a Strategy that will define and produce an infrastructure that supports communities in their prevention efforts through consultative services, sharing of best practices, data gathering, and perhaps most important, program evaluation. With these supports in place, community level agencies and organizations will collaborate in new and more effective ways to mitigate the risk factors associated with suicide, as well as strengthen putative factors that protect people from suicidal risk.

Research shows that many people who kill themselves have a mental or substance abuse disorder, or both. For this reason, removing the stigma associated with mental illness and its treatment must play a central role in the Strategy. In December, I released Mental Health: A Report of the Surgeon General, the first report ever released by a Surgeon General addressing mental health. The report identified critical gaps between those who need mental health services and those who actually receive them. It also identified significant gaps between optimally effective treatment and what many individuals receive in actual practice settings. Clearly, we have much work to do to remove the barriers to optimal mental health service delivery in the U.S.

Suicide has multiple intersecting causes and risk factors, so effective prevention programs must be comprehensive in addressing individual, family and community-level factors. It will require engagement by dozens, and in some instances literally hundreds of stakeholders in each community: schools, faith-based groups, social and housing services, law enforcement, justice, youth and civic organizations-just to name a few. In addition to reducing risk factors, these community agents will play significant roles in enhancing the protective factors to which I just referred. These protective factors may be those pertaining to the individual, like resilience, resourcefulness, help-seeking, respect, and nonviolent conflict resolution skills, or those pertaining to communities, like interconnectedness, social support, and social services.

We now have one example of a large-scale community-based program that appears to have been successful in reducing suicides. For the past five years, the United States Air Force has consciously promoted these protective factors among Air Force members and the Air Force community. During those same five years, the suicide rate among airmen has declined each year, from 16.4 down to 5.6 per hundred thousand-a decline of over 65 percent. The 1999 suicide rate in the Air Force was 40 percent lower than any level recorded in the past two decades, and about one-fourth the national suicide rate when corrected for age, sex, and race. Similar declines did not occur in the other military services. We need to evaluate this program further to understand the contribution of its various components.

CDC, working closely with states, communities, universities, partners in the private sector and others, has contributed in a number of areas to improve our understanding of suicide prevention efforts such as this one. For example, CDC is supporting the development of a suicide-prevention research center that will describe the magnitude of suicidal behavior, promote research, and identify prevention activities. In addition, CDC has funded two suicide prevention evaluation projects: one to enhance awareness, increase utilization, and assess the efficacy of telephone crisis intervention services for teenagers and the other to develop intervention services for adults over 65. CDC has also conducted a study of nearly lethal suicide attempts to investigate, among other things, the role of alcohol use and abuse, the results of which indicate that alcohol use within the three hours before an attempt are important risk factors for suicidal behavior.

SAMHSA, through its Centers for Mental Health Services and Substance Abuse Treatment, is providing grants to schools and community organizations that have provided a plan to build consensus around and pilot an evidence-based program to promote healthy development and prevention of youth violence, including suicide. Last year funds were granted to 40 such organizations across the country. A new Guidance for Applications (GFA) will be out this spring for School Action Grants that will have a special emphasis on the prevention of youth suicide. By coupling public health interventions with disciplined research in the primary prevention and treatment of mental illness, we can reasonably expect to prevent premature deaths due to suicide throughout the life span, while reducing other suicidal behaviors, such as attempts and gestures, as well. And consequently, we will reduce the trauma these suicidal behaviors inflict upon families, friends and others in significant relationships with the suicide victims. But it will do still more. I believe investments in suicide prevention are really investments in human and social capital. The social scientists teach us that these investments produce wide-ranging dividends throughout society and achieve improvements in overall function, resiliency, safety and health that would not otherwise be possible.

At this point, I'd like to talk about the progress we are making toward completing the National Strategy. Since releasing the Call to Action, a cross-cutting team of suicide prevention experts from several agencies within the Department of Health and Human Services has mapped out a systematic process that will ensure timely completion of the strategy. With leadership from SAMHSA, we will be bringing together the most knowledgeable people from outside the federal government to work with our DHHS team on the issue. These are experts with vast experience in not only suicide prevention, but also the clinical and social sciences, criminal and juvenile justice, public policy, business, and occupational health. Their primary responsibility will be to help translate the 15 recommendations in the Call to Action into specific goals and measurable objectives. Following this, a process to gather inputs from major stake-holders at the national, state, and local levels will identify activities to ensure each objective is achieved. At every step, we will draw on the collective expertise and wisdom of persons from many backgrounds and life experiences: scientists, prevention experts, survivors, program planners and evaluators, consumers of mental health services, justice experts, clinicians, public health leaders, educators, social services professionals, and religious leaders. Diversity among prevention partners should produce a Strategy that ensures continued investment and collaboration throughout the implementation phase. I am proud to tell you that we are on schedule to have a strategy ready for the American people before the end of this calendar year.

Before I conclude, I should point out that most of the activities in the National Strategy will be implemented at the community level through existing structures. Settings such as schools, workplaces, clinics, physician's offices, correctional and detention centers, eldercare facilities, religious institutions, recreational centers, and community centers are natural venues for integrated suicide prevention activities. In fact, in many communities, several of these formal agencies are already committed to preventing suicides. The National Strategy will ensure each of these community components assumes an effective role in preventing suicides, and does so in a fashion that is tailored to the unique characteristics of their community. When this happens, we can expect further improvements in health and well being to emerge in every segment of the American population. I believe this collaborative community effort will have an exponential effect; that is, the overall improvements in community health will be far greater than the sum of the contributions of the individual agencies, programs, or interventions.

Am I optimistic? Yes, I am. We are witnessing a convergence of research, practice, recognition, political will and strong grassroots commitment that has the potential to produce historic public health breakthroughs in suicide prevention. Since the mid-90's, we are seeing small but steady declines in suicide rates among some of our highest risk populations: males, both Caucasian and African-American, among both the elderly and youth. Interestingly, these declines appear to be almost entirely attributable to declines in firearm suicides. Still, nearly 60 percent of all suicides are attributable to firearms, and in men over 65, that figure is an astonishing 77 percent. These small declines in suicide rates, though encouraging, pale in comparison to the steep increases seen between 1980 and 1996 among young males, when for instance, the suicide rate among black males aged 15-19 increased 105 percent.

I would like to conclude by saying that the time is right-the opportunities are plentiful. The National Suicide Prevention Strategy will chart the course for the fruitful collaboration of government, advocates, communities and families, energized by the opportunity to realize what for many has been a long-cherished dream-real and sustainable decreases in the devastating consequences of suicide in our society.

Thank you Mister Chairman, Senator Reid, and members of the committee. Again, it is very gratifying to be participating in this this hearing today. This concludes my remarks.

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