[Senate Hearing 106-940]
[From the U.S. Government Publishing Office]
S. Hrg. 106-940
SUICIDE AWARENESS AND PREVENTION
=======================================================================
HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED SIXTH CONGRESS
SECOND SESSION
__________
SPECIAL HEARING
FEBRUARY 8, 2000--WASHINGTON, DC
__________
Printed for the use of the Committee on Appropriations
Available via the World Wide Web: http://www.access.gpo.gov/congress/
senate
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COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
SLADE GORTON, Washington FRANK R. LAUTENBERG, New Jersey
MITCH McCONNELL, Kentucky TOM HARKIN, Iowa
CONRAD BURNS, Montana BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama HARRY REID, Nevada
JUDD GREGG, New Hampshire HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas RICHARD J. DURBIN, Illinois
JON KYL, Arizona
Steven J. Cortese, Staff Director
Lisa Sutherland, Deputy Staff Director
James H. English, Minority Staff Director
------
Subcommittee on Departments of Labor, Health and Human Services, and
Education, and Related Agencies
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
SLADE GORTON, Washington ERNEST F. HOLLINGS, South Carolina
JUDD GREGG, New Hampshire DANIEL K. INOUYE, Hawaii
LARRY CRAIG, Idaho HARRY REID, Nevada
KAY BAILEY HUTCHISON, Texas HERB KOHL, Wisconsin
TED STEVENS, Alaska PATTY MURRAY, Washington
JON KYL, Arizona DIANNE FEINSTEIN, California
ROBERT C. BYRD, West Virginia
(Ex officio)
Professional Staff
Bettilou Taylor
Mary Dietrich
Jim Sourwine
Ellen Murray (Minority)
Administrative Support
Kevin Johnson
Carole Geagley (Minority)
C O N T E N T S
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Page
Opening statement of Senator Arlen Specter....................... 1
Statement of David Satcher, M.D., Ph.D., Assistant Secretary for
Health and Surgeon General, Office of Public Health and
Science, Department of Health and Human Services............... 2
Prepared statement........................................... 4
Statement of Steven Hyman, M.D., Director, National Institute of
Mental Health, National Institutes of Health, Department of
Health and Human Services...................................... 7
Prepared statement........................................... 9
Opening statement of Senator Harry Reid.......................... 14
Prepared statement........................................... 15
Opening statement of Senator Paul Wellstone...................... 16
Statement of John Mann, M.D., chairman, Scientific Council of the
American Foundation for Suicide Prevention..................... 18
Statement of John Fildes, M.D., medical director, University of
Nevada Medical Center Trauma Unit.............................. 19
Statement of Kay Redfield Jamison, Ph.D., professor of
psychiatry, Johns Hopkins University........................... 21
Statement of Susan Blumenthal, M.D., M.P.A., Assistant Surgeon
General and Senior Science Advisor, Department of Health and
Human Services................................................. 23
Statement of Hon. Nancy Pelosi, U.S. Representative from
California..................................................... 30
Statement of Danielle Steel, best-selling novelist and author of
``His Bright Light''........................................... 31
Prepared statement........................................... 35
Statement of Jade Smalls, Evanston, Illinois, first runner-up,
1999 Miss America Pageant...................................... 37
Prepared statement........................................... 40
SUICIDE AWARENESS AND PREVENTION
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TUESDAY, FEBRUARY 8, 2000
U.S. Senate,
Subcommittee on Labor, Health and Human
Services, and Education, and Related Agencies,
Committee on Appropriations,
Washington, DC.
The subcommittee met at 9:30 a.m., in room SD-192, Dirksen
Senate Office Building, Hon. Arlen Specter (chairman)
presiding.
Present: Senators Specter, Reid, and Wellstone.
OPENING STATEMENT OF SENATOR ARLEN SPECTER
Senator Specter. The hour of 9:30 having arrived, the
Subcommittee on Labor, Health and Human Services, and Education
will proceed with this hearing.
Our subject today is suicide awareness and prevention. The
hearing has been convened at the special request of our
distinguished colleague, Senator Harry Reid, who has had a
personal family involvement with the matter and offered a
Senate resolution which called for a national suicide
prevention strategy.
Suicide certainly is a major problem in the United States,
claiming some 31,000 lives annually, contrasted with homicide
which claims 20,000 victims. There is a very high incidence
among juveniles and it is an issue which has not been
adequately addressed either in terms of national awareness or a
strategy for prevention.
Dr. David Satcher, our distinguished Surgeon General, has
done extensive work in the field, as has Dr. Steven Hyman,
Director of the National Institute of Mental Health. And the
Surgeon General's recommendations last year in a Call to Action
listed some 15 recommendations focused on the general topics of
awareness, intervention and methodology.
We have, in addition, a distinguished panel of scientists,
and we have Ms. Danielle Steel, best-selling novelist, whose
19-year-old son committed suicide in 1997, and Ms. Jades
Smalls, first runner-up to the 1999 Miss America Pageant. So,
the combination of our witnesses provides both a scientific
background and the so-called human face on the problem to
create awareness which should lead to a strategy for
prevention.
We have a very long list of witnesses, and we are going to
have to conclude the hearing shortly in advance of 11 o'clock
this morning because this is a very crowded schedule. Our
custom is to allow witnesses to testify for 5 minutes. Our
professionals, Dr. Satcher and Dr. Hyman, are used to that even
though they bring learned treatises with them for insertion
into the record, but they are masters of the summary at this
point in their professional careers.
I know a number of my colleagues will be joining us in due
course, but we will proceed at this time because of our tight
schedule and commitments.
STATEMENT OF DAVID SATCHER, M.D., Ph.D., ASSISTANT
SECRETARY FOR HEALTH AND SURGEON GENERAL,
OFFICE OF PUBLIC HEALTH AND SCIENCE,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Senator Specter. Our first witness is Dr. David Satcher,
16th Surgeon General of the United States, only the second
person in history to simultaneously hold the positions of
Surgeon General and Assistant Secretary of Health. Before
joining the administration, he was president of Meharry Medical
College of Nashville, Tennessee for more than a decade, 1982 to
1993.
The biographical sketch does not include the observation of
Dr. Koop who said that the Surgeon General was the only
individual who was both a general and an admiral.
I think you prefer the title Dr. Satcher, and the floor is
yours.
Dr. Satcher. That is fine. Thank you.
Thank you very much, Senator Specter, for this opportunity
to testify and for holding this very important hearing on
suicide.
Let me just say, as you have pointed out, that suicide is,
indeed, a very serious public health problem in this country.
It is the eighth leading cause of death and the third leading
cause of death among youth and young adults. The highest rate
of suicide is among men, in fact, men over 75 years of age.
But it is important to point out that suicide is a problem
that affects all ages, all races, and all ethnic groups. For
example, while it was once thought that suicide was not a
problem with African Americans, very clearly that is not true
and has never been true. The rate of suicide in young black
males has doubled between 1980 and 1996. So, the concern for
suicide in all of our populations, I think, is a very real one.
As you pointed out also, most people are surprised to hear
that for every two people who are killed by homicide in this
country, three people take their own lives.
I think the stigma that is associated with suicide has kept
us from addressing this issue directly until now, and that is
why this hearing is so important.
I want to thank people like Dr. Kay Jamison and especially
Elsie and Jerry Weyrauch and SPAN, Senator Reid, and other
members of your panels today who have been willing to speak out
about their own tragic experiences. And I know it has been
painful because I have heard from many survivors of suicide the
struggles that they go through. So, their willingness to speak
out and to provide leadership is really making a difference in
this area.
The Nation is now engaged in an open dialogue on suicide,
and through this hearing we hope to gain a better understanding
of the public health problem, but also to gain support for
completing a national suicide prevention strategy.
The national strategy that we are proposing is closely
linked to international efforts. Work by the World Health
Organization, the World Bank, and the Harvard School of Public
Health produced data in 1996 pointing out that mental health
problems were the second leading cause of disability and
premature deaths in the world for industrialized countries, the
second, second only to cardiovascular diseases. WHO called on
countries throughout the world to develop strategies to address
the problem of suicide.
Because of this and because of the backing of organizations
like SPAN, we called a meeting in Nevada in October 1998 to
look at the problem of suicide, and we called together experts
in the field, clinicians, survivors, and advocates to spend 3
days in Reno, Nevada discussing this problem. As a result of
that, we developed the Surgeon General's Call to Action for
Suicide Prevention.
Basically, the recommendations in the Call to Action are
divided into three areas.
One, we think it is critical that we increase the awareness
of suicide in this country as a first step toward de-
stigmatization, and not only suicide, but the awareness of the
mental health problems which lead to suicide. So, a major set
of recommendations relate to increasing awareness.
The second area is intervention. We believe that there are
tremendous opportunities to improve the services and the
programs in this country that could lead to a reduction in
suicide. These are programs to enhance the mental health
infrastructure, which starts with educating people in general.
The third category is methodology. We believe that we must
continue to advance the science of understanding of suicide but
also of suicide prevention.
So, out of this Call to Action, we have been busy within
the Department. A team of people have been working over the
last several months developing recommendations for a national
strategy. There are at least 20 States in the country that are
working on plans for their own strategy for suicide prevention.
We have been able to visit many of these States, many local
programs in the country, and people are working very hard to
develop strategies.
Of our recommendations, we believe the most important one
is this recommendation for the development of a national
strategy that actually calls for a public/private partnership.
It calls for not a Federal program but a national program, a
program in which we relate to different levels of government,
but we also look to communities throughout this country and
organizations in communities like churches and schools and
fraternities and criminal justice programs and others to work
together to develop the infrastructure requirement for a
prevention program.
There are two basic approaches.
One, we have to reduce the barriers to the effective
identification and treatment----
Senator Specter. Dr. Satcher, I am sorry to interrupt you,
but we are going to have to observe the time very meticulously.
So, if you would finish your current thought, we are going to
move on.
Dr. Satcher. OK.
This is the Surgeon General's report, mental health report,
and basically it recommends reducing the barriers to effective
identification.
The second this is CDC is funding many efforts and
partnering with many groups for suicide prevention using a
model that has been used by the Air Force that has been very
successful.
PREPARED STATEMENT
So, we are recommending, of course, that we move forward.
We have a meeting scheduled in March of outside experts to meet
with us and give their input, and then later in the year we
will have a major meeting of partners throughout the country to
see where we are. We hope by the end of the year to be prepared
to present a recommendation for a national strategy for suicide
prevention.
[The statement follows:]
Prepared Statement of David Satcher
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 National Call to Action to Prevent Suicide. 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 United
States.
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
hearing today. This concludes my remarks.
Senator Specter. Thank you very much, Dr. Satcher.
STATEMENT OF STEVEN HYMAN, M.D., DIRECTOR, NATIONAL
INSTITUTE OF MENTAL HEALTH, NATIONAL
INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH
AND HUMAN SERVICES
Senator Specter. Our next witness is the distinguished
Director of the National Institute of Mental Health, Dr. Steven
Hyman. He has a bachelor's from Yale, masters from Cambridge,
an M.D. from the Harvard Medical School. Prior to coming to
NIMH, Dr. Hyman was professor of psychiatry at the Harvard
Medical School and director of psychiatry research at
Massachusetts General.
I might note that the increase for the National Institute
of Mental Health went up by some more than $123 million to an
excess now of $633 million. In the last 3 years, Senator Harkin
and I have taken the lead to add more than $5 billion to NIH
funding, and yesterday we introduced a resolution with many
cosponsors to raise National Institutes of Health funding by
some $2.7 billion. We believe NIH is the crown jewel of the
Federal Government. That may be the only jewel of the Federal
Government.
Dr. Hyman, the floor is yours.
Dr. Hyman. Mr. Specter, you even understated the number
that you have been generous enough to give us. We now have a
budget, including AIDS research, of about $975 million, and for
that we thank you and your colleagues for your support and we
hope to be worthy of that.
I also want to thank you because it was clear in a series
of meetings that you conducted last year that you have taken an
important role in putting such subjects as youth suicide and
youth violence in the proper public health context, and this is
very much appreciated.
I also want to thank David Satcher who is the first Surgeon
General to take these issues with this kind of very important
seriousness, and it is a privilege to be here with him.
We are all going to talk a little bit about the numbers in
suicide, but they are absolutely staggering. I have put up a
chart here just charting youth suicide rates because my
colleague here emphasized, just due to the time, rates in the
elderly.
But what you can see is that since the mid-1960's rates of
youth suicide have doubled until they have more recently
plateaued, and since the 1950's--the chart just was not long
enough--rates of youth suicide have actually tripled. It is now
the case that among youth suicide is responsible for more than
two times as many deaths as all natural causes combined. So,
this indeed is an enormous national tragedy and national public
health problem.
I also want to acknowledge Senator Reid who, of course, has
had an enormous impact on our suicide focus.
In addition, in some populations, such as Alaska Natives
and some Native American tribes, the suicide rate among youth
is 10 times the national average, so there are some
extraordinary problems here.
Now, suicide is a complex phenomenon. We know--and I am not
going to dwell on this--it involves genes as well as
experience, but these genes are not fate. In other words, there
are things that we can do to intervene in the course of mental
illness and genetic predisposition to prevent and make a
difference in suicide.
NIMH and other research has shown that, in the United
States and in many other countries, more than 90 percent of
suicides reflect a mental illness, especially depression, often
together with alcohol abuse, manic depressive illness, and also
schizophrenia and borderline personality disorder. Just by
naming these diagnoses, it suggests that there are
interventions. But unfortunately, there are obstacles to
interventions.
In children, we have inadequate knowledge as to the safety
and efficacy of antidepressant treatment. The NIMH is trying to
address this. We initiated a year ago a very large scale,
multi-center trial in the treatment of adolescent depression,
but we still do not have in the United States an adequate
research infrastructure to study antidepressants in younger
children when depression often begins and we are working on
this.
In addition, there are other obstacles. Many studies of
depression have actually excluded suicidal individuals because
of ethical issues and liability issues, and we want to be
working with some of the foundations represented here to come
up with ethical and legal guidelines so that people who are
suicidal will be included in treatment trials so that we will
have precise knowledge as to how to intervene best when people
are suicidal.
Even where we have knowledge, however, there are tragic
gaps. I think it is well known that more than 70 percent of
elderly males who commit suicide saw a primary care physician
in the last month of their life. Clearly, there is an enormous
disconnect. We have been attempting, through research, to
understand how to close this gap. One important multi-center
trial called PROSPECT which is being conducted at the
University of Pennsylvania, the University of Pittsburgh, and
at Cornell--sorry, one is outside of Pennsylvania, Senator--is
looking at having a mental health professional in primary care
clinics and in closing the educational gap with providers.
In addition, we are aware that the issue of depression in
the medically ill is often very much under-attended to. There
is a sense that, well, if you had a heart attack, would you not
be depressed or if you had cancer? But in fact, we are leaving
depression very much untreated in these individuals and also
pain, and people should never wish for death in the context of
a medical system that could, in fact, provide them with
adequate treatment.
In youth again we have many prevention programs. Very few
of them have actually been subjected to research, and indeed we
know from studies of some prevention programs that if anything
is powerful enough to make a difference, it is also powerful
enough to have side effects. And some well-intentioned programs
aimed, for example, at de-stigmatizing suicide have actually
had--and I will sum up--some adverse consequences. We want to
de-stigmatize mental illness so that people get treatment and
de-stigmatize the idea that you can ask for help, but we want
to keep the barriers to suicide high.
PREPARED STATEMENT
We have a number of announcements out and we are supporting
research, a good deal of research, on suicide prevention and
evaluation. And we want to work closely with the Surgeon
General, with other Federal agencies, and also with foundations
and non-Government partners to ensure that we have well-tested
prevention measures out there that are being appropriately
evaluated.
Thank you.
[The statement follows:]
Prepared Statement of Steven E. Hyman
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 United States. 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.
CONCLUSION
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.
Senator Specter. Thank you very much, Dr. Hyman.
I want to yield now to my distinguished colleague, Senator
Harry Reid, who I said at the outset had requested this hearing
specially because of his own family involvement in the issue.
Senator Reid?
Opening statement of Senator Harry Reid
Senator Reid. Senator Specter, thank you very much. I
appreciate your holding this hearing. You have a tremendously
busy schedule with all of the budgetary hearings. Your
subcommittee is responsible for most of the work because you
cover so many different areas. I cannot say how much I
appreciate your working this hearing into your schedule. You
have approached this really professionally, and I am so
grateful to you.
I have a statement that I would like to be made part of the
record.
Senator Specter. Without objection, it will be made part of
the record.
Senator Reid. I apologize for not being here, but I had to
open the Senate for the minority this morning.
Dr. Satcher, thank you very much for being here. You have
done so much for suicide prevention by adding the weight of
your office and the stature you have on this issue. We have had
very few people who are willing to step out in front. You have
been willing to do that, for which I am grateful.
I also say I appreciate every one of the witnesses being
here, but some come at a little greater risk than others. I
want to express my appreciation to Danielle Steel for being
here. This is always very difficult when you have to talk about
a loved one that has been lost, and when you are someone as
well known as Danielle Steel, that makes it doubly difficult.
Again, like Dr. Satcher, we appreciate very much your being
here because the more attention we focus on this, the more we
are going to learn.
PREPARED STATEMENT
During the time that this hearing started till now,
someplace in the United States someone killed themselves, and
as a result of that, there are husbands and wives and children
and friends at a total loss as to why someone would take their
own life. That is what this hearing is all about.
Thank you very much, Mr. Chairman.
[The statement follows:]
Prepared Statement of Senator Harry Reid
Good morning Mr. Chairman and distinguished guests. I would like to
extend my gratitude to Senator Specter for convening today's hearing.
As one of the many Americans who has lost a loved one to suicide, this
hearing holds special significance for me.
Suicide is not something that only happens to other people. It is
the 8th leading cause of death in the United States, and is ranked as
the 3rd leading cause of death among our youth. More young adults die
from suicide than from cancer, heart disease, AIDS, birth defects,
stroke, pneumonia, influenza and chronic lung disease combined.
Suicide claims the lives of 31,000 Americans annually--this means
that every day we lose 85 people to suicide. In this country, there is
one suicide every 17 minutes. For every suicide, there are survivors
left to cope with tragic loss and to struggle with unanswered
questions.
The best place to start a story is at the beginning, so allow me to
take a moment to bring you back a few years so you may understand my
interest in suicide prevention.
The year was 1972, and I had just spent a memorable afternoon with
the legendary Muhammad Ali. When I returned to my Las Vegas law office,
I was given an urgent message to call my mother at our home in
Searchlight, Nevada. That is when I learned my father had shot himself.
Prior to this moment, I had never thought of suicide as something
that would affect my life. Suicide was something that only happened in
other people's families.
Over the years that followed, my family simply did not talk about
my father's suicide. In retrospect, I guess I was somewhat embarrassed
and even ashamed. My family and I were left alone and carried this
experience in a very private way--- the same private and lonely way
that many families across this country carry their pain today.
Thankfully, through hearings like this one today, many who
previously suffered in silence are now able to turn today's grief into
hope for the future. Suicide is a preventable tragedy and by addressing
this public health challenge we can change the course of the future for
so many Americans.
A few years ago, I was contacted by Jerry and Elsie Weyrauch from
SPAN--The Suicide Prevention Advocacy Network. They knew I had lost my
dad to suicide and asked if I would speak at their second annual
suicide awareness event here in Washington. I agreed, and on the day of
the SPAN event, I introduced a Senate Resolution that would focus
attention on the issue of suicide in America. My resolution calling for
a national strategy to address suicide in America passed in the Senate
the same day it was introduced. This marked a promising first step
towards the establishment of a national strategy for suicide
prevention.
In October 1998, a national conference on suicide prevention
convened in Reno, Nevada. One result of this conference was the
publication of the Surgeon General's ``Call to Action to Prevent
Suicide.'' This is a blueprint for suicide prevention and I am pleased
that the Surgeon General is here to tell us more about this effort.
Our next step is to translate the Surgeon General's framework for
suicide prevention into action and to increase direct spending for
suicide prevention. We need to establish a way to ensure the money
allocated to suicide prevention is spent wisely an in accordance with
our national strategy. We must ensure that every dollar we spend makes
a difference.
Suicide is a public health challenge. It is not a topic we can
afford to sweep under the rug and silently hope it will improve over
time. Instead, we must dedicate ourselves to eradicating the staggering
rate of suicides in this country. We have already begun to make a
difference and I am optimistic about what we can accomplish through a
National Suicide Prevention Strategy.
We have an outstanding panel of witnesses here today. I would like
to thank everyone for participating in this hearing, and I look forward
to hearing from all of our distinguished guests. Thank you.
Senator Specter. Thank you, Senator Reid.
Senator Wellstone.
Opening statement of Senator Paul Wellstone
Senator Wellstone. Thank you, Mr. Chairman. I know we are
under time constraints, so let me just thank Dr. Satcher and
Dr. Hyman for their leadership. It is much appreciated.
Let me thank you and Senator Reid for your engagement with
this issue.
Let me thank all the people that are here, all the
panelists. I want to mention to Dr. Jamison that I read your
book and it was a very, very important book to me and I think
many people in the country.
Then finally, let me just thank one organization back in
Minnesota, Save, which is an organization that both Sheila, my
wife, and I have done a lot of work with. As you know, Mr.
Chairman, I am very interested in this area and I look forward
to hearing from all the panelists.
And that is as brief as I can be.
Senator Specter. Thank you very much, Senator Wellstone.
Just a couple of questions. Dr. Satcher, what advice would
you give to someone who was thinking about suicide?
Dr. Satcher. Well, someone who is thinking about suicide--
as a physician, of course, I would want to talk with that
person at length to learn more about why that person is
thinking about suicide.
Senator Specter. Would you give that person some advice as
to seeking professional help?
Dr. Satcher. Yes. I am starting with myself because I am a
professional. But, yes, I would recommend that all primary care
providers ask their patients about depression and anxiety and
the other mental health problems that lead to suicide and, when
indicated, refer them to specialists in the field. But one of
our big problems, as you know, in this country is we need the
primary care sector more involved in identifying people who are
at risk for suicide. So, I am sorry. When I referred to myself,
I was speaking as a physician.
Senator Specter. Would you think it useful to try to set up
a hot line, an 800 number, or is there any such mechanism now
in effect where the thought is running through somebody's mind,
however tentatively, however tenuously, to seek help?
Dr. Satcher. There are 800 numbers. Let me just say they
are not well evaluated. Dr. Hyman might want to speak to that.
CDC is now evaluating the use of crisis hot lines for
teenagers, for example, and hopefully over a period of time, we
will learn more about the impact that these have.
One of the concerns, of course, is that many of the people
who are at greatest risk for suicide do not call those numbers.
Of course, Dr. Jamison has written about that. The problem we
have is that the people who are at greatest risk of suicide are
usually not the ones that call numbers seeking help. So, we
have got to learn more.
That is why we need programs in communities. We need
ministers and teachers and others who are leaders in
communities to be aware of the fact that there are many people
who are depressed, and when we identify these problems, we need
to make sure that people get the help they need. We have got to
be more supportive. We have got to have a stronger
infrastructure, and that is what we hope to do with this
national strategy.
Senator Specter. Dr. Hyman, picking up on those who do not
seek help--and we know the heavy incidence of suicide among
teenagers--what advice would you give to parents or teachers or
anyone who has extensive contact with teenagers as to what
danger signals to look for and what sort of precautionary
suggestions or advice to teenagers especially?
Dr. Hyman. I think what is really critical is the
difficulty of telling the difference between a passing stage
and something that is really serious. I think the advice to
parents and teachers is that if somebody's behavior changes, if
their grades go down, if they become disinterested, and it is
pervasive and it lasts more than a few weeks, it is a time to
talk to the child and perhaps bring them to a professional.
Teachers I think would like--and we have talked about this
before--more training in understanding warning signs both for
depression and suicide and also for risk of violence. But Dr.
David Satcher at Columbia has also pointed out that again many
of the most suicidal youth actually hide very well these
feelings.
One of the things that has been suggested through research
is actually screening tools that can now be administered,
perhaps using a computer, so there is very little
embarrassment, that might identify kids who would not otherwise
come forward or who are not giving outward signs, and these
screening tools then could be used to make clinical referrals.
Senator Specter. Thank you very much, Dr. Hyman. Thank you
very much, Dr. Satcher.
I would like to call now our second panel: Dr. John Mann,
Dr. John Fildes, Dr. Kay Redfield Jamison, Dr. Admiral Susan
Blumenthal.
While the second panel is stepping forward, let me
acknowledge the presence among our very many distinguished
visitors Senator Bob Packwood, a colleague, distinguished
chairman of the Finance Committee, and an expert squash player.
Senator Packwood. The only experience I have in self-
destruction is playing squash with you.
Senator Specter. Would you stand and be heard, Senator
Packwood? I would not catch all of that.
Senator Packwood. I told him the only experience I have in
self-destruction is playing squash with him.
Senator Specter. He is ordinarily a good squash player
except for the six stitches which appear under my left eye.
STATEMENT OF JOHN MANN, M.D., CHAIRMAN, SCIENTIFIC
COUNCIL OF THE AMERICAN FOUNDATION FOR
SUICIDE PREVENTION
Senator Specter. Our first witness today on the second
panel is Dr. John Mann who heads the Department of Neuroscience
at New York State Psychiatric Institute and is professor of
psychiatry and radiology at Columbia University which runs the
clinical research center for the study of suicidal behavior.
Thank you for joining us, Dr. Mann, and the floor is yours.
Dr. Mann. Thank you very much, Senator Specter, for the
opportunity to present here today.
I am here in my academic capacity as well as in my capacity
as chairman of the Scientific Council of the American
Foundation for Suicide Prevention. That Scientific Council
comprises 50 of the most distinguished experts in suicide
throughout the country, and the foundation, which represents a
large body of survivors, is the only private foundation in the
United States dedicated to the funding of suicide research,
over 200 projects in the last few years, education and support
for survivors.
These survivors have placed their faith in scientific
approaches to the identification of the causes and risk factors
for suicide and in the identification and development of
effective treatment interventions. And I would like to focus my
remarks on the latter, what can we do about this problem.
We have made enormous progress in trying to understand
causes and risk factors of psychiatric illnesses and suicide is
a complication of psychiatric illnesses. It is not a result of
social problems. It is a compilation of factors which
fundamentally stem from psychiatric illness.
But in trying to develop better treatments for psychiatric
illness--and we have been enormously successful with the
support of Congress in doing that--we have made relatively
little progress in denting the tremendous toll due to suicide.
The reason for that is that almost all of the clinical trials
that have been conducted have specifically addressed general
psychiatric patients and not specifically those who are feeling
suicidal. In fact, most studies have actually excluded those
patients. So, when the clinician is asked the question, what
should I use for the suicidal patient, they have to extrapolate
from other types of studies. This is really a shocking
deficiency in our clinical armamentarium, given how
sophisticated we are in other respects.
The American Suicide Foundation does not have the funding
to support these kinds of studies. Many private foundations are
in the same situation. The only approach that will make a dent
in the situation will be a partnership between Government and
private foundations.
The American Suicide Foundation has partnered, for example,
with the Soros Foundation to conduct a treatment intervention
study on suicide in Hungary. Hungary has three times the
suicide rate of the United States. Certain provinces of Hungary
are particularly vulnerable. We believe that this kind of model
in Hungary will potentially be usable in other places. We, in
particular, have in mind the State of Nevada which, like
Hungary, has a very high suicide rate, double that of the
United States, a small population, a place where we can conduct
a manageable, affordable intervention that could be a model for
the rest of the country.
The second proposal that the American Foundation for
Suicide Prevention wishes to put before the committee is a
proposal for a national network of treatment evaluation centers
akin to the kinds of national networks that we have for
surgical cancer, for heart disease, and so on, centers that
specialize in the identification, the assessment, and the
treatment of suicidal patients. This national network would
then be the infrastructure or the vehicle for conducting
controlled, clinical, scientific treatment trials to develop
strategies for treating suicidal patients.
For example, we know there are medications that may work
better than other medications in depression and manic
depression for preventing suicide. In other words, these drugs
do have properties that are valuable to these patients for
their psychiatric illness, but they have an additional
property, such as lithium, which may reduce the risk of
suicidal behavior independent of improving the psychiatric
condition.
An analogy is when you are driving a car recklessly or very
fast or you hit some ice or there is an accident, you need your
seat belt system to save your life. When you develop a
psychiatric illness, what determines whether or not you act on
the suicidal feeling is not just the psychiatric illness but an
inherent predisposition or vulnerability to act on powerful
feelings. There are treatments that may well improve this
restraint system that we all have to varying degrees and may
help us help patients live through the crisis of the
psychiatric illness while we are waiting for the treatment to
work.
There are promising treatments in the area of mood
disorders and in psychoses and we would like to propose that
funds be set aside for this kind of national treatment research
network to evaluate these kinds of promising treatments as the
step forward to actually giving clinicians the tools to save
lives in the United States as soon as possible.
Senator Specter. Thank you very much, Dr. Mann.
STATEMENT OF JOHN FILDES, M.D., MEDICAL DIRECTOR,
UNIVERSITY OF NEVADA MEDICAL CENTER TRAUMA
UNIT
Senator Specter. We now turn to Dr. John Fildes, medical
director of the University of Nevada's Medical Trauma Center,
where he developed the Suicide Prevention Research Center
responsible for more than 100 physicians who treat more than
9,000 admitted patients. Thank you for joining us, Dr. Fildes,
and the floor is yours.
Dr. Fildes. Thank you very much, Senator.
As a surgeon, I became interested in treating patients with
suicide after years and years of tending to their wounds and
knowing that I could only master part of the problem. I have
been involved in a broad number of injury control projects
throughout our State and region and felt that suicide
prevention was a paramount issue.
Senator Reid has been instrumental in supporting us in that
effort, and we were fortunate enough to open up the Suicide
Prevention Research Center through funding provided by the CDC.
Nevada, as many people know, has the highest per capita
suicide rate in the United States and has so for the past 10
years. This only tells part of the problem. In the
Intermountain Western States, 8 of these States make up the top
12 highest suicide rates in the Nation, placing us in the
center of an endemic region and being the natural home for this
sort of research.
The Suicide Prevention Research Center has been charged to
fill in some of the gaps with regard to creation of tools to
take a public health approach for injury control.
All the information that we know about suicide and
everything that you have heard today only tells about the
number of deaths. There is no real-time, on-line surveillance
system in the United States or in any individual State that can
record the number of attempts that actually take place, and
these outnumber completions by a large number. In order for us
to implement effective programs and know whether those programs
are making things better or making them worse or just remaining
the same, we need to have an ongoing, on-line, real-time
measurement of suicide activity, both attempts and prevention,
throughout the United States.
We are pioneering that task in Nevada and will spread it to
six of the eight Intermountain States during the 3-year program
that we have with the CDC.
In addition, we require the need to standardize
nomenclature. When you try to meta-analyze and compare studies
done by different research groups at different times, it is not
always entirely clear what is being described or how these
studies are comparable. And operationalizing a language for
suicide research is the second objective that we hope to
accomplish.
The third is to create a standardized inventory tool, one
which can be self-administered throughout the rural and
frontier of the Intermountain West, to follow back the intimate
acquaintances of those who have committed suicide, as well as
to be used on attempters and to try to characterize some of the
risk factors, the behavioral issues, and other external forces
that have caused these acts to take place.
Fourth, we would hope to create an inventory of research-
proven prevention programs from around the globe so as not to
recreate the wheel, to make these prevention programs available
to communities that have demonstrated the highest rates, and to
aid their implementation by identifying local experts who are
willing to embrace and to longitudinally propagate these
activities within their home communities with the support of
the center.
And finally we hope to do this by creation of an
educational task group to help disseminate our findings, as
well as our interventions, and to guide us through their
implementation.
Dr. Satcher has said that even the most well considered
plan accomplishes nothing if it is never implemented. What I
have shared with you today is the model of an evidence-based,
outcome-driven, injury control model applied to the problem of
self-directed intentional injury and death. It utilizes the
Surgeon's General Call to Action by expanding the awareness, by
implementing intervention programs that are practical and
readily available, and using methodology based on public health
and epidemiologic principles. In order for this work to be
implemented on a broad scale, it will continue to require
support and the attention of public and private sources.
Suicide is not an irrational or an inevitable act. It is a
public health problem of ever-growing proportion and requires
the same level of commitment provided to other diseases. As a
trauma surgeon and as a specialist in injury control and injury
prevention, we see it as one form of intentional injury which
can be worked on effectively and which can be reduced.
Thank you.
Senator Specter. Thank you very much, Dr. Fildes.
STATEMENT OF KAY REDFIELD JAMISON, Ph.D., PROFESSOR OF
PSYCHIATRY, JOHNS HOPKINS UNIVERSITY
Senator Specter. Our next witness is Dr. Kay Redfield
Jamison, professor of psychiatry at the Johns Hopkins
University School of Medicine and co-author of the standard
medical text on manic-depressive illness. Her list of
accomplishments is very extensive, but one of the most
significant is that she is the recipient of the American
Suicide Foundation Research Award for her more recent book,
``Night Falls Fast: Understanding Suicide.'' In the jacket of
the book, a matter of some sensitivity, but in the public
domain, is the comment at the age of 28, after years of
struggling with manic depression, she attempted to kill
herself.
Dr. Jamison, thank you for joining us.
Dr. Jamison. Thank you. I am a psychologist and professor
of psychiatry at the Johns Hopkins School of Medicine, and I
thought this morning I would talk more personally since my
colleagues will be and have been addressing the science of
suicide. Thank you very much for the opportunity to speak here
today.
Suicide has been a professional interest of mine for more
than 20 years and a very personal one for very much longer. I
have a hard-earned respect for suicide's ability to undermine,
overwhelm, outwit, devastate, and destroy. As a clinician,
researcher, and teacher, I have known or consulted on patients
who hanged, shot, or asphyxiated themselves, jumped to their
deaths from stairwells, buildings, or overpasses, died from
poisons, fumes, prescription drugs, slashed their wrists, cut
their throats. Close friends, fellow students from graduate
school, colleagues, and children of colleagues have done
similar or the same. Most were young and most suffered from
mental illness. All left behind a wake of unimaginable pain and
unresolvable guilt.
Like many who have manic-depressive illness, I have also
known suicide in a more private, and awful sort of way, and I
trace the loss of fundamental innocence to the day that I first
considered suicide as the only solution possible to an
unendurable level of mental pain.
I was 17 when, in the midst of my first depression, I
became knowledgeable about suicide in something other than an
existential and adolescent way. For much of each day, during
several months of my senior year in high school, I thought
about when, whether, where, and how to kill myself. I learned
to present to others a face at variance with my mind, ferreted
out the location of two or three nearby tall buildings with
unprotected stairwells, discovered the fastest flows of morning
traffic, and learned how to load my father's gun.
The rest of my line at the time fell into a fast and black
night. Everything seemed a ridiculous charade to endure, a
hollow existence to fake one's way through as best one could.
But gradually, layer by layer, the depression lifted, and by
the time my senior prom and graduation came around, I had been
well for months. Suicide had withdrawn to the back squares of
the board and become once again simply unimaginable.
Over the years, though, my manic-depressive illness became
much worse and the reality of dying young from suicide became a
dangerous undertow in my dealings with life. Then when I was 28
years old, after a particular damaging and psychotic mania,
followed in turn by a prolonged and violent siege of
depression, I took a massive, lethal overdose of lithium. I
unambivalently wanted to die and I nearly did. Death from
suicide had become a possibility, if not a probability, in my
life.
This time it was not a very long walk from personal
experience to clinical and scientific investigation. I was a
young assistant professor in a department of academic
psychiatry. I studied everything I could about my disease and I
read all I could about the psychological and biological
determinants of suicide. As Dr. Satcher and Dr. Hyman have made
clear this morning, there is a great deal known about these
psychological and biological determinants, but there is a
terrible gap between what we know and what we do about it. And
this gap is lethal.
And there is, in fact, much we know about suicide that is
strangely heartening. As a clinician, I believe there are
treatments that can save lives. As one surrounded by scientists
whose explorations of the brain are elegant and profound, I
believe our basic understanding of the brain's biology is
radically changing how we think both about mental illness and
suicide. And as a teacher of young doctors and graduate
students, I feel the future holds out great promise for the
intelligent and compassionate care of the suicidal mentally
ill.
All of these things I deeply believe. The science is of the
first water. It is fast-faced and it is laying down pixel by
pixel, gene by gene the dendritic mosaic of the brain.
Psychologists are deciphering the motivations for suicide and
throughout the world, from Scandinavia to Australia, public
health officials are mapping a clearly reasoned strategy to cut
the death rate of suicide. We are fortunate--and I cannot say
how fortunate we are--in this country to have had and continue
to have the superb leadership of the Surgeon General, Dr. David
Satcher.
Still, the effort seems remarkably unhurried. Every 17
minutes in America someone commits suicide. And I will wrap up.
Where is the public outrage? Where is the public concern?
I have become more impatient--and I am generally
impatient--and more acutely aware of the problems that stand in
the way of denting the death count. I cannot rid my mind of the
desolation, confusion, and guilt I have seen in the parents,
children, friends, and colleagues of those who kill themselves.
Nor can I shut out the images of the autopsy photographs of 12-
year-old children or the prom photographs of adolescents who
within a year's time will put a pistol in their mouths or jump
from the top floor of a university dormitory building.
Like many of my colleagues who study suicide, I have seen
time and again the limitations of our science and been
privileged to see how many good doctors there are and appalled
by the callousness of others. Mostly, I have been impressed by
how little value our society puts on saving the lives of those
who are in such despair as to want to end them. It is a
societal illusion that suicide is rare. It is not rare.
Certainly the mental illnesses most closely tied to suicide are
not rare. They are common conditions and unlike cancer and
heart disease, they disproportionately affect and kill the
young.
We need to do more, far more, and now. Thank you.
Senator Specter. Thank you very much, Dr. Jamison, for
sharing your personal experiences.
STATEMENT OF SUSAN BLUMENTHAL, M.D., M.P.A., ASSISTANT
SURGEON GENERAL AND SENIOR SCIENCE ADVISOR,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Senator Specter. We next turn to Dr. Susan Blumenthal, Rear
Admiral, Assistant Surgeon General, and Senior Science Advisor,
Department of Health, national expert in suicide research and
prevention and has written extensively on the health concern,
including a major volume, ``Suicide over the Life Cycle.'' From
1982 to 1985, Dr. Blumenthal served as head of the suicide
research unit at the National Institute of Mental Health, and
as the Nation's first Deputy Assistant Secretary for Women's
Health, she is credited for putting women's health on the
national policy agenda.
Thank you for joining us, Dr. Blumenthal, and we look
forward to your testimony.
Dr. Blumenthal. Good morning and thank you, Chairman
Specter, Senator Reid, Senator Wellstone, for your outstanding
leadership and commitment throughout your careers in Congress.
You have worked tirelessly to raise awareness and to convene
members of the Federal Government and private sector to work on
major public health problems like violence and suicide. It is
an honor to participate in this hearing today.
I also want to commend the work of our Surgeon General, Dr.
David Satcher, and Dr. Hyman, Director of the NIMH, for their
work and to the scientists here, the grassroots advocates, and
families who contribute so much to raising awareness about this
public health problem.
I am here today in my private capacity.
Senator Specter, it is over 15 years ago that I first
testified before you on this issue in 1985 when I was head of
the suicide research unit at the National Institute of Mental
Health. At that time several clusters of youth suicides had
occurred in communities across our Nation, including
Westchester County, New York and in Plano and Dallas, Texas,
running through these communities like a lethal, infectious
disease, leaving the Nation heartbroken and perplexed about the
reasons for these tragedies and urgently in need of strategies
to help prevent future loss of life in ways not unlike our
communities have been ravaged recently by school violence where
young people have killed their classmates and then killed
themselves.
You see, as you have heard, since 1950 there has been a
tripling in suicide rates for our Nation's young people, ages
15 to 24, but the sharp upturn in rates of suicide among
adolescent and young adults in the United States that began in
the 1950's and emerged as one of the most highly visible and
alarming public health trends of the 1980's perhaps obscured
also the fact of the pervasiveness and persistence of suicide
and suicidal behavior in all other age groups of the population
throughout the course of the 20th century and the fact that
risk factors for suicide appear to differ across the life
cycle.
Suicide is a complex human behavior. It reflects many
determinants, biological, psychological, and environmental,
present in the absence of protective factors. Thus, preventing
suicide requires multifaceted interventions, individual,
medical, community-based and environmental. Suicide occurs
across the life cycle and its risk increases with age. It
occurs in both men and women and across racial and ethnic
groups. Yet, many people who commit suicide have exhibited
warning signs to friends, parents, teachers, colleagues, and
doctors, but their symptoms have not been recognized and they
have not received appropriate intervention. Thus, as concerned
citizens, educators, legislators, and health care
professionals, we all have a critical role to play in suicide
prevention.
In the testimony today, you are hearing what we have
learned over the past 15 years about suicide and how to prevent
it and the challenges ahead if suicide rates are going to be
reduced further in the future.
Perhaps the most significant achievement during this time
period has been the important progress made in our ability to
diagnose and treat mental and addictive disorders that are so
disproportionately represented in the life histories of those
who commit suicide. You see, research tells us that as many as
90 percent of people across the life cycle who end their lives
by suicide are suffering from a mental and/or addictive
disorder.
But as Dr. Jamison underscored, unfortunately what we know
from best practices does not get translated into ordinary
practice in our communities around the Nation, that people are
not getting detected, that they are not being referred for
appropriate treatment, and because of the shameful stigma that
exists in our society that treats mental illnesses like
personal weaknesses or character flaws rather than real,
disabling illnesses just like heart disease or diabetes, for
which there are extremely effective treatments.
Over the past decade, we have finally witnessed an opening
of understanding about these illnesses that has resulted in
more effective treatments and in people seeking help. Over the
past century, the rates of suicide have remained remarkably
stable, although in the past decade we have seen about a 10
percent drop in suicide rates.
To put a framework around what we know and to stimulate
collaborative actions to prevent this tragic loss of human
lives, in the 1980's we fostered a public health approach to
suicide prevention, saying that it was not a result of just
social and environmental factors. It encompasses a strategy to
maximize the benefits and efforts and resources for prevention
across this Nation, and this is the approach that has been
taken by our Surgeon General's Call to Action.
The public health approach has been used widely to respond
to epidemics of infectious disease and over the past decades
has been used to address other challenging health problems such
as chronic diseases like the fight against heart disease. In
public health, there are three levels of prevention, primary,
secondary, and tertiary.
Primary prevention is like vaccinating for the prevention
of infectious disease--and I will wrap up in a minute--doing
community-based interventions, for example, to prevent smoking,
encourage a healthy diet and physical activity for heart
disease. To prevent suicide, it means de-stigmatize mental
illness and educating the public and health care providers
about mental illness and substance abuse. It means providing
every child with a healthy start, promoting mental health
across the life span, including school-based interventions to
foster problem solving skills, conflict resolution, and
resiliency.
Secondary prevention means identifying high risk people and
intervening.
Senator Specter. Dr. Blumenthal, are you summing up now?
Dr. Blumenthal. I am.
In heart disease, it means detecting those with high blood
pressure or cholesterol. To prevent suicide, it means detecting
those who have suffered a loss who are at high risk, who are
depressed, and intervening.
And tertiary prevention means intervening with people who
have exhibited suicidal behaviors, as we would with people with
heart disease. And again, studies are underway to find the most
effective treatment strategies.
We also must promote better surveillance of the problem,
avoid inadvertently glamorizing suicide in educational programs
and in the media. We need to establish community task forces to
respond before a crisis occurs. We need to build coalitions
between grassroots, between the public, between policymakers,
health care leaders. We need to decrease access, easy access,
to lethal methods in our homes.
Well, in closing, Voltaire has said that the man--let us
also make that the woman--who, in a fit of melancholy, kills
himself today would have wished to live had he waited a week.
Our understanding of suicide is benefitting from rapid advances
in the neurosciences and the behavioral sciences from the kind
of public awareness that is coming from this hearing, from the
Surgeon General's Call to Action to Prevent Suicide, and
hopefully with it will come hope in the future, hope that we
will further reduce suicide, an untimely loss of human life, in
the 21st century.
Thank you for the opportunity to be here today.
Senator Specter. Thank you very much, Dr. Blumenthal.
Senator Reid.
Senator Reid. Thank you very much, Mr. Chairman.
Coming here today, in addition to this being a unique
opportunity to have our first congressional hearing of this
magnitude dealing with suicide, has been personally very
rewarding for me because over here on the wall--and I did not
know it was going to be here--is a quilt that had a number of
people from Nevada who committed suicide, and one of those is
my father. Just walking over there and visiting with my dad for
a few seconds was important to me.
And also it brought to my mind, even though my father was
uneducated--he didn't graduate from the eighth grade not
because he was not smart enough; he just did not have the
opportunity--maybe in his death there was some meaning because
I am sure that he would be surprised if we had all these
eminent scientists here talking about one of his problems or
talking about his problem--and that is, in effect, what you are
doing. So, in his death, today maybe I see the benefit of
speaking out on this subject because we are talking more about
it.
I think the question I would like to ask this panel, Mr.
Chairman, is in my opinion the biggest problem with suicide is
there needs to be public awareness that it happens all the
time. Suicide always happens to someone else. Since my dad
killed himself, I really focus on suicide. It is all around us.
Well, it happens every 17 minutes here in America, four times
as much, we were told earlier today, in Hungary. It is a real
problem in America and the world.
So, my question is what can we do, what should we do to
allow the American public know that 31,000 people die every
year? Do you have any ideas, any of you?
Senator Specter. Dr. Blumenthal.
Dr. Blumenthal. Well, I think that we need to do more
educational campaigns, but I think we have to start with
educating about the incredible prevalence of mental and
addictive disorders in America because one out of five
Americans will have a mental illness in any year-period.
I think our Surgeon General's Call to Action about suicide
and mental health is an important step forward. We had a White
House conference on mental health. That is an important step
forward. We need to educate our health care providers to
understand that suicide is the most tragic complication of
undiagnosed and treated mental illness.
But shamefully in our country there are disparities in
terms of coverage for mental illness that treats them like they
are not other physical illnesses. And I think we have to
rectify that. We have to encourage people to seek help, but we
have to ensure that help is state of the art, and we have to
ensure that all Americans have access to lifesaving treatment
and health care.
Senator Reid. We have public service announcements about
wearing seat belts. Not nearly as many people are killed every
year by virtue of not wearing seat belts as die from suicide. I
personally have not seen any public service announcements about
suicide.
Dr. Mann. I think that is a very important point. People
who are feeling suicidal need to understand that there is help
out there, and we need to focus specifically on this group
because this is the group that is at risk for dying. Patients
who have psychiatric illnesses but do not have suicidal
thoughts are at extremely low risk in terms of suicide. So, the
ones who are at risk are having these thoughts. Somehow we have
to reach out to them and we have to reach out to their families
because they tell their families about the fact that they are
feeling suicidal.
At the same time, it is a bit like World War II. The first
thing we have to do is stop retreating. The next thing we have
to do is to build enough tanks so that we can go on the
offensive, developing treatment strategies that are shown to be
specifically beneficial for the suicidal patient in the main
conditions that are associated with suicide like manic
depression or bipolar disorder, unipolar disorder,
schizophrenia, and substance abuse.
We have to give the clinician the tools. We talk about
educating the public. We talk about educating the clinician,
but the clinician knows that they need specific tools for this
problem, and to get those tools, we need factories that make
those tools. The factories that make those tools are
specialized centers that know about suicidal patients, that are
used to looking after them, that conduct, in the safest
possible way, the treatment trials to determine what treatments
work best for them.
Senator Reid. Thank you, Mr. Chairman.
Senator Specter. Thank you very much, Senator Reid.
Senator Wellstone.
Senator Wellstone. Mr. Chairman, I will try and be brief.
Let me, first of all, just say to Dr. Jamison your words:
``that there is a gap between what we know and what we do and
that gap is lethal'' I think sort of rings out to me and I hope
to the country.
I want to sort of talk about two issues. It is less in the
form of a question, but just a comment.
First of all, on the whole issue of discrimination. We have
gone through this in my own State. The Governor of Minnesota,
Governor Ventura, said in an interview, ``I've seen too many
people fight for their lives. I have no respect for anyone who
would kill themselves. If you're a feeble, weak-minded person
to begin with, I don't have time for you.'' So, we have a ways
to go in terms of just dealing with some of the insensitivity
or lack of knowledge. I can think of other words. But I think
that that is one challenge.
But, Mr. Chairman, I want to make a comment first about
Senator Reid and then about you.
First on Senator Reid, you were talking about your dad. I
think what your father might be most proud of is not the
experts that are here, but that you are here as U.S. Senator. I
think that is what he is looking down from heaven and seeing,
especially with your outspokenness and your courage to talk
about your own family and the way in which you have brought
that before the country.
And, Senator Specter, everybody has said this. Dr.
Blumenthal said it. Everybody has said it in one way or
another. Dr. Satcher said it. Dr. Hyman. There is a direct
connection also between suicide and people who are struggling
either with mental illness or with substance abuse or
addiction. You, Mr. Chairman--and very few people have been
willing to do this--you have now been willing to cosponsor the
Fairness in Treatment Act which essentially says when people
are struggling with substance abuse, we have to treat this. You
cannot view it as a moral failing. You have been the one who
has been willing to step forward, and I appreciate your effort
to do this with me.
Senator Specter. Do not forget yourself. It is your bill.
Senator Wellstone. I usually do not pass bills here. I
always need some help.
Senator Domenici and I are working together on this Mental
Health Equitable Treatment Act.
My point is, first of all, what we are not doing goes back
to what Dr. Jamison said, the gap. There is too much
discrimination. We are not covering this with health insurance.
We are not getting the treatment to people, especially
children, especially minorities, especially poor, especially
rural areas, especially seniors. At the minimum, we ought to
end that discrimination and make sure there is the coverage for
the treatment.
Then the second point is even if you end the
discrimination, for those who cannot afford any coverage at
all, we have got to make sure there is some coverage.
Then finally, even if you have got the coverage, quite
often there are communities where we do not have the
infrastructure of the men and women and the people to deliver
the care.
To me, we can do this. We can do this. We have to. That is
my statement.
Senator Specter. Thank you very much, Senator Wellstone.
Dr. Jamison, my first question is for you. We thank you
specially for sharing with us your own personal experiences,
which are very, very powerful. As Senator Reid has, it has
unique meaning when you come forward and tell us what happened
to you. That is very, very authoritative, obviously.
Your statement has much to commend it, but I would like you
to amplify on one line where you said, referring to suicides,
``Most were young and suffered from mental illness. All left
behind a wake of unimaginable pain and unresolvable guilt.''
Would you amplify that?
Dr. Jamison. Yes. Actually I had no intention of writing a
book about suicide because I thought it would be, from a
scientific point of view, overwhelming and, from a personal
point of view, something I just did not want to do.
I did a book tour for a book I had written about my manic
depression, and every single place I went, someone came up to
me--and usually four or five people would come up with
photographs of 15- or 17- or 20-year-old kids who had killed
themselves. The cumulative effect of that was--it is one thing
to read the statistics and another thing to go to town after
town, city after city across the United States and see the
death toll and see the guilt, the unresolvable guilt, 20, 30
years later. What could I have done differently? What ought I
have done? What can I do to protect my other children? It just
seemed to me an appalling indictment of somewhere in society,
given what we know about the scientific basis, the biological
basis of the illnesses that are responsible for suicide, that
people would feel so personally accountable for them.
I just think that unless you have been there, there is no
way of knowing the kind of guilt that people feel because there
is always something that somebody could have done differently.
I mean, that is just a given. Whether it is a friend or a
colleague or a family member, we all know we could have done
something more or different.
You are asking about what can people do. One of the things
I am struck by is people will send their kids off to college,
and they will go check out the libraries. They will go check
out the graduate record scores. They will go check out the
admissions into law school rates. They will check out
everything. But they will not check out the mental health
facilities at the campuses. They will not sit down and talk
with their kids about, look, we have got depression in our
family, or your uncle committed suicide. You are a little bit
at risk. What can we do about it? Let us talk about it. There
are things that people can do now within families and
communities that are not being done, much less at the
government level. That is what I find, I guess, so awful.
Senator Reid. Mr. Chairman, would the chairman yield just
for a brief statement?
Senator Specter. Sure.
Senator Reid. We talk about every 17 minutes someone
killing themselves. Those are the reported suicides. The
automobile accidents and the many other things that happen that
are not counted as suicides that really are would increase that
number. Would you agree?
Dr. Jamison. Yes, absolutely. I spent a fair amount of time
with medical examiners over the last several years, and they
talk about a child who was 17 years old and had a gunshot wound
to the head, wrote a suicide note. The parents will still say
it was an accident because they cannot bear to live with the
fact that it was a suicide and put pressure on the medical
examiner's office to classify it as an accident.
Senator Specter. Thank you, Dr. Jamison.
Dr. Mann, you talk about studies which you would like to
undertake. What response are you getting from the National
Institute of Mental Health on your applications? The $5.2
billion increase in the last 3 years ought to have given some
extra leeway. Are you having much luck?
Dr. Mann. Well, thanks to your leadership and your
colleagues', there has been a very significant increase in
funding at the NIMH.
Senator Specter. Is it filtering down?
Dr. Mann. Yes. In fact, we have had a meeting with Steve
Hyman not so long ago, and he has been very supportive and
forthcoming in terms of creative funding mechanisms and
arrangements to try and implement the kind of treatment trials
that we have been talking about today. So, we are very
optimistic, with your support and working with the NIMH, that
we will see some of this bearing fruit in the very near future.
Senator Specter. Dr. Hyman is still here. He liked that
comment.
Dr. Hyman. Yes. This is a very well-funded man speaking.
Senator Specter. Perhaps even better in the future.
Dr. Fildes, what would you recommend to a parent who sees
some danger signals in his or her child?
Dr. Fildes. I have the opportunity to actually treat
patients like this, and we have these patients and their
families talk about the problem and do so with the help of
professionals.
There are many, many times when I treat a young patient, or
even an elderly individual, who has had a very serious, serious
suicide attempt and saved their lives, only for a few days
later for them to say, oh, I cannot believe what I have done. I
do not understand what I have done, but I will never do it
again. In that moment, that crystallizes the elements of the
cure that we are talking about, that we are all trying to find
and apply across the numbers of patients around the United
States.
Senator Specter. Dr. Blumenthal, the red light is on. I do
want to ask you one final question for this panel. You were
here, as you noted, 15 years ago. What has been the extent of
the progress on dealing with suicide, if any progress in fact
has been made? And is it adequate?
Dr. Blumenthal. Well, I think we have seen progress. We
have seen recent declines in some of the suicide rates over the
past decade for certain populations, although others have gone
up, for example, young black males. We have seen more
systematic research being conducted at the NIMH and at CDC, the
testing of new intervention trials in SAMHSA. But clearly, much
more needs to be done.
I just want to underscore that suicide is a complex human
behavior. It requires interventions that are multiple, targeted
to those risk factor domains. For example, most people who
commit suicide have a mental illness, but most people with
mental illness do not commit suicide. Therefore, we need to
strengthen the protective factors for people. We need to
increase social supports, decrease access to lethal methods in
the homes, such as guns. We need to promote resiliency and
educate young people about mental health in the schools, and we
need to, again, increase access to mental health services in
our country.
Senator Specter. Thank you very much, Dr. Blumenthal, Dr.
Jamison, Dr. Fildes, Dr. Mann. We appreciate very much your
being here.
We now go to our final panel: Ms. Danielle Steel and Ms.
Jade Smalls. Congresswoman Nancy Pelosi will introduce Ms.
Danielle Steel.
STATEMENT OF HON. NANCY PELOSI, U.S. REPRESENTATIVE
FROM CALIFORNIA
Senator Specter. First we will call on Congresswoman Pelosi
for the introduction. She is serving her seventh term in the
House, representing California's 8th congressional district,
won her last election by a narrow margin, with 86 percent of
the vote. She is a member of the House Select Intelligence
Committee and is a member of the House Appropriations Committee
and serves on the Subcommittee of Labor, Health and Human
Services, where we have all collaborated on a great many
appropriations matters.
Congresswoman Pelosi.
Ms. Pelosi. Thank you very much, Mr. Chairman. Thank you
for your leadership on this issue, to you, to Senator Reid, to
this committee, for facing this issue head on. There is so much
denial about it in the country.
Senator Wellstone extended his regrets in having to go to
another meeting, but you pointed out his tremendous leadership,
in addition to Senator Reid's and yours, on this issue.
Mr. Chairman, Senator Reid, I am here this morning as a
proud Representative of San Francisco, proud of my constituent,
Danielle Steel, and delighted that I can say that she is a
personal friend for many, many years.
She is a household word in many homes in America, but she
is a very private person.
When I think of Danielle Steel, I think of one word:
mother. She is first and foremost a mother of a beautiful
family. Many of her children are with her today at this
hearing.
This is a real act of courage on the part of Danielle
Steel. She is a very, very private person although, as I say,
well known. She shared her apprehension with me about facing
this committee, and I told her she had nothing to fear, that it
would be painless. But that is the small part of the courage.
The larger part of the courage is her being here to tell the
personal story of Nick Traina. It is in that spirit of Danielle
as a mother that I am proud to sit with her and present her to
the committee.
Thank you, Mr. Chairman.
Senator Specter. Thank you very much, Congresswoman Pelosi.
STATEMENT OF DANIELLE STEEL, BEST-SELLING NOVELIST AND
AUTHOR OF ``HIS BRIGHT LIGHT''
Senator Specter. Ms. Steel, as noted, is a world-renowned
author, 77 books. The Guinness Book of World Records noted that
one of her books was on the New York Times Best Seller List for
381 consecutive weeks. Her most important piece of work perhaps
is the one she wrote in honor of her son Nick who committed
suicide at the age of 19. The book, entitled ``His Bright
Light,'' was written to remove the stigma associated with
mental illness.
She is the mother of nine children and comes before us
today to comment about her very extensive and tireless efforts
to help other children who suffer from emotional distress.
Thank you for joining us, Ms. Steel.
Ms. Steel. Thank you very much, and thank you for the
lovely introduction.
I would like to thank the ladies and gentlemen of the
Senate Appropriations Committee for having me here today. I do
not ever speak publicly, but it was an honor and an invitation
that was impossible to resist.
I also feel better being here today because all of my
children assured me that I am not famous.
I was asked to speak about my son Nick. It is a huge
challenge to paint a portrait of him for you in so little time.
Brilliant, charming, wonderful, loving, talented, funny,
outrageous, tormented, unforgettable.
Senator Specter. Ms. Steel, we have moved rather
expeditiously. Senator Reid has weighed in in your favor for an
extra 5 minutes, and we have the time. So, take 10.
Ms. Steel. Thank you very much. I was frantically crossing
things off before I sat down.
He was a magical child, an extraordinary boy. He suffered
from manic depression all his life and committed suicide at 19.
As a baby, when people would ask his name, he would answer,
I'm incredible. Because people said it of him so often, he
thought that was his name. He was a remarkable child and became
an even more remarkable young man.
By the time he was 2, I knew something was wrong with him.
He was like a record playing on the wrong speed, way, way too
fast. By 4, I know now that he was manic. I feared even then
that he was sick. At 7, I was convinced of it. He was
brilliant, had good grades, but was moody, troubled, easily
enraged. I turned to doctors and psychiatrists throughout his
early childhood and was always told that he was fine. I felt in
my heart that was not true, although I wanted it to be true. I
sensed that there were terrible demons lurking deep within. I
cannot even tell you how I knew, but I knew.
At 12, his best friend died in an accident. Nick was doing
well in school, but he began dabbling in drugs and he was
deeply depressed much of the time, sitting in the dark in his
room. He was full of contrasts. Sometimes he would be jubilant.
He was loving and funny. Sometimes he was too depressed to
move. Often he was awake all night, sometimes till 8 a.m.
Nonetheless, the psychiatrists we saw insisted he was fine.
They were charmed by him.
By 13, Nick's life began to fall apart. From then on, his
life was a constant merry-go-round of schools where he could
not conform, psychiatrists, special programs for emotionally
disturbed kids, and brief stays in mental hospitals to evaluate
him. They said he was difficult and blamed it on his high IQ.
He remained undiagnosed and unmedicated until 15 when I was
told he had attention deficit disorder. By 15, I believed he
was suicidal, although he never put it in words. My instincts
were right. When I read his journals after his death, I
discovered that from the age of 11 on, he wrote about killing
himself every single day.
At 15, he became more and more impossible to manage. He
spent 5 months in mental hospitals, and we could not get him
functional enough to come home. Yet, through it all, he was
brilliant, charming, affectionate, angry, confused. We tried
three different hospitals in 1 year. No one was able to do
anything for him. By the end of that time, he was curled in a
ball, terrified and sick.
At 16, he was finally diagnosed bipolar and put on lithium.
Within 3\1/2\ weeks, he was sane, whole, functional, and back
in school getting straight A's.
Life began for Nick at 16. He said that on lithium he felt
normal for the first time in his life. He did well in school.
He began in earnest a music career that he had longed for and
worked towards for years. Music was his passion and his joy. He
had huge charisma and talent, and in the next 3 years, he
released nine CD's, played hundreds of concerts, did two
national tours with his band, appeared on MTV, and was
scheduled to tour Europe and Japan. He was a lyricist,
composer, musician, and lead singer of an increasingly
successful punk rock band.
He became then the boy I knew and loved so fiercely who was
not only my son, but became my best friend. He had compassion,
wisdom, joy, and a sense of humor about others and himself. He
worked tirelessly. He had a quick tongue and a big heart, and
where he saw pain, he would reach out a hand.
His hospital stays then were to readjust his medications.
He had two psychiatrists, a live-in psychiatric counsellor, and
took three medications daily, upon which his life and well-
being relied. He had nurses from the age of 14 to accompany and
protect him from his lack of impulse control. Once on lithium,
he was virtually drug-free.
From 16 on, Nick lived in a cottage of his own with his
nurses and the psychiatric counsellor who oversaw everything he
did.
He graduated from high school and did one term of junior
college, and his life in his late teens was a whirlwind of
rehearsals, concerts, and road tours. Wherever he went, he was
accompanied not only by his fellow musicians and his equipment,
but by his nurses, his counselor, his medications, and his
disease. Wherever he was, even on tour, we checked his lithium
levels, with blood tests weekly, to make sure that they were
high enough. We tested him daily for drugs to make sure that he
was not dabbling, and with rare, rare exceptions he was not.
We thought we were home free. Only in reading his journals
later did I realize how constantly tormented he still was and
how close to the abyss he always lived. On medications, he
appeared balanced and happy most of the time. He insisted, and
we wanted to believe, that he was fine. That outward appearance
of fineness even fooled him.
At 18, Nick decided he no longer needed medication. He felt
great. He stopped taking lithium, became almost instantly
manic, and within 5 weeks attempted suicide by taking a virtual
arsenal of drugs. It left him with damaged kidneys, liver,
spleen, heart, temporarily deaf, briefly incoherent, and
paralyzed both his legs.
Before he had even recovered, 10 days later he tried again
in a locked suicide ward while on suicide watch. And he
attempted suicide yet again for a third time 2 months after
that.
We got him back on Prozac and lithium and he finally
accepted the seriousness of his disease. From then on, he
handled his illness and medications extraordinarily well, with
maturity and responsibility, telling us if he did not feel
right. When that was the case, we would put him in the hospital
for a few days to readjust his meds.
Five months after his third suicide attempt, Nick was on
medication, healthy, strong, in great spirits, the best he had
ever been. On a 3-month tour with his band, exhaustion set in
and he began to get depressed and spiral down. Ten days before
the end of the tour, he knew he had to leave. He was too sick
to stay. He knew his health and life were in jeopardy, and in
despair, he left the tour and quit the band. He flew home and
took to his bed for 5 weeks. I had never seen him as down.
Determined to rise from the ashes, he started another band
immediately and, in a short time, played two local concerts and
recorded a new CD. But he still did not feel right and asked to
be put in the hospital. Two hospitals refused to admit him,
said there was no reason to, that he was fine.
Ten days later, Nick took a massive overdose of morphine, a
substance to which he knew he was fatally allergic, and this
time his attempt was successful. He died at 19.
I believe he did it because he could not bear to sink to
the depths again and knew he would one day. He did it because
he knew he could no longer tour and was not strong enough to
endure the rigors of his musician's life, which he loved so
much. He felt he had no other choice. It was his only way out.
His final freedom from pain.
Nick taught me to let go of every preconceived idea I ever
had. He forced me to be open and creative in new ways every day
of his life. He taught me to focus on what he could do rather
than what he could not, to celebrate and value his
accomplishments and accept his defeats with grace. He was a
lesson in accepting people who are different and loving them as
they are. Even with his illness, he accomplished more than most
people I know. His life was a victory in so many ways.
I tell you his story not so you can mourn him or pity me,
but because his story needs to be heard. He was not alone in
his illness or his outcome. He is unusual perhaps only because
he had a family which was so fiercely devoted to him. He had
loving parents and eight siblings who adored him and a team of
supporters who worked tirelessly to keep him happy and alive.
We had enormous resources and energy with which to support him.
For as long as we could, in every way we could, we would not
let Nick die. I no longer feel that we lost him early, although
his life was certainly far too short, but I feel that we kept
him alive for 8 years longer than he planned.
A great number of manic depressives attempt suicide and
many of them succeed. What we need to think of now is how to
best serve others like him. The question is: How do we rouse
psychiatrists to diagnose and medicate bipolars early enough to
make a difference to save lives?
Five years ago, it was a rarity for Nick to get lithium at
16. It is a miracle if children are being diagnosed and
medicated now, and if so, I believe it will improve and maybe
even save their lives. If Nick had been treated at 5 or 6, he
would have been spared 10 years of agony and might perhaps be
alive today. I believe that early diagnosis and medication are
crucial to the well-being and survival of kids like Nick; and
to give them a better chance.
I am turning to you now, asking you to open eyes in this
country, the eyes of the public, the eyes of the doctors who
treat them. Open not only eyes but hearts. You have the power
to affect how and when and in what ways mental illness is
treated. Together we can change how it is perceived. Each of us
in some way is touched by a life like Nick's. Use us, use me,
use Nick as an example. Use others like him to cast a bright
light into the dark abyss where people like Nick live. It is no
longer good enough to diagnose bipolars in their 20's, as was
the tradition. They are sick long before that. They need help
long before that. They need medication long before that. They
die long before that.
PREPARED STATEMENT
Nick Traina is one boy, one child, one life lost. But he
speaks for an army of people out there who need your help, not
only people who are themselves sick, but people who love them
and care about them, mothers, brothers, fathers, sisters,
husbands, wives, friends, daughters, sons. Let us all reach out
to help. Let us make a difference for even one life. And may
God bless you for your courage, your wisdom, and your kindness.
On behalf of Nick and my family and those of us who have lost
loved ones, and particularly those who are still struggling
with them, I give you my thanks for the lives you will touch
and save.
[The statement follows:]
Prepared Statement of Danielle Steel
I would like to thank the ladies and gentlemen of the Senate
Appropriations Committee for having me here today. I do not ever speak
publicly, but it was an honor and an invitation that was impossible to
resist.
I was asked to speak about my son Nick. It is a huge challenge to
paint a portrait of him for you in so little time. Brilliant, charming,
wonderful, loving, talented, funny, outrageous, tormented,
unforgettable. He was a magical child, an extraordinary boy. He
suffered from manic depression all his life, and committed suicide at
nineteen.
Nick spoke English and Spanish fluently before he was one. He
walked at eight months, loved disco music before he could walk, and
when people would ask his name, he would answer, ``I'm incredible!''
because people said it of him so often, he thought that was his name.
He was a remarkable child, and became an even more remarkable man.
By the time he was 2, I knew something was wrong with him. He was
like a record playing on the wrong speed, way, way too fast. By four, I
know now that he was manic. I feared even then that he was sick. At
seven, I was convinced of it. He was brilliant, had good grades, but
was moody, troubled, easily enraged. I turned to doctors and
psychiatrists throughout his early childhood, and was always told he
was fine. I felt in my heart that that was not true, although I wanted
it to be true. I sensed that there were terrible demons lurking deep
within. I cannot even tell you how I knew, but I knew.
At 12, his best friend died in a car accident. Nick was still doing
well in school then, but he began dabbling in drugs, and he was deeply
depressed much of the time, sitting in the dark in his room. He was
full of contrasts. Sometimes he would be jubilant, he was loving and
funny, sometimes he was too depressed to move. Often he was awake all
night, sometimes til 8 a.m., nonetheless, the psychiatrists we saw
insisted he was fine. They were charmed by him.
In his early teens, Nick's life began to fall apart. By 13, Nick's
demons were in full swing. From then on, his life was a constant merry
go round of schools where he couldn't conform, psychiatrists, special
programs for emotionally disturbed kids, and brief stays in mental
hospitals to evaluate him. They said he was difficult, and blamed it on
his high IQ.
He remained undiagnosed and unmediated until 15, when I was told he
had Attention Deficit Disorder. He was put on Prozac then. By 15, I
believed he was suicidal. He never put it in words, but was so often
depressed and so isolated that I was afraid to go into his room, sure
that I would find him dead, by his own hand. I know now that my
instincts were right. When I read his journals after his death, I
discovered that from the age 11 on, he had written about killing
himself every single day. It took another eight years to accomplish it.
At 15, his life was a shambles. He became more and more impossible
to manage. He spent five months in mental hospitals, and we couldn't
get him functional enough to come home. Yet through it all, he was
brilliant, charming, affectionate, angry, confused. We tried 3
different hospitals in one year. No one was able to do anything for
him. By the end of that time, he was curled in a ball, terrified and
sick.
At 16, we took him to UCLA, and he was finally diagnosed bi-polar,
and put on Lithium. It was a miracle drug for him. Within three and a
half weeks, he was sane, whole, functional, loving, funny, and back in
school, getting straight A's.
Life began for Nick at sixteen. He said that on Lithium, he felt
normal for the first time in his life. He did well in school. He began,
in earnest, a music career that he had longed for, and worked towards
for years. Music was his passion and his joy. He had huge charisma and
talent, and in the next three years, he released 9 CD's, played
hundreds of concerts, did two national tours with his band, appeared on
MTV, and was scheduled to tour Europe and Japan. He was a lyricist,
composer, musician, and lead singer of an increasingly successful punk
rock band. And he became then, the man I knew and loved so fiercely,
who was not only my son, but became my best friend. The depths to which
he had been gave him an understanding, compassion, wisdom, joy, and a
sense of humor about others and himself. He worked tirelessly. He had a
quick tongue and a big heart, and where he saw pain, he would reach out
a hand, he could never pass a homeless person without buying them a
meal. And despite the angelic qualities we see so clearly now, there
were undeniably times when, much as we loved him, he drove us up the
wall.
His hospital stays then were only to readjust his medications. He
had two psychiatrists, a live-in psychiatric counsellor, and took three
medications daily, upon which his life and well-being relied. He had
constant nurses from the age of fourteen, to accompany and protect him
from his lack of impulse control, which could cause him to walk across
a freeway, or hang too far out a window. Once on Lithium, he was
virtually drug-free. But there was a fragile quality to Nick, an
ephemeral sense that he could break easily, or his life could instantly
slip away.
From 16 on, Nick lived in a cottage of his own, with his nurses,
and the psychiatric counsellor who oversaw everything he did.
He graduated from high school and did one term of junior college
and his life in his late teens was a whirlwind of rehearsals, concerts,
and road tours, driving endless hours across the country in a van to
play with his band. Wherever he went, he was accompanied, not only by
his fellow musicians and his equipment, but by his nurses, his
counsellor, his medications, and his disease. Wherever he was, even on
tour, we checked his Lithium levels with blood tests, weekly to make
sure that they were high enough. We tested him daily for drugs, to make
sure that he wasn't dabbling, and with rare, rare exceptions, he was
not. We thought we were home free. Only in reading his journals later
did I realize how constantly tormented he still was, and how close to
the abyss he always lived. On medications, he appeared balanced and
happy most of the time. He insisted, and we wanted to believe, that he
was fine. That outward appearance of ``fineness'' even fooled him.
At 18, Nick decided that he no longer needed medication. He felt
great. He stopped taking Lithium, became almost instantly manic, and
within five weeks attempted suicide by taking a virtual arsenal of
drugs. It left him with damaged kidneys, liver, spleen, heart,
temporarily deaf, incoherent briefly, and paralyzed both his legs.
Before he had even recovered, ten days later he tried again, in a
locked psychiatric ward, while on suicide watch. And he attempted
suicide yet again, for a third time, two months after that.
We got him back on Prozac and Lithium, and sometimes a third
medication. He himself finally accepted the seriousness of his disease,
and that it would be not only a life-time battle, but a lifetime
maintenance issue for him. I compared it to diabetes, which made sense
to him. From then on, he handled his illness and medications
extraordinarily well, with maturity and responsibility, telling us if
he didn't feel right. When that was the case, we would put him in the
hospital for a few days to readjust his meds.
Five months after his third suicide attempt, Nick was on
medication, healthy, strong, and in great spirits, the best he had ever
been. And he left on a 3 month tour with his band. But with the rigors
of the tour, exhaustion set in, and he began to get depressed and
spiral down. Ten days before the end of the tour, he knew he had to
leave. He was too sick to stay. He knew his health and life were in
jeopardy. And in despair, he left the tour and quit the band. He flew
home and took to his bed for 5 weeks. I had never seen him as down.
Determined to rise from the ashes, he started another band
immediately, and in a short time, played two local concerts, and
recorded a new CD. But he still didn't feel right, and asked to be put
in the hospital. Two hospitals refused to admit him, and said there was
no reason to. Ten days later, Nick took a massive overdose of morphine,
a substance to which he knew he was fatally allergic, and this time his
attempt was successful. He died at nineteen.
Nick committed suicide in the 90 minute window in his nursing
schedule at 4:30 a.m. On the only night in five years that his
counsellor in charge, who loved him dearly, had gone away. I believe he
did it because he could not bear to sink to the depths again, and knew
he would one day. He did it because he knew he could no longer tour,
and was not strong enough to endure the rigours of his musician's life,
which he loved so much. He felt he had no other choice. It was his only
way out. His final freedom from pain.
Nick taught me to let go of every preconceived idea I ever had. He
forced me to be open and creative in new ways every day of his life. He
taught me to focus on what he could do, rather than what he could not,
to celebrate and value his accomplishments, and accept his defeats with
grace. He was a lesson in accepting people who are different, and
loving them as they are. Even with his illness, he accomplished more
than most people I know. His life was a victory in so many ways.
I tell you his story not so you can mourn him, or pity me, but
because his story needs to be heard. He was not alone, in his illness,
or his outcome. He is unusual perhaps only because he had a family
which was so fiercely devoted to him. He had loving parents and 8
siblings who adored him, and a team of supporters who worked tirelessly
to keep him happy and alive. We had enormous resources and energy with
which to support him. For as long as we could, in every way we could,
we would not let Nick die. I no longer feel that we lost him early,
although his life was certainly far too short, but I feel that we kept
him alive eight years longer than he planned.
A great number of manic-depressives attempt suicide, and many of
them succeed. What we need to think of now is how to best serve others
like him. The question is: How do we rouse psychiatrists to diagnose
and medicate bi-polars early enough to make a difference to save lives?
There are other questions as well: How do we offer mental health care
to people who cannot spend what we did? How do we reach out among the
homeless and figure out who is mentally ill, and give them the medical
attention they need? How do we erase the stigma of an illness so
vicious, so brutal, and so costly, so that people will no longer be
embarrassed or afraid to get help, either for themselves, or the people
they love?
In the two years since Nick has been gone, I have heard of a few
early diagnoses, of children as young as 5 or 6 being diagnosed bi-
polar, and being given Lithium. Five years ago, it was a rarity for
Nick to get Lithium at 16. It is a miracle if children are being
diagnosed and medicated now, and I believe it will improve and maybe
even save their lives. If Nick had been treated at 5 or 6, he would
have been spared 10 years of agony, and might perhaps be alive today. I
believe that early diagnosis and medication are crucial to the well-
being and survival of kids like Nick; and to give them a better chance.
I am turning to you now, asking you to open eyes in this country.
The eyes of the public, the eyes of the doctors who treat them. Open
not only eyes, but hearts. You have the power to affect how and when
and in what ways mental illness is treated. Together we can change how
it is perceived. Each of us, in some way, is touched by a life like
Nick's. Use us, use me, use Nick as an example, use others like him to
cast a bright light into the dark abyss where people like Nick live. It
is no longer good enough to diagnose bi-polars in their twenties, as
was the tradition, they are sick long before that. They need help long
before that. They need medication long before that. They die long
before that.
Nick Traina is one boy, one child, one life lost. But he speaks for
an army of people out there who need your help, not only people who are
themselves sick, but people who love them and care about them, mothers,
brothers, fathers, sisters, husbands, wives, friends, daughters, sons.
Let us all reach out to help, let us make a difference, for even one
life. And may God bless you for your courage, your wisdom, and your
kindness. On behalf of Nick, and my family, and those of us who have
lost loved ones, and particularly those who are still struggling with
them, I give you my thanks for the lives you will touch, and save.
Senator Specter. Thank you very much, Ms. Steel, for that
very powerful testimony, and thank you for the book about Nick
and sharing it with so many other people. We thank you.
Congresswoman Pelosi, we know of your busy schedule, so
whenever you feel like departing, you are obviously free to go.
STATEMENT OF JADE SMALLS, EVANSTON, ILLINOIS, FIRST
RUNNER-UP, 1999 MISS AMERICA PAGEANT
Senator Specter. We next turn to Ms. Jade Smalls, currently
taking a year off from her studies as a senior at Northwestern
University to serve as Miss Illinois. At the Miss America
Pageant where she was first runner-up, she promoted youth
suicide prevention as her platform, and she continues to speak
statewide and nationally on the topic. She has conducted
research in the area of suicide prevention with institutions
such as the National Institute of Mental Health and the Center
for Disease Control. Thank you very much for joining us, Ms.
Smalls, and we look forward to your testimony.
Ms. Smalls. Thank you and I am definitely honored to be
here amongst all these experts and humbled by the courage of
the survivors. I will be honest and let you know that I tend to
run about 22 to 34 seconds over. I hope that you can forgive me
for that in advance.
Senator Specter. That is fine. Thank you.
Ms. Smalls. About 5 years ago, I did lose a classmate in a
very unnecessary way, and it began with her dating an older boy
who was a bad influence and suddenly turned into the two of
them going on a cross-country crime spree that left an innocent
bystander dead. In the end, it ended in a tragic double suicide
where my friend and her boyfriend ended their own lives. Five
years ago, this would have been an isolated incident, but here
we are today and can we even count the number of times that we
have seen suicide and homicide combine within our schools?
As Miss Illinois, I have been blessed with the amazing
opportunity to speak in schools about suicide prevention. And I
have to tell you that not so long ago, I would have never been
allowed there because we thought that suicide should not be
discussed with students. But now things are changing, and if
anything good has come from these recent tragedies in our
schools, it would have to be the newfound willingness now of
these administrations to address issues that they had either
pretended or had not realized existed.
Of course, there is still some hesitation on the part of
school administrators, and who can blame them? But that does
not mean that they do not want to be a part of the solution. I
am here to ask for the funding that is going to provide them
with the resources they need to help them become the lifesavers
we know they can be. And I am here because I have seen the
faces of children affected by suicide and I have heard the
voices of teens that are crying out for help not only for
themselves, but for their peers around them. Most importantly,
I am here to make sure that we use this opportunity wisely.
Right now our schools are eager to help and because of the
Surgeon General's initiatives, our Government has the means and
the research now more than ever to bolster the spread of
information.
I think you have heard every single panelist here talk
about suicide having a stigma, being a silent killer. When I go
to schools, sometimes I ask the kids to raise their hands if
they have ever broken an arm or a leg before, and they all
raise their hands. Then I ask them if they were ashamed to have
to wear a cast or if their first reaction was to pretend like
nothing was wrong or did they try to fix their broken leg by
themselves. And, of course, they look at me in disbelief
because they know that when they are hurting, they are supposed
to ask for help. But why is it so different for mental illness?
Students agreed that mental illness and depression were often
viewed as things to be ashamed of or issues that they should
work out by themselves. But we do not tell cancer patients to
snap out of it or we do not tell AIDS patients to get over it.
In one high school with an audience of over 2,000, a girl
raised her hand and shared that she had been diagnosed with
manic depression. She had suffered for years by herself and had
in her own words experienced the shame attached to her illness.
Right there that day in her own school she broke down so many
walls of stigma that had been built up, and she told her
student body that it was okay to ask for help. Her comments
brought forth confessions of past suicide attempts, opened
doors to healing for survivors of suicide in her school, and
helped to close the gap between the student body and the
faculty. But she should not have to bear this burden alone.
My work in the schools has convinced me that the need is
great and the tools of solution are few. I think we should
provide funding that will institute, as we heard said before,
self-check opportunities and depression screening in our
schools so students can be diagnosed early. Let us provide
funding to develop mental health curriculums for school aged
children to teach the language of mental health and to bring
awareness to the signs of depression and suicide.
Only 1 percent of suicide prevention curriculum has
actually reached the schools. Nevertheless, we have
organizations like the Ronald McDonald House Charities who has
already created a suicide prevention CD-ROM to give out to
schools. But they are only one organization in the private
sector and they cannot possibly reach the countless numbers of
schools. I suggest that maybe our Government agencies like the
Department of Health and Human Services, the Department of
Education, and the National Institute for Mental Health
collaborate to create mental health cd-rom's that will provide
in-school resources and, of course, could be distributed on a
faster and farther scale. Schools also need funding initiatives
to support behavior modification programs aimed at breaking
stereotypes that are inhibiting our children from seeking help.
I am really here to let you know that young people want to
help their peers. YM magazine, a young women's magazine with a
readership between the ages of 13 and 19, recently ran an
article on suicide, and they listed the toll-free number for
SPAN for anyone interested in fighting the war against suicide.
I spoke with Elsie Weyrauch, founder of SPAN and survivor of
suicide, and she told me of the overwhelming response by young
people under the age of 25 who wanted to help. But in
particular, there was one girl, and she wanted to learn how to
help a friend who had repeatedly attempted suicide. Elsie told
me that that little girl was only 12 years old, and that said
so much. She is obviously younger than the average readership
of YM magazine.
When we think of little children, we associate them with
things like Disney or bicycles and Barney, but through my
research, I learned of a 5-year-old boy. He committed suicide
and he left his note in crayon. I am trying to imagine this
little guy who had probably only begun to learn how to write,
and there he was forming his little fingers around that crayon,
writing those final words. We cannot wait any longer.
So, the reason I am here is to stand before you
representing that 5-year-old little boy and that 12-year-old
little girl and the thousands of kids that we have lost this
week alone to suicide. I also represent the thousands of living
young people who want to be a part of the solution.
PREPARED STATEMENT
I want to make sure that that little girl will never again
have to call Marietta, Georgia to find out how she can help her
loved ones. So, I am here to call you to action and ask you for
the funding that is going to allow these initiatives to become
not yet another document that is one of those ones that sit on
the shelves and collect dust, but one that is going to help
save many, many lives. And I believe the time to act is now.
[The statement follows:]
Prepared Statement of Jade Smalls
About five years ago, I lost a classmate in a very unnecessary way.
It began with her dating an older boy who was a bad influence and
suddenly turned into a real life nightmare. The two of them went on a
cross-country crime spree that left an innocent bystander dead. After
finally being cornered by police, my friend and her boyfriend refused
to surrender and instead they killed each other inside of the car they
had stolen. Five years ago, this would have been an isolated incident.
But here we are today and can we even count the number of times we have
seen suicide and homicide combine within our schools?
As Miss Illinois, I am blessed with the amazing opportunity to
speak in the schools and spread the message of suicide prevention. Not
so long ago, there would have been no place for me in these schools
because it was thought that suicide was not a topic to be discussed
with students. Now things are changing. If we can find that anything
good has come from these recent tragedies in our schools it would have
to be the newfound willingness of these schools and their
administrations to address issues they had pretended or had not
realized existed.
Of course, there is still some hesitation on the part of school
administrators and who can blame them? But that does not mean that they
do not want to be a part of the solution. I am here to ask for the
funding that will provide them with the resources they need to help
them become the lifesavers we know they can be. I am here because I
have seen the faces of kids who have been effected by suicide. I have
heard the voices of teens that are crying out for help not only for
themselves but for their friends as well. Most importantly, I am here
to make sure that we use this window of opportunity wisely. Right now
our schools are eager to help and--because of the Surgeon General's
initiatives--our government has the means and the research now more
than ever to bolster the spread of information on suicide prevention to
our nation's youth.
Some of you have heard suicide previously referred to as the
``quiet epidemic''. Suicide is such an effective silent killer because
of the stigma that surrounds it. I often ask students to raise their
hands if they've ever broken an arm or a leg before. Many hands go up.
When I ask them if they were ashamed to have to wear a cast or if their
first reaction was to pretend like nothing was wrong, to hobble around
with a dislocated joint, or to try and fix the bone themselves they
look at me in disbelief. They know that when they are hurting they are
supposed to ask for help. So why is it so different for mental illness?
Students agreed with me that mental illness and depression were often
viewed as things to be ashamed of, issues that should be worked out
within the individual himself. Yet no one tells a cancer patient to
``snap out of it'' or an Aids patient to ``get over it''.
In one high school, with an audience of two thousand, a girl raised
her hand and shared that she had been diagnosed with manic depression.
She had suffered for years by herself and had, in her own words,
``experienced the shame attached to her illness''. She wanted her
student body to know that it was okay to ask for help. That day she
broke down walls of stigma that had been built up in her own life and
in her own school. Her comments brought forth confessions of past
suicide attempts, opened doors to healing for survivors of suicide in
her school, and helped to close the gap between the student body and
the faculty. But she should not bear that burden alone.
My work in the schools has convinced me that the need is great and
the tools of solution are few and far between. Let us provide funding
that will institute self-check opportunities and depression screening
in our schools so students can be diagnosed early enough to receive
proper care. Let us provide funding to develop mental health
curriculums for all of our school aged children to teach the language
of mental health, to help students become aware of the signs and
symptoms, and to provide educators with links to those agencies
available to save our children. Sadly, only 1 percent of suicide
prevention curriculum has reached our high schools. The Ronald McDonald
House Charities has taken a step in the right direction by creating a
suicide prevention cd-rom, called ``Team Up to Save Lives'', to be
distributed in schools. They are doing their part in many communities
but as one private sector foundation they cannot possibly reach the
countless number of schools in need. I suggest that our government
agencies such as the Department of Health and Human Services, the
Department of Education and the National Institute for Mental Health
collaborate to create mental health cd-roms that will provide in-school
resources, information and prevention strategies that could be
distributed faster and farther on a national scale. Schools also need
funding initiatives to support behavior modification programs aimed at
breaking stereotypes that inhibit our children from seeking help.
I am here to let you know that young people want to help keep their
peers alive. YM magazine--a young women's magazine with a readership
between the ages of 13 to 19--recently ran an article on suicide and
listed the toll free number for SPAN, the Suicide Prevention Advocacy
Network, for anyone interested in fighting the war against suicide. I
spoke to Elsie Weyrauch, founder of Span and survivor of suicide, and
she told me of the overwhelming response from young people who wanted
to know how they could help. She remembered one particular call from a
little girl who said she wanted to help a friend who had repeatedly
attempted suicide. That little girl was only 12 years old. She was
younger than the average readership for YM magazine.
When we think of little children we associate them with Disney,
bicycles and Barney. Through my research I learned of a little boy, who
was only 5 years old. He committed suicide and he left his note in
crayon. I am trying to imagine this little guy who had probably just
learned to form his fingers around that crayon. Yet, there he was
writing those final words. We cannot wait any longer! That is why I am
standing before you, speaking for that 5 year old boy, the 12 year old
girl and the young people who have died this week and over the years by
suicide. I also represent the thousands of living young people who want
to be a part of the solution.
Let us make sure that that little girl will never again have to
call Marietta, Georgia to learn how she can help a friend. We are
calling you to action, asking you to fund the initiatives set forth by
the Surgeon General to assure that this document does not become yet
another article that collects dust, but a living breathing one that
saves lives. The time to act is now.
Senator Specter. Well, thank you very much, Ms. Smalls.
The request that you have made is work in progress. We are
seeking to increase NIH funding by $2.7 billion. It is now
right at $19 billion. It has come up $5 billion in 3 years.
Those are astronomical increases because we believe that the
National Institute of Mental Health and other agencies require
that kind of help.
As Dr. Hyman commented, a special initiative was put into
effect last year reallocating more than $700 million for school
violence which is very closely associated with these kinds of
problems.
Senator Reid, we are going to have to close within the next
2 minutes.
Senator Reid. Mr. Chairman, I just wanted to again express
my appreciation to you. I do not think that we need to ask
questions to these witnesses. They are here because of who they
are. And you have focused attention on an issue that needs
focusing. We are grateful to you and we look forward to working
with you down the road to make sure that some of the things we
talk about become realities to stop suicides every 17 minutes.
Ms. Smalls. Thank you.
Ms. Steel. Thank you so much.
Senator Specter. Senator Reid, thank you very much, and
thank you very much, Ms. Steel and Ms. Smalls. Your testimony
is very powerful, obviously.
Ms. Steel, as you recounted the sequence of events with
your son, you did so very much. I do not know what more you
could have done. When you bring the insight about starting at
the age 5, I think that is a very telling factor.
Ms. Steel. I think we wait too long very often and people
hesitate to brand children with the label ``mental illness,''
and I think that is the issue of stigma, as Ms. Smalls says. We
need to treat it like diabetes or any other physical condition.
Senator Specter. And when Miss America runner-up puts her
fame, fortune, and beauty on the line, that speaks eloquently
and loudly.
This hearing is only one step of many activities which this
subcommittee and the full committee and the Congress will
undertake.
So, we thank you very much.
Ms. Steel. Thank you very, very much. Thank you, Senator.
CONCLUSION OF HEARING
Senator Specter. Thank you all very much for being here,
that concludes our hearing. The subcommittee will stand in
recess subject to the call of the Chair.
[Whereupon, at 11:02 a.m., Tuesday, February 8, the hearing
was concluded and the subcommittee was recessed, to reconvene
subject to the call of the Chair.]
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