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Testimony on Suicide Awareness and Prevention by Steven E. Hyman, M.D.
Director, National Institute of Mental Health
National Institutes of Health
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

Mr. Chairman and Members of the Committee, thank you for the opportunity to discuss the tragic public health issue of suicide and the urgent, challenging questions associated with its prevention.

To those not suffering from depression or another mental illness, suicide is fundamentally an incomprehensible act - but for others it is all too real, and it claims the lives of some 30,000 Americans each year: people of every age, both men and women, within every group of our population. The World Bank/World Health Organization-sponsored, Global Burden of Disease study reveals that suicide was the 9th leading cause of death among developed nations in 1990. What happens to these people? How do the neurochemicals and electrical impulses that account for the function of one's brain translate into a decision about death over life? Do the methods and messages of media contribute as precipitants of suicide, or are they potentially useful tools in its prevention?

Studies from the U.S., Finland, Sweden, and the U.K., all find that 90 percent of people who kill themselves have depression or another diagnosable mental or substance abuse disorder. From studies of the prevalence of depression - that is, the number of new and existing cases of depression over a given period of time - and data on the treated prevalence of depression, we can infer that as many as one-third to a half of those individuals with depression who die by suicide likely are undiagnosed or are not receiving adequate and appropriate treatment for this potentially lethal disorder. Although I have specified clinical depression, high rates of suicide also are associated with bipolar disorder, or manic depressive illness, with schizophrenia, and with other mental disorders. Estimates of the number of suicide victims who have had psychiatric treatment in their lifetimes range from 30 to 75 percent. These estimates vary depending on gender, age, their primary psychiatric illness, and where these people lived. A smaller group, 20 to 45 percent, was receiving psychiatric treatment at the time of their deaths that, for many was inadequate. Some suicide victims who were not receiving psychiatric treatment were in contact with primary health care providers. This is particularly true for elderly persons who committed suicide; studies have shown that 70 percent of these individuals were in contact with a primary care provider within a month of their suicide.

Suicide is always tragic; but because it is, in my view, potentially preventable through timely recognition and treatment of mental illness, the tragedy is compounded.

NIMH Activities

I have been asked to describe for you what NIMH is doing to find effective ways of dealing with this very complex behavior. I will describe to you what we have learned about suicidal behavior, and tell you what directions we are heading with regard to suicide prevention efforts.

Before I discuss NIMH's efforts, however, I would like to thank you, Senator Reid, for your unwavering support of suicide prevention efforts for the Nation. Your disclosure of your own family's experience with suicide, your introduction of Senate Resolution 84 a few years ago, your Senate Resolution 99 designating November 20, 1999 as National Survivors for Prevention of Suicide Day, and your support of the first National Suicide Prevention Conference in Reno, which set the stage for our being here today.

I also would like to thank Senator Specter for his leadership in fostering interagency collaborations to deal from a public health perspective with mental health concerns of youth, including violent behavior directed at others and self in the form of suicide.

We appreciate your foresight and determination to tackle these tough, yet approachable, problems. And let me add that I deeply appreciate Dr. Satcher's having taken the initiative to issue his Surgeon General's Call to Action to Prevent Suicide. The credibility of his office and of his own voice has done and will do much to call our Nation's attention to the largely silent epidemic of suicide.

What We Know About Suicide

Obstacles to understanding and preventing suicide notwithstanding, we are continuing to learn a great deal about it.

  • We have made substantial scientific progress by determining that almost all suicidal behavior occurs in the context of a mental disorder. The risk is elevated further when mental disorders are complicated by substance use. These well-documented findings carry significant implications for prevention strategies.

  • We have known for some time that suicide rates vary dramatically by gender and ethnic group in this country. We are just beginning to understand how other risks and protective factors interact with mental disorders and substance abuse in these groups - again, information that is critical to targeting interventions more effectively. Last summer, in conjunction with an NIMH-sponsored statewide conference in Alaska, I traveled to an Alaskan Native village in an effort to better understand the conditions leading to lack of availability of mental health services. More than 95 percent of all rural villages in Alaska cannot be accessed by road and are several hours flying distance from the more populated cities of Alaska. Often, it is impossible to reach these communities due to weather conditions. High rates of unemployment, low education, and poverty render many villages in rural and frontier Alaska vulnerable to family and community violence, suicide and other health and mental health problems. It is not entirely surprising, therefore, that Alaska has the second highest rate of suicide in the nation. In fact, the State ranked second among the 50 states in suicide rates and perennially records nearly double the overall U.S. suicide rate. American Indians/Alaskan Natives, who account for about 16 percent of the state's population, are among the racial/ethnic groups that have the highest suicide rates in the U.S. Among American Indian and Alaskan Natives, suicide rates are 70 percent higher than overall U.S. rates. This is an issue that demands our attention.

  • Perhaps most importantly, our knowledge that mental disorders and substance abuse contribute to suicide risk has helped raise awareness that adequate detection and treatment of mental disorders can truly be a life or death issue. The Surgeon General's Report on Mental Health emphasizes correctly that we must intensify our efforts to address the stigma that surrounds mental disorders in order to get individuals the help they need before it is too late.

What We Know About Risk Factors

Despite the 30,000 lives that suicide claims each year, and despite the searing intensity of the act of suicide - for family members and other survivors, as well as for the victim of an attempted or completed suicide - the relative infrequency of suicide in the population at large was long believed to have stymied attempts to identify specific, reliable risk factors. In fact, we know a considerable amount about risk factors for suicide.

  • The first and most profoundly important risk factor was cited already but bears repeating: From psychological autopsy studies in which a suicide victim's medical, psychological, social history are systematically studied, we have learned that the vast majority - estimated at more than 90 percent - of suicide victims have had a mental and/or substance abuse disorder.

  • Follow-up studies of adults with mental or substance abuse disorders reveal the inordinately high risk of suicide associated with these disorders. Some 30 years ago, Guze and Robins documented that patients who had been hospitalized for affective disorders had an alarmingly high rate of suicide and subsequently estimated that persons with depression had a lifetime risk for suicide of 15 percent. Since their work, numerous other studies have followed other patients with depression - including less severely ill patients who had been treated in outpatient as well as inpatient settings - for longer periods of time. Although the revised estimates from this research are less dismal, the lifetime risk for suicide is still 6 times higher for persons with a diagnosable depression than for a person without the illness. Among persons with schizophrenia, over the typically life-long course of this illness, the risk for suicide is between 4- and 6 percent (Inskip et al, 1998; Fenton et al., 1997), but with risk higher earlier in the course of illness (Inskip et al, 1998). Approximately 7 percent of those with alcohol dependence will die by suicide. Persons with mental disorders who attempt suicide are at significantly elevated risk - 3 to 7 times greater than others with the same illnesses - for eventually completing suicide. In the U.S. population at large, an "average" American, has less than a 1 percent likelihood of dying by suicide.

Clinical risk "profiles" vary by age and gender. For example, among adolescent male suicide victims, the most common profile is depression, complicated by a pattern of problematic behavior at home and in school, including alcohol or other substance abuse, that often leads to isolation and rejection. Among adolescent females, a mood disorder is most likely, with conduct problems and substance abuse less likely. Among older white males--that is, men 55 and older, who comprise the group with the highest rates of suicide, at six times the national average--alcohol use is very infrequent, and a moderately severe, late onset depression is most common. More so than among other age groups, depression in the elderly is often obscured by symptoms of physical illness, and by loss and loneliness that all too often mar late life; thus depression is not recognized or treated adequately.

Ongoing Scientific Efforts

Efforts by NIMH-sponsored investigators to find proven and safe prevention efforts are a work in progress, and one that we strive to promote and nurture. The obstacles to such research are formidable. For one, it is challenging to convince researchers to pursue careers in suicide prevention, given the difficulty of showing a reduction in suicidal behaviors over the typical, 5-year funding period of an intervention study. To demonstrate effects, particularly within this time frame, would require trials of very large size. Also, most researchers who received funding from NIMH for clinical trials traditionally have excluded suicidal patients from clinical trials, as does the pharmaceutical industry, because these patients are seen as too "high risk" and represent potential legal liability. All of these barriers leave little opportunity to judge how effective our treatments are for persons who are suicidal.

Fortunately, attitudes are changing, and clinical researchers appear more optimistic about identifying effective ways of treating suicidal patients. This reflects, in part, remarkable gains in the safety and efficacy of treatments for severe mental disorders such as depressive illness and schizophrenia.

Perhaps more importantly and more critical to the progress that research is making, is the willingness of brave individuals to participate in treatment studies and the unwavering focus of advocacy groups made up of families and friends who have suffered the devastating loss of a loved one to suicide.

We at NIMH and in the larger research community are aware, too, of ethical problems inherent in not studying persons who are suicidal. Thus NIMH is seeking innovative ways to assist and encourage willing researchers and research participants by identifying useful measures of suicidal behavior that can be used in clinical trials, as well as developing some guidelines for consent, monitoring, and crisis protocols.

I am genuinely heartened that leaders such as the members of this Committee and the Surgeon General endorse and actively promote a public health- oriented approach to treating mental disorders. Not only is this the reasonable and effective thing to do, but it also provides the research community with opportunities to look more broadly and over longer periods of time at treatment outcomes, which should improve our assessment of how effective treatments and preventive efforts are at reducing suicidal behaviors.

Different Risk Factor Profiles

Because different age and gender groups seem to have different risk factor profiles, I will describe our current treatment and prevention efforts for reduction of suicidal behavior within specific age groups.

Youth Suicide:
  • In the area of school-based suicide awareness programs, we have learned a very important lesson: That it is critical to evaluate prevention programs. Despite good intentions to raise awareness of suicide and its risk factors among youth in schools, few programs have been evaluated to determine if, indeed, they are effective at reducing suicide. And more to the point, of those relatively few programs that were evaluated, none has proven to be effective. In fact, some programs have had unintended negative effects by making at-risk youth more distressed and less likely to seek help. By describing suicide and its risk factors, some curricula may have the unintended effect of suggesting that suicide is an option for young people who have some of the risk factors and in that sense "normalize" it - the very opposite of what we should be trying to do. Many school districts, worried about liability issues, are purchasing suicide counseling packages from entrepreneurs seeking "quick fixes" to prevent suicides. Unfortunately, most of these programs have not been evaluated, and we are very concerned about potential risks associated with participation in suicide prevention programs that have not been subject to rigorous evaluation. Because of the tremendous effort and cost involved in starting and maintaining programs, we should be certain that they are safe and effective before they are further used or promoted.

  • There are a number of prevention approaches that are less likely to have negative effects, and to have positive outcomes beyond that of reducing risk for suicide. One approach is to promote overall mental health among school-aged children by addressing early risk factors for depression, substance abuse and aggressive behaviors. In addition to the potential for saving lives, many more youth benefit from overall enhancement of academic performance and healthy peer and family relationships.

  • A second approach is to detect youth most likely to be suicidal by identifying those who have depression and/or substance abuse, combined with serious behavioral problems. Events such as recent tragic shootings in schools and other settings that capture public attention and concern are not typical of youth or adult violence, including suicide, but have focused the nation's attention on these important issues. By focusing research attention on high-risk groups, researchers have learned much about depression, substance abuse and frequently co-occurring aggressive and violent behavior. Studies have shown that all of these problems share similar risk factors and processes - that is, the same experiences and influences act to increase risk for these problems. One might reason that comprehensive programs designed to reduce these risks also will reduce the often tragic outcomes, including suicide, that often are associated with such problems. Community efforts, involving parents, school systems, law enforcements officials, and other resources must communicate and work together to provide supportive, seamless treatment for youth with mental disorders. A report of preliminary findings from one NIMH grantee who is refining a family-based treatment approach for reducing conduct disorder in adolescents notes a reduction in suicidal behaviors - both suicidal thoughts, or ideation, and actual attempts - as well as reductions in aggression towards others.
Adult Suicide

Most of the prior and current research on suicide prevention in adults has focused on those with the highest risk of suicide - those who have made repeated suicide attempts. A few clinical research groups in the U.S., Europe, and Australia have evaluated interventions that include both medications and psychotherapy, but many of the studies did not have adequate numbers of patients to determine with any degree of certainty whether the intervention was truly effective. Fortunately, increasing numbers of researchers are becoming interested in developing treatments for such high-risk patients. Adults in the treatment system who report high rates of suicide attempts include women with borderline personality disorder; men and women with depression who also abuse drugs or alcohol; and men and women with bipolar depression. At present, NIMH is collaborating with the Centers for Disease Control and Prevention (CDC) to support a treatment trial with suicide attempters who appear at an inner city emergency room. In this study, specially trained therapists will work immediately with these individuals to address their hopelessness and depression, and also to help them obtain necessary treatments for their substance abuse disorders. This immediate, on-the-spot, high-intensity intervention will be compared to the treatment such individuals normally receive. If proven effective, our next step will be to disseminate the intervention strategy widely.

As you may be aware, NIMH has embarked on several large, clinical trials--for bipolar disorder, treatment resistant depression, adolescent depression, and best use of new antipsychotic medications. The reason for these efforts is to improve our knowledge about treatments for patients in the "real world"--those with co-occurring mental and substance abuse disorders and other, general medical illness; young and older people; and other persons who typically are encountered in diverse treatment settings. All of the trials will involve large numbers of participants - from about 430 for the study of adolescent depression, to more than 2,000 patients who will be involved in the evaluation of sequenced treatment alternatives for resistant depression. It is highly likely that there will be patients in these trials who will become suicidal. NIMH is assisting the researchers to plan and provide a high level of monitoring and care for such patients; our hope is that with adequate safeguards, fewer of these potentially suicidal patients will be excluded from the trials, more patients will be helped with the treatments being tested, and in the end, more will be learned about effective treatments for these patients.

Up to two thirds of all patients who commit suicide have seen a physician in the month before their death. However, in few adult suicide victims is a mental disorder detected, and among those, treatment is usually inadequate. Training health care professionals, particularly those in the primary care sector, to treat recognize and treat or refer mental disorders appropriately is an urgent order of business if we are to reduce suicides. No less important - and, again, a challenge to the Nation that Dr. Satcher issues most compellingly in the Surgeon General's Report on Mental Health, is to combat the stigma attached to mental disorders and to encourage persons to seek treatment for mental disorders.

Suicide Among Older Adults

Among older adults - and, particularly, among older white males - late onset depression is the mental disorder most commonly associated with suicide. This form of depression, which typically is uncomplicated by substance abuse, is among the more readily treatable depressive disorders. Yet older persons at risk for suicide, like the majority of older adults in this country, tend not to seek mental health treatment. Rather, most have seen their primary care provider within the month, if not the week, of their death.

In response to this finding, NIMH issued a request for applications (RFA) for grant support to test more effective approaches to detecting and treating depression in older adults in primary care settings. I am pleased to report that we have awarded a grant for a very promising collaboration involving three of our clinical intervention centers. Termed PROSPECT, for Prevention of Suicide in Primary Care Elderly: Collaborative Trial, this project will assess the degree to which physicians can be trained and assisted to improve detection and treatment of depression in 6 primary care clinics, and compare them to 6 "usual care" clinics. This study complements a multi-site trial supported by the John A. Hartford foundation, where comparable outcome measures will be used across all sites.

Several researchers who are involved in the PROSPECT study also are participating in a collaborative study of Aging, Mental Health, Substance Abuse and Primary Care. This cross-agency initiative involves the Substance Abuse and Mental Health Services Administration, the Health Resources and Services Administration, and the Veterans Administration. The design and nature of our collaboration allows comparable measures to be used across many primary care sites. Results from this research should lead to a clearer picture of why and when older adults slip through the system without obtaining the care they need for mental disorders.

What Remains To Be Done

Although we yet have an immense amount to learn about risk reduction and prevention of suicide, we should be encouraged, I feel, by the fact that we can spell out with some certainty next steps in research. Let me suggest several of these.

One, we are increasingly hopeful that we will find effective treatments for persons at greatest risk for suicide (those who have already made a suicide attempt). But we have much more to learn about how effective treatments - both medications and psychotherapies - may reduce both the short- and long-term suicide risks for persons with depression, schizophrenia, and anxiety disorders. Early findings suggest, for example, that the new antipsychotic medications appear to reduce suicidal ideation in some treatment trials for persons with schizophrenia. Greater numbers of prescriptions of newer antidepressant drugs have been associated with lower rates of suicide in Sweden.

Two, we must encourage more investigators in more treatment studies to include more - and consistent - measures of suicidal behavior. Resulting data will help investigators think through treatment strategies that allow patients who become suicidal to be treated safely and returned to study trials.

We need to be more creative in devising tools and strategies to detect those at risk for suicidal behavior. Persons outside the mental health treatment system - for example, those who engage in domestic violence, who are failing in school or social relationships, or who are substance abusers - may benefit from consultation with a trained professional and, in some instances, may benefit from treatments at a time when they will be most effective.

Three, we need to better understand if and how prevention efforts aimed at preventing or reducing aggression, hyperactivity, depression, psychoses, and substance abuse also reduce the risk for suicidal behavior. This information is desperately needed by schools and communities with limited resources. We need to understand the most efficient, effective, and sustainable approaches to meet these goals.

Fourth, we need to encourage more minority investigators to pursue research in this area, in part to help us to understand better how "protective factors" work. For example, African American women have among the lowest rates of suicide, although they have mental disorders at rates comparable to those experienced by white women. It is important to understand the factors that protect one from suicide. We also need to examine differential suicide rates among other ethnic groups. As I mentioned earlier, American Indians/Alaskan Natives, who account for about 16 percent of Alaska's population, are among the racial/ethnic groups that have the highest suicide rates in the U.S. Among American Indian and Alaskan Natives, suicide rates are 70 percent higher than U.S. rates.


Mental disorders and substance abuse disorders - alone and co-occurring - are the major risk factor for allowing human beings to overcome one of nature's most compelling instincts--the urge to survive. Why do people kill themselves? We urgently need to know more. We are grateful that with the support of many people, our society is increasingly willing to address and resolve the legal and ethical issues surround clinical investigations on this topic and that for too long have been permitted to unduly complicate knowledge development. With the help of dedicated scientists, wise policy leaders, the courage of those affected by mental and substance abuse disorders, and the committed advocacy of those who genuinely care about these tragedies, we have learned a tremendous amount, and we will continue to learn more.

Thank you.

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