We are so pleased to have you join us as we investigate this crucial topic. Violence is a leading cause of death, disability and health care use worldwide. Violence is a complex problem and can only be understood and reduced though a multidisciplinary approach. This course introduces you to experts who study different forms of violence and we will discuss the various causes of violence. You will also learn about efforts to reduce violence and engage in a day of compassion. We are very fortunate that PRESIDENT JIMMY CARTER is participating in our course. He delivers a lecture on the efforts of the Carter Center to end violence around the world, and he engages in a discussion with us about his life and work in human rights. Do join us for short videos, readings and discussions. And also see our coffee chats, where we (Pamela and Deb) summarize and reflect on each module. And we want to hear from you! Feel free to reach out via Twitter or through the course, or through our Facebook Page: https://www.facebook.com/groups/understandingviolence01/.
Suicide
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Understanding Violence
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Meet the Instructors
Deb Houry, MD, MPHAssociate Professor
Emergency Medicine
Pamela Scully, Ph.D.Professor
Women’s, Gender, and Sexuality Studies, and African Studies
Hello, my name is Alex Crosby.
I work as a medical epidemiologist in the division of Violence Prevention at
the Centers for Disease Control and Preventions Injuries Center.
Today, what I'm going to talk about is the public health approach to
preventing suicidal behavior.
I wanted to thank the people at Emery University for the invitation.
And what I will do, is I will try to layout for
you, the public health approach to preventing suicidal behavior.
It's an important topic, as many of you may be aware.
It's one of the leading causes of death in the United States and around the world.
And not just a leading cause of death but
also has a significant burden of morbidity and mortality.
Those who are made ill.
Those who made suicide attempts.
The families, the friends, the communities that are effected by suicidal behavior.
As I mentioned, why is suicidal behavior a public health issue?
Many people approach suicidal behavior as strictly a mental illness related problem.
That does limit the ability to look at the different strategies,
the different solutions, the recommendations, the research.
And so by looking at suicidal behavior as a public health issue,
it broadens our ability to bring in more instruments.
Bring in more disciplines.
Bring in more different, diverse populations that can be involved in
the solution of trying to address suicidal behavior.
Why should it be addressed as public health issue?
Well, one thing is the morbidity and mortality.
In the United States, it is the 10th leading cause of death.
In 2011, that's our most recent mortality data, accounted for
over 39,000 deaths in the United States.
It's estimated that almost half a million,
over 480,000 emergency department visits for self-inflicted injury in 2012.
There are many health consequences as a result of suicidal behavior.
Physical, mental, behavioral, reproductive, and
sexually transmitted diseases can all be associated with suicidal behavior.
There's an impact that public health can make.
If it wasn't able to do anything then maybe it shouldn't be part of
a public health approach.
But public health can help in the aspect of approaching and
addressing suicidal behavior because of its focus on prevention.
Because of the science base that's associated with public health, and
also because it stresses a multi-disciplinary approach.
Thirdly, the mission of public health includes the issue of suicidal behavior.
Part of the mission of public health is to reduce the amount of disease, or
adverse health conditions, premature death and disease producing discomfort and
disability in the population.
This is what the public health approach looks like.
And oftentimes, it's depicted in these four different stages.
One is assessing the problem.
What's the who, what, when, where of a particular issue?
Next is identifying the causes.
What are the risk factors, the protective factors, the ideology?
Why did it happen?
Then moving on to developing and evaluating programs and policies.
Trying to figure out what works and what doesn't, so
that you can apply it to the problem.
And then, lastly, implementation and dissemination.
How do you do it?
How do you take what you've learned and spread the news?
That's the dissemination part.
How do you get information out to the communities that are trying to
address the problem?
And then implementation, taking those programs and
actually applying them in a diverse range of different locations.
First, I'll talk a little bit about assessing the problem.
Here's what suicidal behavior looked like in the United States in 2011.
These are deaths due to suicide.
One thing that's remarkable about this is that males die of
suicide about four times higher, four times higher rate than females.
And you can especially see that kind of the two peaks in regards to
male suicide rates are among those over age of 70 and those in the middle age.
But that's particularly pronounced in terms of looking at females that have
died of suicide in which their highest rates are among those in
their forties and fifties.
Another aspect of looking at assessing the problem is what are the methods that
occur and I've been demonstrated as the predominant methods in regards to suicide.
As you can see in the United States,
over 50% of the suicides, a firearm was in the mechanism of that.
Around the world you could see that there is quite a range in terms of
how suicide rates affect different populations.
From areas in Asia that have very high suicide rates.
To those in some places in South America that have very low suicide rates.
And so these are some of the things that can affect what happens in regards to
suicide and how people try to address it.
Deaths are just really one piece of the puzzle in
regards to looking at suicidal behavior.
In the United States, using 2011 as an example, over 39,000 deaths with a rate
of 12.3, over 147,000 hospitalizations, the rate of 47.2 per 100,000.
So, you can see just in regards to those two aspects that the rate of deaths to
hospitalizations, hospitalizations are about four times higher.
And then we look at emergency department visits, over 400,000 emergency department
visits due to self inflicted injury, a rate of 157.4.
And so the magnitude of the burden increases as you move from deaths,
to hospitalizations, to emergency department visits.
And then when we've done surveys,
in which we've asked people in the past 12 months have you made a suicide attempt?
Those numbers tend to be even bigger.
Among adolescents, about 8% of all adolescents reported in 2013
that in the past 12 months they've made a suicide attempt, about 1% of all adults.
This is the data in regards to emergency department visits for
self-inflicted injury.
One of the contrasts here between this data and the data regarding deaths due to
suicide is that you can see the highest rates are among adolescents and
young adults.
Whereas with deaths due to suicide, highest rates were among middle age and
older adults.
The other thing here is,
I mentioned that males die of suicide about four times higher than females.
But you can see in almost every age group here among emergency department visits,
females have more predominance in terms of victimization.
So it's important to look at the contrast between fatal and non-fatal behavior.
Identifying the causes, why did it happen?
There's much research that has tried to look at
the issues regarding various aspects of suicidal behavior.
One of the ways is looking at the social ecological model.
What that does is it tries to look at individual level factors,
factors that effect the family and the peer level.
The other factors that look at the community level.
And then others that look at the societal level.
The individual level might be things like age, like sex, like mental illness.
At the family and
peer level it may be exposure to violence or previous victimization.
Or history of violence in the family.
Whether that's interpersonal violence, assault related or self-inflicted violence
that others in the family have been victims of suicidal behavior.
At the community level, it may be things like looking at spirituality,
which is actually a protective factor.
Or aspects like social isolation and social social network and social support.
Social isolation being the risk factor.
Social support being the protective factor.
And then at the societal level, it may be inappropriate access to lethal means.
Things like the economy have been demonstrated to play a role in
suicidal behavior along with aspects like geography and culture.
The next aspect of the public health approach is developing and
evaluating programs and policies.
What works and what doesn't, and the various schemes for
trying to take a look at applying prevention practice to suicidal behavior.
As you see across the, the top row,
universal programs that try to do a program within the entire population.
Those might be things that are done across a whole community, across a whole school.
One aspect might be restricting access to lethal means.
And then second is selective interventions that look at at-risk populations.
Things like gatekeeper programs in which you try to train people to be on
the lookout for those that might be at-risk for suicidal behavior.
And then an example in the indicated type of strategy are those that are high-risk
individuals in which you are treating those that have exhibited a risk factor.
So, for instance, maybe those that have a previous suicide attempt, that you try to
prevent them from repeating that attempt or dying as a result of suicide.
There are also integrated programs in which they try to incorporate all of
those different kinds of strategies.
Universal, selective, and indicated strategies.
The United Nations and World Health Organization, for example, back in
the early 90s released recommendations for how nations can develop national
strategies for suicide prevention that incorporate a broad range of strategies.
And then the U.S. Air Force back in the 90s also developed a program that
incorporated a number of different kinds of strategies.
From universal strategies, in which they targeted the whole Air Force,
all the way to those that were more indicated in which they tried to
identify those that were at-risk individuals.
Lastly, implementation and dissemination and one example of that is the U.S.
National Strategy for Suicide Prevention.
That strategy was just revised and released in 2012,
it has four strategic directions, 13 goals, 59 objectives.
The strategic directions try to incorporate a wide range of
different kinds of approaches.
Healthy and empowered individuals, families, and
communities are one of those strategic directions.
Another is developing clinical and community preventive services, so not just
services directed at medical care, but also those kind of preventive services
that might be addressed to a broad range within the community residents.
There's also treatment and support services.
And then lastly, surveillance, research and evaluation.
How do we better identify the extent of the problem, the burden, the magnitude?
What kind of research needs to go into trying to identify factors in
which we can make modifiable changes?
And then evaluation.
How well are we able to tell, whether our programs are working, they're not working,
what kind of difference are they making?
In conclusion, suicide is a significant public health problem.
It affects a broad range within our society.
The tenth leading cause of death,
affects many families, communities, relatives and friends.
It results from an interaction of various factors.
From factors that occur within an individual, within a family,
within a community, within a society.
There's never a single item that causes suicide.
And so we really have to address it from a broad range.
There are multiple opportunities for action which allow many different ways in
which prevention practitioners can make an effect.
Research has shown much of suicidal behavior can be prevented.
Oftentimes suicidal behavior had been looked at as
something that was unavoidable.
And unpreventable, but nothing, anybody could do about it.
But actually, research has shown that there are things that we can look at and
know that these are risk factors that can be addressed.
There's a broad responsibility for addressing the issue of suicidal behavior.
Communities must work together.
Because it is a societal problem, there's no one agency or
one organization that can do it by themselves.
It's not just public health.
It's not just the medical community.
It's not just the schools and education.
It's not just social services.
Not just law enforcement, but all of them working together across a broad,
a broad range of different kinds of strategies, disciplines,
organizations, that can really make the difference in suicidal behavior.
And it has been demonstrated that those kind of approaches can make a difference.
Thank you very much.
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