[Senate Hearing 108-489]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-489

               SUICIDE PREVENTION AND YOUTH: SAVING LIVES

=======================================================================

                                HEARING

                               BEFORE THE

       SUBCOMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                                   ON



 EXAMINING CERTAIN MEASURES TO HELP PREVENT SUICIDE AMONG CHILDREN AND 
                              ADOLESCENTS

                               __________

                             MARCH 2, 2004

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  JUDD GREGG, New Hampshire, Chairman

BILL FRIST, Tennessee                EDWARD M. KENNEDY, Massachusetts
MICHAEL B. ENZI, Wyoming             CHRISTOPHER J. DODD, Connecticut
LAMAR ALEXANDER, Tennessee           TOM HARKIN, Iowa
CHRISTOPHER S. BOND, Missouri        BARBARA A. MIKULSKI, Maryland
MIKE DeWINE, Ohio                    JAMES M. JEFFORDS (I), Vermont
PAT ROBERTS, Kansas                  JEFF BINGAMAN, New Mexico
JEFF SESSIONS, Alabama               PATTY MURRAY, Washington
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island
LINDSEY O. GRAHAM, South Carolina    JOHN EDWARDS, North Carolina
JOHN W. WARNER, Virginia             HILLARY RODHAM CLINTON, New York

                  Sharon R. Soderstrom, Staff Director

      J. Michael Myers, Minority Staff Director and Chief Counsel

                                 ______

       Subcommittee on Substance Abuse and Mental Health Services

                      MIKE DeWINE, Ohio, Chairman

MICHAEL B. ENZI, Wyoming             EDWARD M. KENNEDY, Massachusetts
JEFF SESSIONS, Alabama               JEFF BINGAMAN, New Mexico
JOHN ENSIGN, Nevada                  JACK REED, Rhode Island

                    Karla Carpenter, Staff Director

                  David Nexon, Minority Staff Director

                                  (ii)






                            C O N T E N T S

                               __________

                               STATEMENTS

                             MARCH 2, 2004

                                                                   Page
DeWine, Hon. Mike, a U.S. Senator from the State of Ohio, opening 
  statement......................................................     1
    Prepared statement...........................................     2
Dodd, Hon. Christopher J., a U.S. Senator from the State of 
  Connecticut, opening statement.................................     4
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa, opening 
  statement......................................................     6
Clinton, Hon. Hillary Rodham, a U.S. Senator from the State of 
  New York, opening statement....................................     7
Kennedy, Hon. Edward M., a U.S. Senator from the State of 
  Massachusetts, prepared statement..............................     7
Smith, Hon. Gordon, a U.S. Senator from the State of Oregon and 
  Sharon Smith, Spouse...........................................     8
Tunkle, Reverend Paul D., Ph.D., Rector, the Episcopal Church of 
  the Redeemer, Baltimore, MD; Cheryl A. King, Ph.D., Associate 
  Professor, Department of Psychiatry, University of Michigan, 
  Ann Arbor, MI; Fran M. Gatlin, School Psychologist, Robinson 
  High School, Fairfax, VA; Joelle M. Reizes, MA, Director of 
  External Relations, Screening for Mental Health, Loveland, OH; 
  and Laurie Flynn, Director, the Carmel Hill Center for Early 
  Diagnosis and Treatment, New York, NY..........................    14

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Reverend Paul D. Tunkle......................................    34
    Response to questions of Senator Bingaman from Reverend Paul 
      Tunkle.....................................................    35
    Response to questions of Senator Dodd from Reverend Paul 
      Tunkle.....................................................    36
    Cheryl A. King...............................................    37
    Response to questions of Senator Dodd from Cheryl A. King....    41
    Joelle Reizes................................................    44
    Letter from Screening For Mental Health......................    45
    Response to questions of Senator Dodd from Joelle Reizes.....    45
    Response to questions of Senator Reed from Joelle Reizes.....    46
    Response to questions of Senator Bingaman from Joelle Reizes.    47
    Laurie Flynn.................................................    49
    Response to questions of Senator Bingaman from Laurie Flynn..    56
    Response to questions of Senator Dodd from Laurie Flynn......    58
    Response to questions of Senator Reed from Laurie Flynn and 
      Cheryl King................................................    59
    Response to questions of Senator Bingaman from panel.........    61
    Robert H. Aseltine, Jr., Ph.D................................    64
    Fran M. Gatlin...............................................    72
    Response to questions of Senator Bingaman from Fran Gatlin...    76
    Response to questions of Senator Dodd from Fran Gatlin.......    77
    Alliance for Human Research Protection (AHRP)................    78
    American Academy of Child and Adolescent Psychiatry and the 
      American Psychiatric Association...........................    82
    American Occupational Therapy Association (AOTA).............    84
    National Association of School Psychologists.................    87
    Suzanne Vogel-Scibilia, M.D..................................    88
    University of Connecticut Health Center......................    90

                                 (iii)

  

 
               SUICIDE PREVENTION AND YOUTH: SAVING LIVES

                              ----------                              


                         TUESDAY, MARCH 2, 2004

                               U.S. Senate,
 Subcommittee on Substance Abuse and Mental Health 
                                          Services,
of the Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 10:08 a.m., in 
room SD-430, Dirksen Senate Office Building, Senator DeWine, 
(chairman of the committee) presiding.
    Present: Senators DeWine, Kennedy, Dodd, Harkin, and 
Clinton.
    Senator DeWine. Good morning. We welcome all of you this 
morning.
    Senator Kennedy will be here in just a moment. I think we 
had better get started as we have a series of votes that begin 
at 11:30 and there are many votes, which means that we will not 
be able to get back here at all after 11:30. So this hearing 
will end at 11:30.
    We have a number of very important witnesses. So I think we 
will go ahead and get started and I will make an opening 
statement.

                  Opening Statement of Senator DeWine

    Senator DeWine. We are meeting today to discuss the problem 
of youth suicide and how we can help to prevent it. Statistics 
tell us that approximately every 2 hours a person under the age 
of 25 commits suicide. We also know that from 1952 to 1995 the 
rate of suicide among children and young adults has tripled, 
and that between 1980 and 1997 alone the rate of suicide in 15- 
to 19-year-olds increased by 11 percent.
    According to the National Institute of Mental Health 
suicide was the 11th leading cause over all for death in the 
United States in 2001. However, it was the third leading cause 
for youths ages 15 to 24. Shockingly, we also know that 
suicides outnumber homicides three to two.
    We also know that boys are killing themselves at a ratio of 
five to one to girls in the 15-to-19-year-old age group and at 
the ratio of seven to one in the 20- to 24-year-old age group. 
However, while boys are dying at higher rates, girls in these 
age groups are attempting at a much higher rate. It has been 
estimated that there may be from 8 to 25 attempts made for 
every suicide death.
    These alarming numbers emphasize the need for early 
intervention and prevention efforts. Too often the signs may be 
subtle or hidden until it is too late. While research has 
created improved medications and methods for helping those with 
mental health problems to recover, there is still much work to 
be done in identifying those who need help.
    A great deal of study has been done on the risk factors 
related to suicide. In children and youth these are known to 
include depression, alcohol or other drug use, physical or 
sexual abuse, and disruptive behavior. Of people who die from 
and who attempt suicide, many suffer from co-occurring mental 
health and substance abuse disorders.
    We also know that attempts at suicide are not just harmless 
bids for attention. These attempts indicate a serious problem. 
Like anyone else with a life threatening condition, those 
suffering from a desire to do themselves harm should not be 
left alone and should receive immediate medical care and 
attention.
    As a result of the need for increased attention to the 
problem of suicide and the need to provide access to help, I am 
currently working with Senator Dodd on a bill to provide 
support for state-wide plans to intervene and prevent the 
occurrence of suicide in youth. We commend the States which 
have already created such plans and hope to encourage all 
States to take this important step.
    I look forward to the recommendations that we will hear 
today from experts on the mental health of young people with 
regard to this bill and for those who work with children and 
youth and from those who lost loved ones.
    I know that through the stories of their tremendous loss 
and heartache, they can help us to understand the scope of this 
problem and what needs to be done.
    [The prepared statement of Senator DeWine follows:]

                  Prepared Statement of Senator DeWine

    Thank you all for being here today. I'd like to welcome 
Ranking Member Kennedy, with whom I have worked on many issues 
concerning children over the years.
    Today, we are meeting to discuss the problem of youth 
suicide--how we can help to prevent it. Statistics tell us that 
approximately every 2 hours, a person under the age of 25 
commits suicide. We also know that from 1952 to 1995, the rate 
of suicide in children and young adults has tripled and that 
between 1980 and 1997, alone, the rate of suicide in 15 to 19 
year-olds increased by 11 percent. According to the National 
Institute of Mental Health, suicide was the 11th leading cause 
overall for death in the United States in 2001. However, it was 
the 3rd leading cause for youth ages 15 to 24.
    Shockingly, we also know that suicides outnumber homicides 
3 to 2.
    We also know that boys are killing themselves at a ratio of 
5 to 1 to girls in the 15- to 19-year-old age group and at a 
ratio of 7 to 1 in 20 to 24-year-olds. However, while boys are 
dying at a higher rate, girls in these age groups are 
attempting at a much higher rate. It has been estimated that 
there may be from 8 to 25 attempts made for every suicide 
death.
    These alarming numbers emphasize the need for early 
intervention and prevention efforts. Too often, the signs may 
be subtle or hidden until it is too late. While research has 
created improved medications and methods for helping those with 
mental health problems to recover, there is still much work to 
be done in the identifying of those who need help.
    A great deal of study has been done on the risk factors 
related to suicide. In children and youth, these are known to 
include depression, alcohol or other drug use, physical or 
sexual abuse, and disruptive behavior. Of people who die from 
and who attempt suicide, many suffer from co-occurring mental 
health and substance abuse disorders.
    We also know that attempts at suicide are not just harmless 
bids for attention. These attempts indicate a serious problem. 
Like anyone else with a life-threatening condition, those 
suffering from a desire to do themselves harm should not be 
left alone and should receive immediate medical care and 
attention.
    As a result of the need for increased attention to the 
problem of suicide and the need to provide access to help, I am 
currently working with Senator Dodd on a bill to provide 
support for statewide plans to intervene and prevent the 
occurrence of suicide in youth. We commend the States which 
have already created such plans and hope to encourage all 
States to take this important step. And, I look forward to the 
recommendations we will hear today from experts on the mental 
health of young people with regard to this bill, from those who 
work with children and youth, and from those who have lost 
loved ones. I know that through the stories of their tremendous 
loss and heartache, they can help us to understand the scope of 
this problem and what needs to be done.


                             INTRODUCTIONS


    First, I would like to welcome my colleague from Oregon, 
Senator Gordon Smith, and his wife Sharon, who tragically lost 
their son, Garrett, in September to suicide. I thank you both 
for coming here today and for your willingness to share your 
experience with us.
    Second, I would like to introduce Dr. Cheryl Ann King. Dr. 
King is a licensed clinical psychologist and Associate 
Professor of Psychology at the University of Michigan. She also 
serves as director of the Child and Adolescent Program at the 
University's Depression Center and as Chief Psychologist in the 
Department of Psychiatry at the University of Michigan Medical 
School. For the past 15 years, Dr. King has focused on the 
problem of youth suicide and has devoted the majority of her 
clinical research to this devastating problem.
    Third, I would like to introduce Ms. Joelle [joe-ell] 
Reizes [rise-es]. Ms. Reizes is the Director of External 
Relations for Screening for Mental Health. She was instrumental 
in transforming this nonprofit organization into one of the 
leading mental health screening organizations. Screening for 
Mental Health was responsible for creating the first-ever 
National Alcohol Screening Day and has also developed the SOS 
High School Suicide Prevention Program.
    Mrs. Reizes has overseen the production and development of 
the Screening for Mental Health's educational videos, including 
``SOS: Suicide Prevention Training,'' and has authored 
educational brochures, some of which have been distributed to 
more than 7,000 sites nationwide.
    Fourth, I would like to introduce Laurie Flynn. Mrs. Flynn 
is the director of The Carmel Hill Center for Early Diagnosis 
and Treatment in the Division of Child and Adolescent 
Psychiatry at Columbia University. She is also currently 
serving as the national director of Positive Action for Teen 
Health. Before joining Columbia University in 2001, Mrs. Flynn 
served as the executive director of the National Alliance for 
the Mentally Ill for 16 years. She is a member of many national 
advisory boards and professional association committees, 
including the Clinical Trial Advisory Group and the Research 
Center on Managed Care for Psychiatric Disorders. Mrs. Flynn is 
the author of several articles and books on health services for 
the mentally ill and family support and was presented with the 
CNS award for Outstanding Service to Humanity in 2000.
    Finally, I would like to introduce Fran Gatlin. Ms. Gatlin 
is currently in her 29th year as a practicing school 
psychologist and her 27th year in the Fairfax County, Virginia, 
public schools. She has been named Psychologist of the Year in 
a school system with more than 168,000 students. She has a 
Master of Arts degree in Educational Psychology. Ms. Gatlin is 
a member of the National Association of School Psychologists 
and the American Association of Suicidology. Ms. Gatlin has 
provided invaluable leadership in implementing school-based 
suicide prevention programs and is currently serving on a task 
force with the Fairfax Partnership for Youth to increase youth 
suicide prevention efforts across Fairfax County.
    Senator DeWine. Before I introduce the panel members, I 
would recognize Senator Dodd, if he has any comments.

                   Opening Statement of Senator Dodd

    Senator Dodd. Thank you very much, Mr. Chairman. And Sharon 
and Gordon, thank you very much for being here. It means a 
great deal to have both of you here. I cannot tell you how 
saddened we all were to hear what you have been through, and 
your willingness to be here with us this morning says volumes 
about both of you.
    And thank you, Mr. Chairman, for being involved in this as 
well. This is a very important hearing. This is the kind of 
hearing you wish you never had to hold. We have hearings, from 
time to time we like to talk about things that we think will 
make a difference. We think we can here. But this is the type 
of a hearing I wish we just never had to convene.
    So I want to thank the chairman for calling it. It is a 
very important issue obviously, for all of us.
    I want to thank Senator Kennedy as well, and other members 
of the committee who have expressed strong interest in this 
subject matter.
    And of course, I would like to welcome all of our witnesses 
who are with us and who will be speaking a little later this 
morning, and in particular Sharon and Gordon. Again, thank you 
both for being with us.
    The loss on Garrett is something that all of us have felt 
as a result of our friendship with you. We want you to know 
that not a day goes by we do not think about you, and pray for 
both of you. And so thank you again for joining us here this 
morning.
    In September of the year 2001 I chaired the first Senate 
hearing on youth suicide in the Children and Families 
Subcommittee of this full Committee. And I want to begin this 
morning as I did then. I wish this year were not necessary. Yet 
we all know that it is.
    Youth suicide is both a public and mental health tragedy, a 
tragedy that knows no geographic, racial, ethnic, cultural, or 
socioeconomic boundaries.
    According to the Centers for Disease Control and Prevention 
over 3,000 young people take their lives each year, making 
suicide the third overall cause of death between the ages of 10 
and 24.
    Young people under the age of 25 accounted for 15 percent 
of all suicides in the year 2000. More children and young 
adults died from their own hand than from cancer, heart 
disease, AIDS, birth defects, stroke, and chronic lung disease 
combined.
    Equally alarming are the numbers of young people who 
consider taking or attempt to take their lives. Recent CDC 
figures estimate that almost 3 million high school students, or 
20 percent of young adults between the ages of 15 and 19 
consider suicide each year. And over 2 million children and 
young adults actually attempt to take their own lives. I find 
these figures to be staggering and simply unacceptable.
    And sadly, we rarely find these facts disseminated widely 
among the public audiences. We rarely read about them in 
newspapers or hear them on television. We know that youth 
suicide is intricately linked to mental health issues like 
depression and substance abuse. Yet we also know all too well 
that both youth suicide and children's mental health continue 
to carry an unfortunate stigma, a stigma that all too often 
keeps these crucial issues unspoken and discourages children 
and young adults from seeking the help that they so desperately 
need.
    We have a societal obligation, in my view, to break through 
this stigma of youth suicide, to understand its causes, to 
reach out to our young people in this country so that they 
understand that whatever difficulties or illnesses they might 
be experiencing, they are not beyond help at all. We also have 
a societal obligation, in my view, to instill in our young 
people a sense of value, of self-worth and resilience so that 
they recognize their full potential in life and the love that 
their families, friends and communities have for them every 
single day.
    I am pleased that our Nation has taken several positive 
steps toward better understanding the tragedy of youth suicide 
and its emotional and behavioral risk factors. The Federal 
Government, States and hundreds of community-based programs 
across this Nation are raising awareness by providing 
coordinated early intervention and prevention services to 
thousands of children and young adults, services that include 
comprehensive screening, assessment, individualized counseling 
and information resources.
    Yet despite these important gains we still face some very, 
very significant challenges. Today, a very large number of 
States and localities are finding themselves with unprecedented 
budget deficits, making the establishment of new services and 
the retention of existing services increasingly more difficult. 
State-wide strategies to coordinate services are often 
underfunded or understaffed to be properly effective.
    In addition, significant questions had been raised about 
the use of antidepressants in children. It is critical and 
crucial, in my view, that we take steps to understand the 
effects of these drugs so that our children receive the best 
possible care.
    Chairman DeWine and I plan to introduce bipartisan 
legislation that will further support the good work being done 
on the community level, the State level and the Federal level 
with regard to youth suicide. This initiative will support the 
further development and expansion of state-wide youth suicide 
early intervention and prevention strategies and the community-
based services they seek to coordinate. It will encourage 
greater Federal support in the planning, implementation and 
evaluation of these strategies and services, and it will create 
a new interagency collaboration that will focus on research, 
policy development and dissemination of data specifically 
pertaining to youth suicide.
    Finding concrete, comprehensive and effective remedies to 
the epidemic of youth suicide cannot be done by lawmakers alone 
on Capitol Hill. Those remedies must come from individuals, 
doctors, psychiatrists, psychologists, counselors, nurses, 
teachers, advocates, survivors and affected families who are 
dedicated to this issue or spend each day with children or 
young adults that suffer from illnesses related to suicide.
    Therefore, Mr. Chairman, I look very much forward to 
hearing from our witnesses today, particularly Gordon and 
Sharon. I also look forward to working with all of you so that 
collectively all of us here together today and others, 
thousands and thousands across this country who want to be 
involved in this effort, that we can better understand this 
tragedy and that we can better develop effective public and 
mental health policies and initiatives that will reach every 
child and young adult in this country. Compassionate 
initiatives that give them encouragement, hope and above all 
life.
    I thank you, Mr. Chairman.
    Senator DeWine. Thank you very much. Senator Harkin?

                  Opening Statement of Senator Harkin

    Senator Harkin. Thank you very much, Mr. Chairman.
    I just ask that my statement be made part of the record.
    And again, I just really wanted to be here to show support 
to our friend and our colleague, Senator Smith and Mrs. Smith. 
What happened to you and Garrett and your family is just 
something that any parent just--I just do not know how you hold 
up under that kind of tragedy.
    So I am here just as a friend and a colleague and just as a 
fellow parent, just to say that your faith and your strength 
and your willingness to be here to openly talk about your own 
tragedy gives us the courage, I believe, and the motivation to 
persevere and to come to some consensus on how we start 
addressing this issue that kind of has been swept under the rug 
for far too long in our society.
    I just want you to know that you give us the courage and 
the motivation to persevere.
    Thank you, Mr. Chairman.
    [The prepared statment of Senator Harkin was not available 
at print time.]
    Senator DeWine. Thank you very much.
    Senator Clinton?

                  Opening Statement of Senator Clinton

    Senator Clinton. Thank you very much, Mr. Chairman. And I 
thank both Gordon and Sharon. Thank you very much for being 
here. And I look forward to working with the chairman and with 
Senator Dodd.
    And I hope, too, that we can put this into the larger 
context of how difficult it is for families to find the help 
that they need when their child exhibits either behavior or 
feelings or even attempts suicide. It still is very rare that a 
family can get access to the kind of mental health services 
that are sometimes quite helpful, and not always successful, 
but at least for some provide a real safety net.
    So I thank you for holding this hearing, Mr. Chairman, and 
I particularly thank the Smiths for being here.
    I would just ask that my full statement be included in the 
record.
    [The prepared statment of Senator Clinton was not available 
at print time.]
    Senator DeWine. It will be made part of the record.
    [The prepared statement of Senator Kennedy follows:]

                 Prepared Statement of Senator Kennedy

    Thank you all for being here today for this hearing on one 
of the most tragic and personal issues affecting children and 
families across our Nation today--youth suicide. I especially 
want to thank Senator and Mrs. Gordon Smith and all the 
families here today for their courage in helping us understand 
this rising problem, that for so long has been misunderstood. 
Your testimony here today opens the door to a deeper 
understanding of mental illness and the steps we must take as a 
Nation to help troubled young people.
    We all understand that no words can heal the deep pain or 
replace the great loss of an anguished child we love. But we 
can act to change the broken system of mental health services 
in our Nation. And we can strive to better understand the 
despair that leads young people to take their own lives.
    The death of a young person has a devastating and long-
lasting effect on family, friends, and the whole community, but 
it also says a lot about the society we live in. As Senator 
DeWine has pointed out, suicide is the third leading cause of 
death among adolescents--yet the years of lost potential and 
productive living are never really captured in those 
statistics.
    We need to pay attention to the wake-up call these young 
people are giving so that another life is not lost due to 
mental illness. Access to mental health services is one of the 
most important civil rights issues facing our Nation today.
    Our mental health system is fragmented, in crisis, and 
inadequate. Too many people are falling through the gaps and 
not getting the care they need, particularly children. One of 
the saddest symptoms of the crisis is more and more families 
are compelled to give up custody of their children because they 
cannot find and afford the mental health services and supports 
they need. This is a disgrace to this Nation.
    Last year, when President Bush announced the formation of 
the New Freedom Commission on Mental Health, he urged Congress 
to enact legislation that would provide full parity in the 
health insurance coverage of mental and physical illnesses. We 
must move forward on those proposals, because every day of 
delay represents lost lives.
    It has been 3 years since ``The Mental Health Equitable 
Treatment Act'' was first introduced, and in this Congress it 
has broad bipartisan support. America's families should not 
have to wait any longer for this help.
    But we must do more than assure adequate private insurance 
coverage for mental health. We must address structural 
weaknesses in our health care system which denies adequate 
care.
    We must stem the flight of mental health practitioners from 
managed care networks. We must provide access to mental health 
services in schools.
    We must fund training programs and provide incentives to 
address the shortage of mental health professionals who are 
trained to work with children and adolescents, particularly 
those who live in rural areas. And disparities in mental health 
services need to be eliminated.
    The failure of one young person to obtain and continue with 
treatment can mean years of shattered dreams and unfulfilled 
potential. Children and young people with mental illness 
deserve health and happiness too--just as do those with 
physical illness.
    In my State of Massachusetts alone, 13 percent of children 
face emotional challenges and are in need of mental health 
services. Nationally, one in five Americans will suffer some 
form of mental illness this year--but only one-third of them 
will receive treatment. Our Nation's families should not be 
left alone to endure the isolation, pain and sadness of seeing 
their child battle illnesses that seize the mind and break the 
spirit.
    I commend Senator DeWine and Senator Dodd for their 
leadership and initiative in proposing grants to aid States 
with youth suicide prevention programs, particularly at a time 
when cash-strapped States are cutting funds for many vital 
services.
    Now is the time for Congress and the Administration to take 
action to address the youth mental health crisis in our Nation, 
and I look forward to the important testimony we will hear 
today to help us frame the action we should take.
    Senator DeWine. We now welcome our colleague from Oregon, 
Senator Gordon Smith and Sharon Smith, who tragically lost 
their son Garrett in September. Gordon and Sharon, we thank you 
both for being here with us. We welcome your statement.

 STATEMENT OF HON. GORDON SMITH, A U.S. SENATOR FROM THE STATE 
               OF OREGON AND SHARON SMITH, SPOUSE

    Senator Smith. Thank you, Chairman DeWine, Senator Dodd, 
Senator Harkin, Senator Clinton.
    Thank you for holding this hearing. As much as you wish you 
did not have to hold this hearing, we wish we were not your 
witnesses, but we need to be.
    I also want to thank my wife Sharon, my colleague Ron 
Wyden, members of my staff who are here to help me get through 
this emotionally, to provide that kind of support.
    September 8th, 2003 is a date that will forever tug at the 
heart strings of the Smith family. I was retiring for the 
evening when I heard a knock at the front door and moments 
later my wife, Sharon, was frantically calling me to come 
downstairs. Policemen were at the door.
    These fine Montgomery County officers dutifully asked if 
they could sit down with us to share some difficult news. 
Respectfully, they told us that our son, Garrett Lee Smith, had 
been found dead in his college apartment--forgive me--the 
apparent victim of his own hand.
    As his parents, we know how long and how desperately 
Garrett had suffered from his bipolar condition and his dark 
depressions. And while we knew intuitively that suicide was 
possible in Garrett's case, there are no adequate parental 
preparations, no owner's manual, to help one in burying a 
child, especially when the cause is suicide.
    For me, in that moment, time stopped, joy evaporated, my 
public life seemed vain, and my hopes and dreams appeared as 
ashes. I felt I had failed at my most important responsibility 
in life--that as a father.
    Now nearly 6 months later, a lot grayer and hopefully 
wiser, I can report to you, my Senate colleagues, what I have 
learned and what I hope to do in the wake of Garrett's death. I 
have learned that time goes on and that there is an end to 
tears. I have discovered that the best antidote to grief is 
gratitude, gratitude that the good Lord gave us Garrett for 22 
years less a day.
    I have determined that the best way to add meaning to 
Garrett's life and to find new meaning for my own is to 
discover ways and means to succor those who suffer like 
Garrett.
    Sharon and I unwittingly began to do this as we wrestled 
with how, as public people, to share the news of our private 
loss. We decided simply to tell the tragic truth about our boy, 
that after years of psychological suffering and deep depression 
Garrett took his life to end his emotional pain.
    Despite the lingering stigma of suicide, we decided just to 
announce it that way. The wisdom of this approach was confirmed 
to us weeks later by a sympathetic comment made to me by the 
dean of students at the University of Oregon. She consolingly 
said ``Senator, thank you for telling the truth about your 
son's suicide. The next day our student health center was 
flooded by students seeking help, fearing that they were 
suffering Garrett Smith's problem.''
    Next in the midst of our mourning, we were sustained and 
nurtured by the help and prayers of family and friends and 
thousands, even ten thousand, well-wishers. People wanted to 
help. They wanted to do something proactive if possible to 
intervene in the lives of young people who may be dealing with 
depression and considering suicide.
    So with the generosity of thousands, and under the auspices 
of St. Anthony's Hospital, the home town hospital in which I 
was born, at Pendleton, Oregon, we established the Garrett Lee 
Smith Memorial Fund. These resources will be utilized to 
purchase the computers necessary to annually screen, with 
parental permission, all of the sixth grade children in 
Pendleton, Oregon using the Columbia TeenScreen program to 
identify children who are at risk for depression, suicide, or 
other schooling difficulties.
    Also, St. Anthony's will establish a library resource 
center with books and software on mental health and a website 
for those with mental health challenges.
    Here in the Senate I am working on two pieces of 
legislation which I commend to you, and that is not hard 
because you are the coauthors of them. The first is the Youth 
Suicide Early Intervention and Prevention Act. Senators Dodd 
and DeWine and I will introduce it in the coming days. You have 
probably already summarized it adequately, Senator, but the 
bill does authorize $25 million per year in grants to 
organizations to implement suicide early intervention and 
prevention strategies in schools, juvenile justice systems, 
substance abuse programs, mental health programs, foster care 
programs, and other support entities.
    The second piece of legislation you are also a party to and 
it is the Reed-DeWine-Smith Bill, the Campus Care and 
Counseling Act. It is a competitive grant program for colleges 
to create or expand improved mental and behavioral health 
services for students. The University of Oregon's example is 
just one example of how effective that could be.
    Last, let me tell you for the Senate record why gratitude 
for Garrett helps me to cope with the grief that comes with 
losing him. Sharon and I adopted Garrett a few days after his 
birth. He was such a handsome baby boy, unusually happy and 
playful. And he was also especially thoughtful of everyone 
around him as he grew older. His exuberance for life, however, 
began to dim in his elementary years. He struggled to spell. 
His reading and writing were stuck in the rudiments. We had him 
tested and were surprised to learn that he had an unusually 
high IQ, but with a severe overlay of learning disabilities, 
including dyslexia.
    His struggles in school increased while his self-worth 
decreased, but his efforts were as big as his heart. He would 
often do homework with his mother late into the night and then 
express his appreciation to her for being an ``awesome mom,'' 
then cry himself to sleep out of fear that he could not compete 
in school or provide for a family in life. Despite our 
reassurances of his many redeeming qualities, his self-
confidence was crippled in his youth. Though this was apparent 
only to those closest to him. Everyone else saw a happy boy 
with a beautiful smile.
    Garrett could never hit a curveball, but he was a hit with 
his friends. That big smile and generous spirit allowed him to 
befriend everyone, popular or not. Wisely or not, his mother 
and I showered him with creature comforts as yet another way to 
show him that we loved him and valued him, only to find out 
later that much of what we the gave him he gave away to others 
less fortunate.
    Garrett struggled on in school and in Scouting. He became 
an Eagle Scout and through Herculean effort, seen mostly by his 
mother, he accomplished one of his two lifetime goals, a high 
school diploma. His other goal he fulfilled by qualifying to 
serve a 2-year mission to England for the Church of Jesus 
Christ of Latter-day Saints. He loved the camaraderie of his 
mission companions and he loved his church and his Savior and 
the chance of serving others.
    Yet through all of this we saw Garrett go through periods 
of dangerous mental darkness. He would withdraw from us and no 
rational persuasion on our part could draw him back to us. But 
inexplicably, in fact usually, he would come up in the mornings 
as happy as a lark.
    We sought out help from school and church counselors, 
psychologists, and, ultimately, a psychiatrist. But words of 
encouragement, prayers earnestly offered, and the latest in 
medical prescriptions could not repair our son's hard-wiring 
defects. Garrett's bipolar condition was a cancer to him as 
lethal as leukemia to another. It filled his spirit with 
hopelessness and clouded his future in darkness. He saw only 
despair ahead and felt only pain in the present.
    In his last words to us he wrote ``If it is any 
consolation, your love is the only thing in my life I know will 
never change. I just wish I could feel the same about myself. I 
love you so much. And just think, your son will not feel that 
every day pain anymore.''
    As Norman Maclean wrote in his poignant family story A 
River Runs Through It ``And so it is those we live with and 
live and should know who elude us.''
    That Garrett eluded me haunts me every day and no doubt 
will for the rest of my days. But this much I know, that he was 
a beautiful boy, and I loved him completely without completely 
understanding him.
    Thank you Mr. Chairman.
    Senator DeWine. Gordon, thank you very much. Gordon and 
Sharon, thank you very much for being with us and sharing 
Garrett with us.
    Those of us who have lost children, I think, want others to 
remember them and also want to make some meaning out of their 
death. But more important, make a meaning out of their life. I 
think you are doing that.
    By sharing your experience, you clearly are doing an awful 
lot of good. I think, Gordon, your story about the university 
and the number of students who came forward immediately is very 
instructive. The fact that you had the courage and the wisdom 
to share with people the fact of his suicide, I am sure has 
done a lot of good and it has been a teaching tool for people.
    I wonder if you could maybe reflect on that a little bit 
about the fact that more information is probably needed in this 
area? And what does information do for people? Just the 
information of thinking about it and knowing about it.
    Senator Smith. I think information is an invitation for 
people that it is okay to get help. I think for so long we have 
regarded as a society suicide as so aberrational that it is to 
be shunned and not enough has gone into understanding the why. 
I believe our understandings of mental illnesses and of 
depression are at so rudimentary a stage that we have much to 
learn through research, through study, through outreach, but 
mostly through an invitation to people who contemplate suicide 
that it is okay, it is encouraged, it is necessary for them to 
come in and get help.
    Because while not all people with bipolar conditions or 
manic depression disorders can be helped, many can and live 
their lives fully. I think the more we can do to identify them 
and to help them in a proactive and intervention way, the more 
we will do our responsibility in the public square.
    We were so numb the morning after Garrett's death that we 
just, without much forethought, just said let us just tell 
people what happened. Let us not run away from it. Let us try 
to make some meaning, take some meaning from this. That is why 
we announced it just as the facts were. And it is enormously 
encouraging to us that so many students at the University of 
Oregon apparently felt the need to reach out and to get help.
    We need to be there so there is something for them to reach 
to. And that is why I think the bill, as it relates to 
colleges, is so important because this is a period of time in 
young people's lives where they are under a special mental 
duress as they contemplate careers and providing for family and 
whether they can compete, whether they can get a job, whether 
they can make their way in the world.
    And I think that is why psychological and even psychiatric 
help to reach back on college campuses could be so very, very 
important and lifesaving.
    Senator DeWine. I wonder if you could expand on your 
description of this new, screening process or program that you 
have funded for the local students in your area?
    Senator Smith. We were able to raise, with the help of even 
some of you, Senator Kennedy in particular and his wife Vicki 
were very generous to this fund we established. We raised over 
$70,000. And what is necessary for school systems is to have 
the computers and the software and then to reach out to parents 
and get permission to test their sixth graders because there 
are, through this Columbia University teen screening program, 
there is a very high success rate at identifying children 
susceptible to depression, suicide and learning disorders that 
lead to these things.
    One of your witnesses on the next panel, Laurie Flynn, will 
discuss this. As we considered all the options for how to 
utilize this money effectively, we went to what works. That 
apparently is what works.
    So at least for our community, this fund will be used in 
perpetuity and administered by St. Anthony's with our public 
schools to help identifying children in one small town in rural 
Oregon. Perhaps if Garrett's tragedy has any meaning it will be 
because we prevent other kids from a similar fate.
    Senator DeWine. Thank you. Let me now turn to Senator 
Kennedy. Ted, I did not know if you had an opening statement.
    Senator Kennedy. Mr. Chairman, I think all of us are 
overwhelmed by the presentation. Thank you.
    Senator DeWine. Thank you. Senator Dodd?
    Senator Dodd. Just again, just to both of you, thank you 
immensely. And as I said, just by your presence here today and 
talking about this, we can talk about bills and amendments and 
things. Do not underestimate your continuing willingness to be 
a part of a public debate and discussion on this. I know it is 
difficult. It is difficult for us up here. I cannot imagine the 
difficulty it is to be here and talk about this.
    So just know it has great value and we really, really 
appreciate it. I have a feeling we are going to get this bill 
done. We may not get much else in this session of Congress, but 
I have a feeling we are going to get this legislation passed, 
Mr. Chairman.
    So thank you both for being here.
    Senator DeWine. Senator Kennedy, any questions?
    Senator Kennedy. No.
    Senator DeWine. Senator Harkin?
    Senator Harkin. I do not have any questions. I just thank 
you both again for your strength and your courage. You are just 
both good human beings. Thank you for that.
    Senator DeWine. Senator Clinton?
    Senator Clinton. No, thank you, Mr. Chairman.
    Senator DeWine. Again, thank you both for being with us. We 
appreciate it very much.
    As Senator Dodd said, working together, let us get this 
piece of legislation done.
    Senator Smith. Count me as one of your soldiers.
    Senator DeWine. We will follow your lead. Thank you, 
Gordon.
    Senator DeWine. Let me introduce our next panel.
    Senator Kennedy, did you want to introduce the first member 
of the next panel?
    Senator Kennedy. Thank you very much, Mr. Chairman. If I 
could put my full statement in the record, and I appreciate 
just so much that you and Senator Dodd are having these 
hearings and for your initiatives. It is a very overwhelming 
kind of presentation that we have just heard.
    We are fortunate in our next panel to have a very 
distinguished group. One is Father Paul Tunkle, who is a native 
of New York City and rector of the Church of the Redeemer in 
Baltimore and earned a doctor of ministry from a school of 
theology at Drew University.
    Father Tunkle has three children. One of them died in 1997 
at the age of 22, and his involvement postsuicide intervention 
and prevention began a year later in 1998. And he and his wife 
had begun to facilitate support groups for survivors of suicide 
in Louisiana and Maryland.
    In August of 2002, he and his family participated in a 26 
mile walk for suicide awareness and prevention in Washington, 
DC. It was at this walk that he began working on the 
documentary of the Discovery Channel, Surviving Suicide: Those 
Left Behind. And the documentary is in line is broadcast during 
2004.
    Father Tunkle, we thank you very much for joining us today 
and we look forward to your testimony.
    Senator DeWine. Let me also introduce Dr. Cheryl Ann King. 
Dr. King is a Licensed Clinical Psychologist and Associate 
Professor of Psychology at the University of Michigan. She also 
serves as Director of the Child and Adolescent Program at the 
University's Depression Center and is Chief Psychologist in the 
Department of Psychiatry at the University of Michigan Medical 
School.
    For the past 15 years Dr. King has focused on the problem 
of youth suicide and has devoted the majority of her clinical 
research to this devastating problem. We welcome Dr. King.
    Third, I would like to introduce Joelle Reizes. Ms. Reizes 
is the Director of External Relations for Screening for Mental 
Health. She was instrumental in transforming this nonprofit 
organization into a leading mental health screening 
organization. Screening for Mental Health was responsible for 
creating the first-ever National Alcohol Screening Day and has 
also developed the SOS High School Suicide Prevention Program.
    She has overseen the production and development of the 
Screening for Mental Health educational videos including SOS, 
Suicide Prevention Training and has authored educational 
brochures, some of which have been distributed to more than 
7,000 sites nationwide.
    Let me also introduced Laurie Flynn. Mrs. Flynn is the 
Director of the Carmel Hill Center for Early Diagnosis and 
Treatment in the Division of Child and Adolescent Psychiatry at 
Columbia University. She is also currently serving as the 
National Director of Positive Action for Teen Health.
    Before joining Columbia University in 2001, Mrs. Flynn 
served as the Executive Director of the National Alliance for 
the Mentally Ill for 16 years. She is a member of many National 
advisory boards and professional association committees, 
including the Clinical Trial Advisory Group and the Research 
Center on Managed Care for Psychiatric Disorders.
    Mrs. Flynn is the author of several articles and books on 
health services for the mentally ill and family support and was 
presented with a CNS award for outstanding service to humanity 
in the year 2000.
    Finally, we would like to introduce Fran Gatlin. Ms. Gatlin 
is currently in her 29th year as a practicing school 
psychologist and her 27th year in the Fairfax County, Virginia 
public schools. She has been named psychologist of the year in 
the school system with more than 168,000 students.
    She has a masters of arts degree in educational psychology. 
Ms. Gatlin is a member of the National Association of School 
Psychologists and the American Association of Suicidology.
    Ms. Gatlin has provided invaluable leadership in 
implementing school-based suicide prevention programs and is 
currently serving on a task force with the Fairfax Partnership 
for Youth to increase suicide prevention efforts across Fairfax 
County.
    Father Tunkle, we will start with you. Thank you very much 
for joining us.

   STATEMENTS OF REVEREND PAUL D. TUNKLE, PH.D., RECTOR, THE 
  EPISCOPAL CHURCH OF THE REDEEMER, BALTIMORE, MD; CHERYL A. 
  KING, PH.D., ASSOCIATE PROFESSOR, DEPARTMENT OF PSYCHIATRY, 
 UNIVERSITY OF MICHIGAN, ANN ARBOR, MI; FRAN M. GATLIN, SCHOOL 
  PSYCHOLOGIST, ROBINSON HIGH SCHOOL, FAIRFAX, VA; JOELLE M. 
   REIZES, MA, DIRECTOR OF EXTERNAL RELATIONS, SCREENING FOR 
 MENTAL HEALTH, LOVELAND, OH; AND LAURIE FLYNN, DIRECTOR, THE 
CARMEL HILL CENTER FOR EARLY DIAGNOSIS AND TREATMENT, NEW YORK, 
                               NY

    Reverend Tunkle. Thank you. I appreciate the opportunity to 
give testimony before this committee.
    I would like to introduce myself, which will explain a 
great deal about my experience and perspective.
    On August 22nd, 1997 my daughter, Alethea Rose Mary Tunkle, 
died of a self-inflicted gunshot wound to the head. She was 22 
years old. The tragedy and trauma of my child's suicide has 
become one of the defining moments of my life.
    My wife, Judy, who is here with me today, and I have been 
married for 32 years. We have three children. Sam is 30 and is 
a surgery resident in Florida. Elizabeth is 26 and a student in 
San Francisco. Lea is our middle child.
    I am an Episcopal priest serving a congregation in 
Baltimore, MD. Judy is a psychotherapist.
    First, some background and then some observations for your 
consideration. Lea exhibited psychological problems when she 
was a grade school student. In retrospect, these symptoms were 
of childhood depression. Over a 5 year period on two separate 
occasions, we engaged in work with a professional therapist. On 
each occasion Lea was identified as the red flag and we were 
encouraged to work on her family communication skills. Each 
time we agreed but asked the therapist to work with Lea because 
of her special problems. On both occasions, she was not 
identified as a primary concern. They just missed it, twice.
    In her early teens she was compliant and academically 
excellent. She caused little trouble and we were content. She 
was recruited for the biochemical engineering program at 
Rutgers University and we were thrilled.
    We moved to Louisiana as she began her studies at Rutgers 
in New Jersey. Her progress slowed and her grades began to 
suffer. I called the dean of her school to inquire about her 
progress. I was told that since she was an adult, he could not 
discuss her grades with me. I shared that I was concerned and 
he was unable to respond.
    I told him I would fly up and that Lea and I would make an 
appointment to see him. I called Lea and told her I was coming 
so we could see her dean and visit a psychologist at the 
university. Between that phone call and my scheduled trip, Lea 
attempted suicide for the first time. She overdosed on a large 
quantity of prescription drugs, some of which she stole from 
her roommates. She left a note which was a clear statement of I 
am miserable and I want out of here. This is not because you 
are bad parents. Please forgive me.
    The university was unable to help us, even when I asked for 
it. Lea was a victim of rape while at college. She found no one 
who would help her. She held on to her shame guilt and it added 
to her problems. We were unaware of these events until much 
later.
    On her first attempt, she was hospitalized. When she came 
out of her coma, she was furious as she realized she was still 
alive. She refused treatment and we had her involuntarily 
committed to a psychiatric hospital. Our insurance company 
funded a 72-hour stay.
    She was released into our custody while she was still at 
serious risk for self-harm. Our insurance company would not 
help Lea to get the treatment she needed. Lea was willing to 
stay and even requested this. They denied the benefits and Judy 
and I had no financial means to enable this to happen on a 
private pay basis.
    Lea came home with us for a while and then returned to 
school. She worked with a therapist but did not improve or 
remain committed. Each time she was tested she was not 
diagnosed as clinically depressed and no meds were prescribed.
    Several months later, Lea attempted again. She got a hotel 
room and assembled the drugs and knives to use. Her college 
roommate and her sister got wind of her plan and traced her. 
The police came and agreed not to arrest her if she would 
voluntarily go to the hospital. She agreed.
    At the hospital in New Brunswick she waited a long time to 
be seen, was given a cursory exam, and immediately released 
while still hallucinating from the drugs she had already 
ingested. She called us and we arranged to bring her back to 
Louisiana.
    She came home and was increasingly erratic in her behavior. 
She had a violent range episode and did some physical damage to 
our home. She left abruptly, induced her younger sister to 
leave with her, and flew back to New Brunswick. She was 
operating on credit cards that were freely offered to her as a 
college student. Again, she was out of control and neither our 
insurance company nor our resources, nor the resources of the 
university seemed to be able to make a difference.
    Finally, she came home and slowly declined. We arranged for 
an outpatient treatment program. Lea was asked to leave the 
program because she was noncompliant. Of course, her illness 
made her that way but the program seemed unable to handle sick 
people.
    In the end, she went out and purchased a handgun and 
ammunition. Even though she had been hospitalized for 
psychiatric problems and had two previous suicide attempts, she 
had no impediment to purchasing a handgun. She ended her life 
alone and in desperation.
    When I consider all that could be done for young people 
like Lea, I am moved to reconsider her journey. I believe we 
need well-trained counselors available to young people all 
along their path. We need teachers who have been trained to 
identify young people at risk and to work with their parents. 
We need colleges to have resources in place for the shocking 
number of young people who suffer from depression, anxiety, and 
who are victims of date rape that go unreported.
    We need not be afraid of the word suicide nor should we 
think it is contagious. However, it should be noted that a 
suicide survivor, namely one who has lost a loved one to 
suicide, is nine times more likely to die from suicide than the 
general population. So people like me are an already identified 
risk group. So are siblings of young people. So are their 
classmates and friends. They need to talk about their 
experience, to revisit their trauma, and to feel in that 
sharing.
    Lea had friends who were and continue to be deeply affected 
by her death. They are among the many who can benefit from 
professional help.
    I am an ordained minister. In the congregation I served Lea 
died, the leaders became so disturbed by her suicide that they 
asked for my resignation. Their basic statement was that if my 
child had died from suicide, my credentials to be their 
ordained leader had been invalidated. The fear and pain were 
more than they could stand. They decided running away was 
better than facing the depth of the tragedy and growing from 
it.
    I sought the help of my bishop, who intervened and ruled in 
my favor. But the lesson is that people with good intentions 
can make things worse when they lack knowledge and information 
and training.
    Judy and I are now training clergy and lay youth leaders in 
my current diocese on youth suicide prevention skills. 
Survivors such as us have great credibility among those who are 
willing to learn.
    Lea's death would be even more tragic if we could not use 
its lessons to help others. We were not bad parents. She did 
not have bad teachers. Her therapists could have been more 
knowledgeable and proactive but there is so much that we do not 
understand. One of the best things we can do is to open the 
discussion and the dialogue. We can let young people know there 
are those who will understand and will want to help. We can 
underscore that they need not travel the path of despair and 
depression alone. We can help the general population know that 
suicide is like leukemia. It is a disease that needs compassion 
and treatment, not shame and guilt.
    If Lea could be here she would say please, stop and listen 
to me. I am frightened of what is happening to me and I need 
for someone to know and to understand. I do not want to die, 
but I need to know it will not be like this forever. Can you 
help me? Can you love me even though I think I want to die? Can 
you save me from this?
    How I wish I could have heard her and responded better. How 
I wish she had found those compassionate and understanding 
voices when she was a little child, when she was a teenager, 
and when she was a college student. Maybe through your efforts 
others will not have to die like Lea. We lost not only our 
daughter but all the future potential she held for a life 
filled with blessing and joy.
    Let us do all that we can to save our children. As our 
culture becomes increasingly complex and pressured, our 
children need more help than ever finding their way. Let us be 
part of that helping system, turning them from the darkness 
back toward the light of life.
    Thank you.
    [The prepared statement of Reverend Tunkle may be found in 
additional material.]
    Senator DeWine. Father, thank you very much. Dr. King?
    Ms. King. Good morning, Chairman DeWine and Members of the 
Subcommittee and thank you for inviting me here today.
    The number of youth who commit suicide in our country is 
alarming and I applaud you for taking the lead in addressing 
this tragedy.
    A series of highly visible events have created an historic 
juncture for suicide prevention efforts. These were catalyzed 
in 1999 when the Surgeon General's call to action to prevent 
suicide stressed the need for effective suicide prevention 
strategies.
    In 2002, the Institute of Medicine published Reducing 
Suicide: A National Imperative. And even more recently, the 
report of the President's new Freedom Commission on Mental 
Health stressed the urgent need for action on suicide 
prevention. Now is the time and this is the year that we should 
take action.
    Just to highlight a couple of the major things we know 
about youth suicide that really can guide our prevention 
efforts. As Senator DeWine noted, completed suicide is much 
more common among adolescent males than females in the United 
States. It is a five to one ratio. And even the strategies that 
we are beginning to develop are showing more effectiveness for 
girls. We desperately need research on effective suicide 
prevention strategies for adolescent males.
    Despite that, the reverse is true for thoughts of suicide 
and suicide attempts. These are almost twice as common among 
adolescent girls than boys in our Nation. Although it is not 
the strategy of completed suicide, these attempts are 
associated with severe mental disorders often. Serious 
psychological pain and trauma for these adolescent and their 
families and a great deal of impairment and multiple 
hospitalizations. We also need to prevent these repeated 
suicide attempts that interrupts children's lives.
    In terms of primary risk factors, there are many but there 
are a couple of primary risk factors that have already been 
highlighted this morning. What we know about these will guide 
our efforts.
    The first is that the single strongest predictor of a 
suicide attempt or completed suicide is a previous suicide 
attempt or previous suicidal behavior. Moreover, a family 
history of suicidal behavior substantially increases the risk 
of suicidal behavior and suicide in young people.
    Mental disorders. About 90 percent of all youth suicide 
victims have histories of identifiable mental disorder. The 
most common types we began to hear about already this morning, 
depressive disorders including bipolar disorder, alcohol and 
substance abuse and conduct disorder or patterns of aggressive 
behavior. It may be possible to prevent the onset of some types 
of disorder such as alcohol and substance abuse. For other 
disorders, such as depressive disorders and bipolar disorder, 
early identification, screening, referral and the availability 
of effective services are both urgently needed and feasible.
    So the primary risk factors are a previous history of 
suicidal behavior and the presence of mental disorder.
    Firearms are the most common method of suicide in the 
United States for both boys and girls. In one study, firearms 
were present in the homes of 74 percent of adolescent suicide 
victims versus 34 percent of hospitalized adolescents who made 
suicide attempts and survived them. Because suicidal youth may 
be impulsive or ambivalent about killing themselves, they may 
be under the influence of alcohol when they make suicide 
attempts, the risk period, the period for the most imminent 
risk, is often short-lived. It occurs within a window of time. 
Restricting access to the most lethal means from which there is 
the return, no chance for hospitalization, and no chance for 
treatment is an extremely important prevention strategy.
    Much still needs to be done to prevent youth suicide. Few 
randomized controlled treatment or intervention trials have 
ever been conducted with suicidal youth. We need to develop 
effective strategies to intervene with those who reported 
thoughts of suicide and those who have come to our attention 
following a suicide attempt.
    Yet a comprehensive plan for suicide prevention in our 
Nation should include multiple points for prevention, 
maximizing the likelihood of reaching youth in need. Universal 
preventive interventions are directed at the entire population. 
These might include educational public service announcements 
about depression and the recognition of depression, 
restrictions on advertising for alcoholic beverages. It might 
include school-based health classes that emphasize mental 
health and substance abuse problems or health promotion 
activities.
    Selective interventions would include those that are 
specifically designed for high risk youth. The school context, 
which has already been talked about this morning, has the 
potential to be a very important place to identify and secure 
help for at-risk children. An educated school environment with 
an awareness of the signs of depression and suicide risk among 
students, teachers and others can create a safety net for 
recognition and referral.
    I would also like to take this opportunity to commend 
several members of the subcommittee for the efforts to address 
the increasing incidents of depression and suicide among our 
Nation's college students. A Senate companion bill to H.R. 
3593, introduced by Congressmen Davis of Illinois and Osborne 
of Nebraska could help to save lives. The bill proposes to 
amend the Higher Education Act by providing funding to increase 
access to mental and behavioral health services on college 
campuses. The bill addresses the increasing numbers of students 
at our colleges who are seeking services and the increasing 
severity of their needs which has moved far beyond academic 
counseling.
    This is extraordinarily important. Recognition and 
referral, screening. There are strong screening programs and it 
can be a very positive strategy. But recognition and referral 
is only the first step. We must have services available for 
those who are referred for services.
    Federal agencies play an instrumental role in helping to 
address this National tragedy. The Centers for Disease Control 
and Prevention has demonstrated great commitment to reduce 
youth suicide rates through an array of initiatives. The 
National Institute of Mental Health continues to develop and 
test various interventions to prevent suicide, such as through 
early diagnosis and treatment of depression and other mental 
disorders. With funding from the National Institute of Mental 
Health, I am developing and evaluating a new youth suicide 
prevention strategy which is called YST, the Youth-nominated 
Support Team. This supplements usual mental health services for 
acutely suicidal youth by building an informed, educated 
network of adults to support them.
    The Center for Mental Health Services of the Substance 
Abuse and Mental Health Services Administration also continues 
to provide critically needed mental health promotion and youth 
suicide prevention services.
    In sum, the development and implementation of an 
overarching strategic plan for suicide prevention can be 
achieved with the shared vision, commitment and resources of 
disciplines and Government working with individuals and 
communities.
    Thank you again for the opportunity to present this 
testimony. I would be more than pleased to answer any 
questions.
    [The prepared statement of Ms. King may be found in 
additional material.]
    Senator DeWine. Dr. King, thank you very much.
    Ms. Reizes?
    Ms. Reizes. Thank you very much, Mr. Chairman, Members of 
the Committee.
    I am pleased to be here today to discuss a critically 
important public health issue, teen suicide. I am the Director 
of External Relations for Screening for Mental Health, a 
nonprofit organization based in Wellesley Hills, Massachusetts. 
I operate a satellite office in Loveland, Ohio.
    Screening for Mental Health's mission is to promote mental 
health screening as an integral part of overall health care. 
Our teen suicide prevention program is called the SOS High 
School Suicide Prevention Program. According to the National 
Center for Health Statistics, suicide is the third leading 
cause of death in the 15- to 24-year-old age group. Indeed, one 
in eight adolescents between the ages of 15 through 19 will 
suffer from major depression in any given year.
    By way of introduction, I want to pass along a story that 
was related to me just last month by a school counselor from 
Cape Cod, Massachusetts. She ran the SOS program in her school 
last year. As a result, a young man recognized his own symptoms 
and came to the guidance counselor for help. The guidance 
counselor contacted his parents and together they got him the 
therapy he needed. A year later, he is doing very well and 
succeeding in school.
    But 2 weeks ago, this same young man went to class, sat 
down in his chair, and noticed that the student who had been 
sitting there before him had written on the desk I felt 
terrible and want to kill myself.
    Because he had been through the SOS program, this student 
knew to take this note seriously. He also knew who to go to for 
help. He alerted the school counselor who was able to work with 
the teacher's seating charts to identify the student in need. 
It turns out this young person was actively suicidal. The 
counselor contacted the parents and got the student into the 
local hospital to be evaluated that same day.
    This potentially lifesaving intervention resulted from 
increased awareness achieved through the SOS program. SOS 
provides a mental health check-up via depression screening. It 
also provides the education teens need to recognize depressive 
symptoms in themselves or others and the power to act when they 
see these symptoms. This means that even if the student is not 
depressed or suicidal at the top of the screening, he or she 
will know how to recognize the symptoms and what to do to get 
help if it ever does develop in the future.
    The main teaching components of SOS are the depression 
screening questionnaire and an educational video with 
discussion guide. The video, entitled Friends For Life, 
features dramatized vignettes that model the wrong and the 
right ways to react to a friend exhibiting suicidal signs.
    Schools that want to participate in the SOS program 
register with the Screening for Mental Health office. Screening 
for Mental Health then sends each school a huge box of 
materials which we call a screening kit. This kit contains 
everything the schools needs to implement the program, 
including procedure and training materials for school 
personnel, depression screening forms, the Friends for Life 
video, posters, and a variety of educational brochures. School 
health professionals and local clinicians implement the 
program, creating a team and setting up referral procedures 
based on local resources.
    Most schools learn about the program through one of several 
professional associations. SOS enjoys the support of the 
National Association of School Psychologists, the American 
School Counselors Association, the National Association of 
Secondary School Principals, and many other school-based and 
mental health organizations. Members of these organizations 
serve on our advisory board and, in fact, were instrumental in 
the development of the program from its very beginning.
    This is one of the reasons the SOS program is successful, 
because before we created any materials, we involved these 
groups and asked them what they wanted in a suicide prevention 
program. SOS was designed with the input of the very same 
school nurses, counselors, school psychologists who actually do 
the work with the students in the schools every day.
    A landmark study conducted by Dr. Robert Aseltine of the 
University of Connecticut Health Center will be released 
tomorrow in the American Journal of Public Health. This was a 
randomized controlled study with 2,100 students from five high 
schools and it revealed a 40 percent decrease in suicidal 
behavior, suicide attempts, in exposed to our program.
    This Nation has an over 20-year history with school-based 
suicide prevention programs and yet this is the first time 
anyone has ever seen this kind of result. This groundbreaking 
data is part of the reason why the SOS program is the only 
suicide prevention program currently listed on SAMHSA's 
National Registry of Effective Programs.
    SOS is also cost-effective. Our current per child cost is 
only $1.
    We hope to grow the SOS program with Federal support so we 
can provide the program to as many schools as want it. The 
program is cost-effective, flexible, easily reproduced in a 
variety of school settings, and the only program to have 
evidence of its ability to reduce suicidal behavior. We believe 
this is an important program option for schools looking to do 
suicide prevention programming.
    But most importantly, we simply believe that our children 
are worth the investment.
    Thank you very much for your time and attention, and I 
would be happy to answer any questions.
    [The prepared statement of Ms. Reizes may be found in 
additional material.]
    Senator DeWine. Thank you very much. Mrs. Flynn?
    Ms. Flynn. Thank you. Thank you, Mr. Chairman and Members 
of the Subcommittee. I am very honored to be able to 
participate today as a witness in this very important, very 
moving hearing on youth suicide prevention.
    As for so many here, this issue is personal to me. My 
oldest daughter made a very serious suicide attempt during her 
senior year in high school. She was the valedictorian of her 
class and had starred in school musical and had every sign of 
moving on to a successful career.
    And frankly, as a parent I had no warning. I had no sense 
that there was any danger. Very rapidly she deteriorated. She 
made a serious attempt. Thank God she was saved.
    But it was, for me, the single most terrifying experience 
of my life. And I have been dedicated since that time to doing 
anything I can to prevent these kinds of tragedies which, as we 
have heard from Senator Smith and Father Tunkle, continue to 
have a devastating effect on families and communities.
    Happily in a hearing on such a difficult topic, there is, 
as we have been hearing, real hope for some real advances in 
prevention through early identification and treatment. I am 
very delighted to be able to share with you the work we are 
doing at Columbia University, which is based solidly in 
research that has been going on for more than a decade.
    We believe that this growing body of science indicates that 
we can indeed find those youngsters who are suffering from 
mental health problems, often not visible, not easily 
discerned. We can find these youngsters. We can reduce their 
risk for suicide. We can indeed help them before they move into 
all of the related problems, poor academic performance, 
substance and alcohol use, self-injury, all of the kinds of 
things that derail these young lives and send families into 
despair.
    So we are delighted to offer, through the Columbia 
TeenScreen Program, an opportunity to school districts across 
the country to implement mental health checkups for youth. When 
you think about it, we as parents want our youngsters to have 
physical health checkups every year. It is part of being a good 
parent.
    And yet adolescence is the healthiest time of life. And the 
likelihood of finding, when we put the stethoscope on and 
listen to the heart, symptoms of a heart problem are quite 
rare. The likelihood of finding something in a youngster at the 
time of adolescence that may require and benefit from mental 
health treatment is not so uncommon.
    I am here representing a program based in science pioneered 
by Dr. David Shaffer, who is Chairman of our Department of 
Child and Adolescent Psychiatry at Columbia. But I am here 
principally as an advocate, as an advocate for mental health 
screening, and as an advocate for families and children across 
the country.
    In my family we have three generations of suicide. This is 
an issue that is of some urgency, I believe.
    The Columbia TeenScreen Program originated in research done 
principally in New York City and then replicated in Nations 
across the globe. What we have found is that because we know, 
through psychological autopsy studies, that suicide and 
suicidal behavior is, in over 90 percent of the cases, directly 
related to a psychiatric disorder it stands to reason that if 
we can identify those at risk or exhibiting symptoms of 
psychiatric illness we can indeed intervene and save lives.
    Our program has a simple purpose. We want to screen youth 
for mental illness and we want to identify those who are at 
risk and, importantly, link them to effective treatment. And 
indeed, this is a major challenge but it is one that we do not 
shrink from.
    Over the past several years, as we have moved our program 
from research into service in the community, we have trained 
over 108 sites. We are now active in 34 states. And as you 
heard, we are very proud to be part of the memorial in 
Pendleton, Oregon that has been established for Senator Smith's 
son, Garrett.
    Our program works in a simple way. We create partnerships 
with communities across the country. We look for those who are 
interested. We work principally in schools because that is 
where the kids are. But we are also active in residential and 
foster care programs, in clinics, in shelters, drop-in centers. 
We work with Covenant House in Florida. We work with Boystown 
in Nebraska, anywhere that people care about this problem.
    The heart of the program is a brief diagnostic interview 
screen that is encoded in software that is loaded in a laptop 
computer. With parental consent, the youngster puts on 
headphones and hears the questions spoken and sees the 
questions on the screen. And in a confidential self-
administered way is taken through the basic interest and issues 
that arise in a psychiatric problem.
    Happily, because of a very generous benefactor to our 
university's school of medicine, we at Columbia are able to 
offer this at no cost to sites across the country. Our staff is 
completely paid for by our benefactor. We offer the software, 
the training, the follow-up technical assistance and support to 
enable schools to move forward and implement the program.
    It has been our experience that this is often a critical 
component. We are able to address the concerns about one more 
thing, one more cost, one more issue that is competing for 
attention in schools.
    We are pleased that we were highlighted in the recently 
released report of President Bush's new Freedom Commission on 
Mental Health. And we have indeed moved from working with 
communities to looking at state-based implementation to try to 
leverage some of our early grass roots successes.
    So we are working in a number of States, including Ohio, 
where Commissioner Michael Hogan has taken this program on and 
provided small grants of $5,000 to $15,000 to mental health 
boards at the county level. We now have 10 counties in Ohio 
that are active and we expect to be working with 20 next year.
    In Nevada, unlike Ohio where we work with the State mental 
health department, we are working with the State department of 
education and the State board of education, building on work 
that began in Clark County which is one of the largest and 
fastest growing school districts in the Nation. And as we know, 
States west of the Mississippi have a higher rate of suicide at 
every age.
    In New Mexico, where there is a high proportion of Native 
American students, again with uniquely high risk, we have been 
working with the State department of health and the University 
of New Mexico Department of Psychiatry to work with school-
based health centers, a structure already in place in many of 
the local schools, and to work as well with Native American 
schools in rural parts of the State.
    In Connecticut, we are active in both Bridgeport and 
Wilton. And we will be working, just later this week with the 
Connecticut Society of Pediatrics, as well as the Psychiatric 
Society, to see if we can find others to work with us to 
promote the spread of this program.
    We are active in Iowa, where as a result of a high profile 
suicide of a student at Lincoln High School, former Governor 
Terry Branstad convened the school superintendents and the area 
education agencies to work not only to address the issues in 
the high school's immediate strategy, but also to develop some 
prevention programs across four different districts in the 
State.
    We are active, as you have heard, as well in Oregon. We are 
also active in Florida. We are working with the State office of 
drug control, another potential ally in State government. We 
are mounting a task force activity in two contiguous counties, 
Hillsborough and Pinellas, to screen all ninth graders and 
accompany it with a community partnership to share education, 
information and support to parents and school officials.
    We are very pleased at the flexibility of our program. One 
of our goals is to engage an ongoing infrastructure already in 
place, to look at resources both fiscal and professional, that 
can pick up the program, expand the program, adapt the program 
and make sure that it reaches its target.
    We have been especially pleased to work with Connecticut 
Representative Rosa DeLauro around the introduction of the 
Children's Mental Health Screening and Prevention Act, H.R. 
3063. We are delighted to participate in the other work being 
done here in the Senate to address this problem, because indeed 
we know we can do something to find these kids, to help these 
kids, and indeed to save these kids.
    We have had extensive and positive collaboration with both 
the Substance Abuse and Mental Health Services Administration 
to encourage them not to support our program directly but to 
support these efforts across the country and particularly to 
name someone in each State who can be a focal point for these 
actions.
    And at the Department of Education----
    Senator DeWine. Ms. Flynn, we are going to have to 
conclude.
    Ms. Flynn. Thank you. Thank you very much.
    [The prepared statement of Ms. Flynn may be found in 
additional material.]
    Senator DeWine. Thank you. Ms. Gatlin?
    Ms. Gatlin. Thank you.
    I am a school psychologist and I work in a high school with 
3,000 students in Fairfax County, Virginia.
    The role of schools in the identification of student mental 
health needs cannot be overestimated. Schools are a critical 
component in effective mental health care of children and 
adolescence. We have the opportunity to observe students at 
risk and direct them and their families to appropriate mental 
health treatment.
    We can educate them about the signs and treatments for 
suicide risk and other mental health problems. And as we are 
learning is so important, we can help them understand the vital 
role that they play in saving the life of a friend or classmate 
by telling an adult when they believe a peer is at risk.
    But we need resources to do this work.
    In my State of Virginia the rate of suicide among high 
school aged youth is about one per week. As former Surgeon 
General Dr. David Satcher said, suicide is the most preventable 
form of death but it requires an investment to save these 
lives. The public needs to be educated about suicide. People 
need to understand that most suicide results from untreated 
depression and that depression is treatable.
    Surveys tell us that one in five teenagers seriously 
considers suicide. 520,000 teenagers require medical services 
as a result of suicide attempts each year. Psychological pain 
implied in these numbers is staggering. Unfortunately, most 
parents are in denial that these issues could affect their 
families.
    Talking to students is a central part of any suicide 
prevention effort. I learned early on that of teens who kill 
themselves, 80 percent tell somebody before they die. But the 
person they tell is another adolescent, not an adult, not 
someone likely to take action on their behalf.
    Six years ago I began doing a lesson in all 10th grade 
health classes at my school on signs of adolescent depression 
and suicide. My message to these teens is that they may be the 
only one who knows that a friend is depressed and potentially 
suicidal. And that they have to tell an adult in order to save 
a life. I learned since that this is called peer gatekeeper 
training.
    I also offer a mental health support group at my school for 
students who have had a suicide attempt or a psychiatric 
hospitalization. These are the people at the highest risk for a 
suicide attempt since they have already taken that action. Such 
school-based support groups function both to provide mental 
health services but also to keep a watchful eye on the most 
vulnerable of populations.
    I should interject that this group has included a 
valedictorian, a recruit to a Big Ten football program and many 
bright and talented individuals. Depression and suicidal 
feelings can affect anyone and disproportionately impact highly 
intelligent and creative people.
    Identifying students at risk is an important part of 
suicide prevention efforts. After being a volunteer screener on 
National Depression Screening Day for several years, I was able 
to initiate depression screening at my high school when the 
Signs of Suicide Program became available. Many students have 
been helped in the years we have used it.
    Screening and assessments are critical to effective suicide 
prevention. They need, however, to be fit into a comprehensive 
suicide prevention program. Education of parents and students, 
successful referral to effective treatments, and the 
availability of knowledgeable mental health professionals 
within the school environment are all key to effective suicide 
prevention.
    Teens do not generally have access independently to mental 
health services. Increased access to school-based mental health 
services is vital to improve suicide prevention. As the 
National Institute of Mental Health indicates, of some 7.5 
million children under the age of 18 requiring mental health 
services only one in five receives needed services. This 
statistic has not only alarming implications for suicide rates 
but for other dangerous behaviors as well. We are seeing a 
dramatic increase in students engaging in intentional self-
injury and in substance abuse.
    The use of alcohol and drugs is such a significant factor 
in teen suicide. Fifty percent of teens who die by suicide are 
legally drunk or high at the time of their death. The 
disinhibiting effects of the alcohol or drugs may be the 
dynamic that tips the scale from life to death.
    I believe that any effort to ensure that our schools are 
safe and drug-free must also include school-based mental health 
services to address the great needs of these students.
    Another significant risk factor for teen suicide is access 
to firearms. Nearly two-thirds of teens who die by suicide use 
firearms. And we know from a number of studies that restricting 
access to immediately lethal means save lives.
    Thank you, Senators, for supporting Senate Bill 1807, to 
close the gun show loophole and hopefully prevent juveniles 
from buying firearms at gun shows.
    Schools have another significant advantage in helping to 
prevent suicides, that is familiarity to and access with the 
family and friends. Because suicide does leave a legacy of 
suicide, the immediate family and friends are nine times more 
likely to die by suicide.
    Five years ago, my school year began with the suicide 
deaths of two students at my school in a 3-week period. As a 
result, I joined the American Association of Suicidology. I 
offered a support group to the friends of the deceased 
students. Helping these teens deal with the death and 
understand it as an unfortunate choice will hopefully keep them 
from ever making that same choice. It was reassuring and 
rewarding when they were able to reach a point of remembering 
the life of their friends instead of being stuck in the horror 
of such an unnecessary death.
    The President's new Freedom Commission on Mental Health 
indicates the need for schools to play a crucial role in 
identifying students in need of mental health treatment as well 
as linking them to services. I am in wholehearted agreement. 
Our linkages between school and community-based services need 
to be enhanced. The health and well-being of our next 
generations depend on our capacity to do effective suicide 
prevention, education and services.
    On behalf of the National Association of School 
Psychologists, I thank you for the opportunity to speak to this 
important matter.
    [The prepared statement of Ms. Gatlin may be found in 
additional material.]
    Senator DeWine. Great.
    This has been a wonderful panel. I just frankly wish every 
member of the U.S. Senate would have had the opportunity that 
we have all had this morning to listen to all of you.
    I just have one question before I turn to the other members 
of the panel. Father, you talked about, in your testimony, in 
regards to your daughter, about the college she attended, the 
university she attended, which raises--and Dr. King, you talked 
about it as well--raises the issue of how well our universities 
are doing in providing services.
    And I wonder if you could, members of the panel, if any of 
you would like to discuss that, and what else we could do at 
the university level. Father, you talked about the fact that 
they could not talk to you, I guess, which is a basic problem 
now that we look at young people when they turn 18 as adults. 
That is a problem. They cannot give you a warning, I guess, if 
there is a problem.
    How well are the universities doing, or colleges doing? And 
what else can we do? What else can they do? What can we do to 
help them?
    Ms. King. Across the Nation I think it is fairly consistent 
that they are not doing very well with this right now because 
the history of these university and college counseling centers 
really was a different mission, and that was to provide 
academic counseling and help with the adjustment away from 
home. It really was not to deal, nor are they staffed anywhere 
to my knowledge, to deal with bipolar disorder, major 
depressive disorder, someone who has made multiple suicide 
attempts. And yet, these other services are not usually readily 
available to all youth when they are away from home.
    So I think one possibility is we do think of screening, 
that several people have talked about, as one component in a 
comprehensive program, but it is not sufficient as a sole 
intervention or sole strategy because, of course, not all youth 
or college students will voluntarily participate in the 
screening. They may not all acknowledge these problems because 
of real stigma that they are concerned about.
    And when identified, it is only a subset of those who 
screen positives who actually end up getting services. So that 
is very important in terms of identifying and getting some of 
the youth to services.
    I think what we also need at the colleges and universities 
is a greater awareness among the counseling and other staff, 
perhaps the professors. That is a tough one. This works better 
in the school settings where you can teach the personnel who 
know the kids, the students, about risk factors.
    But the availability of services, in addition to screening, 
is really what we need to have at the colleges. It may be 
redefining the mission of the campus counseling centers or 
finding some other way of filling the gap of the absence of 
service for the more severely mentally ill college students.
    Senator DeWine. Anybody else?
    Reverend Tunkle. I think parents could also benefit from 
having college professionals give them some guidance during the 
orientation process when they bring their children to college, 
on how parents can be partners with the school in looking for 
risk factors with their children and being proactive in that 
score as well. Parents are often clueless and could benefit 
from some guidance.
    Senator DeWine. Ms. Reizes?
    Ms. Reizes. Thank you. I would just like to say that in 
addition to the teen suicide program that I talked about here, 
Screening for Mental Health does run a very large college 
program called College Response. And it is, again, to do what 
Dr. King is talking about, provide colleges with the 
opportunity and the tools they need to participate in National 
Depression Screening Day, for example, and to hold an event on 
campus like a health fair where they can offer screening and 
provide educational outreach. As well as we also provide, as 
part of this, an interactive screening that can be embedded in 
the college's website so that there is ongoing screening 
presence 24 hours a day, 7 days a week, with specific referral 
back to that college's counseling center. We have about 700 or 
so colleges that participate in that.
    Senator DeWine. Good.
    Senator Dodd?
    Senator Dodd. Thanks very much, Mr. Chairman.
    I have so many questions for all of you. I cannot thank you 
enough for your testimony.
    I was saying to the chairman, I kind of regret that we do 
not have more public viewing of what you are saying here. We 
normally have C-SPAN and others that cover these hearings. And 
I am trying to figure out some way to disseminate some of what 
you had to say here that is tremendously worthwhile. I thank 
all of you for being here.
    Let me jump to a question. I have a lot of other questions 
that get to the issues of the studies being done. Ms. Flynn, 
whatever help we can offer you in Connecticut, please let us 
know today or tomorrow where else we can help you with some of 
these studies that are being done.
    And Ms. Reizes, I appreciate your comments about the 
Hartford Public School System. They have done a great job with 
this and I am very anxious to see the study.
    I want to get if, I can, to the use of some of the 
medications. Neighbors of mine here in Washington, wonderful 
people and great, great friends of ours, have a daughter, who 
made at least one or two attempts on her own life, but today is 
doing tremendously well and is a teacher. We were just talking 
about it the other night, we had dinner together, not in 
preparation for this hearing but just fascinated by what they 
went through as a family.
    And one of the problems they had was the medications that 
were being provided. And there was a question about whether or 
not there was a proper dosage medication or combination of 
medications.
    I do not know to which one of you, maybe Dr. King or others 
here who feel competent talking about this, but I would like 
you to address it to some degree.
    We have sent a letter, Mr. Chairman, in the last day or so 
to the Food and Drug Administration. My colleagues here, 
Senator Kennedy, Senator Clinton, Senator Murray, Senator 
Bingaman, Senator Harkin, Edwards, Corzine, Johnson, and 
Mikulski have all signed on, asking the FDA to look at this 
issue. We recently passed--in fact, the chairman was 
tremendously helpful on this--with our exclusivity rule and 
then requiring the rule with Senator Clinton's leadership on 
the testing of these products on children particularly. We have 
only one product that has been approved by the FDA. There are a 
variety of others that have raised some serious questions.
    Others I very clearly think do a tremendous job and have 
saved lives. So I am not drawing a conclusion here but I would 
like to get your feelings about all of this because it is so 
tremendously important, it seems, in addressing this issue.
    The British recently banned the usage of all of these 
things. I do not know how wise that was. But I would be very 
interested in jumping into this subject matter because it is 
one that I think we need to talk about. And clearly the FDA 
needs to address this issue.
    And we would hope they would do it under the exclusivity 
rule, but if they do not, then our letter suggests that they 
order the rule be invoked. There is a debate about the wisdom 
of that approach, but we think it is an important step to be 
taken.
    So I do not know which one of you feels the most competent 
to talk about this. Dr. King, let me start with you. You have 
got doctor in front of your name, so we will start with you.
    Ms. King. I am aware there is an ongoing Federal 
investigation concerning the use of antidepressants in youth. 
It is difficult because none of us or none of our sites 
individually have access to all the data from all the clinical 
trials using antidepressants with youth. This is a combination 
of Federally sponsored trials and pharmaceutical company 
sponsored trials.
    As part of the Federal investigation they will be getting 
all of that data on adverse events that occurred during the 
trials. I think that is extremely important and we need to wait 
and hear.
    But we do now, in the last several years, have evidence 
from randomized controlled double-blind placebo controlled 
studies that antidepressants can be effective with youth. I 
think that one of the issues though, is that the effect size I 
think sometimes this is not talked about. It is not tremendous. 
It is not as large an effect as what we find in studies with 
adults.
    So one of the issues is when you weigh that effect size 
with the possibility, if that is what we learn, of harm, where 
will you balance? And that is why we really need to get these 
findings.
    I think the other issue is that it is easy when we have 
effective antidepressants for many providers to perhaps see 
that as a sole intervention. The problem is that most suicidal 
youth, especially the most severely suicidal at risk for 
completed suicide, often have multiple difficulties in areas of 
their life. It could be school failure or they might be doing 
extremely well. And maybe they have a substance abuse problem. 
So that we often want to see, especially with youth, that even 
when antidepressants are used effectively that they are used as 
one part of a comprehensive treatment that takes into account 
the other possibly serious risk factors for suicide in the 
youth.
    Ms. Gatlin. The funds have not been there to study child 
and adolescent psychiatric kinds of problems, even within this 
metropolitan area. There are not an adequate number of child 
and adolescent psychiatrists available for parents. So they get 
in to see somebody 15 minutes and somebody gives them a pill 
and that is a solution.
    We need a Mayo Clinic of child and adolescent psychiatry in 
this country where people can go for the finest minds and the 
best research being done and so that can be parceled out to the 
individual psychiatrist back home.
    Children are not getting proper care.
    Ms. Flynn. Just to go further with that, certainly at 
Columbia we are doing some of the analysis and the review is 
terribly important, as Dr. King has said.
    But it is also quite true that most of the youngsters in 
this country who are being treated for mental disorders are not 
being seen by child psychiatrists. Quite clearly, one of the 
things we need is to draw in pediatricians, family physicians, 
others who are involved in dealing with these medications so 
they understand them better, can use them more wisely, and can 
open those important channels of communication with families.
    Senator Dodd. Do I have time for another question?
    Senator DeWine. Sure.
    Senator Dodd. Just quickly, let me ask you about the 
postvention notion. We had a tragedy in my hometown of East 
Haddam, CT, few years ago that got national attention. A young 
man took his own life in a car. In fact, in front of the 
Congregational Church in town, drove into a tree.
    Several days later this boy's brother did the same thing, 
to the same tree, in fact. It received a lot of attention. We 
are a small town, a small rural town in Connecticut.
    And I am fascinated by the notion of the postvention in 
dealing with families and what happens, and how quickly we move 
in this area. I wonder if you might comment?
    Reverend Tunkle. I would be glad to comment on that because 
my wife and I have been involved in this postvention activity. 
Our exposure to the postvention community in Louisiana, they 
have been developing a program that brings a survivor group, a 
trained survivor group, to the scene of a suicide death almost 
immediately, with the help of the coroner. I have had the 
opportunity to attend the funeral of a stranger and go up to 
that stranger at the funeral and say my daughter died from 
suicide, here is my card. When you are ready to talk, I am 
here.
    We find that when studies are done of people who received 
this intervention shortly after the death of a loved one, their 
healing process is greatly enhanced and greatly compressed. And 
so that is a very important area, as well. Again, if suicide 
survivors are nine times more at risk than the general public, 
then this is also a suicide prevention program.
    Senator Dodd. I am wondering, too, about unintentionally 
romanticizing of these events among young people and the 
postvention because of her siblings in this case. But I gather, 
as you point out Ms. Gatlin, it is not uncommon for other 
children in the school setting to see this as an example there 
has been a romanticizing of this event.
    Ms. Gatlin. I think we are doing a better job of asking the 
media not to romanticize, to not report as much about it. 
Within the school system we work very carefully to identify 
those at known risk and open up to the population to provide 
services for anybody who deems themself to be at risk.
    You are exactly right, teens are so vulnerable to this 
romanticism. That is why it is so important, in the talk that I 
do with them, to link suicide to mental illness, to link it to 
an ambivalence that they want very much to end the 
psychological pain they are feeling. They just, at that moment, 
see no other way to end the pain without taking their lives.
    That kind of message to them changes their thinking and 
stops the romanticism.
    Senator Dodd. Any other comment on this point?
    Ms. King. Just that cluster suicides do account for 5 
percent of youth suicides and the phenomena of contagion or 
clustering occurs almost entirely among youth and young adults. 
So that postvention programs in schools are extraordinarily 
important.
    Also, I just wanted to comment that Louisiana is considered 
in the Nation to be a model for postvention services for 
families. It is very well known and Frank Campbell is there and 
would have tremendous information for your group if you are 
interested in postvention.
    Senator Dodd. Thank you, Mr. Chairman.
    Senator DeWine. Senator Kennedy?
    Senator Kennedy. Again, thanks to all of you. It has been 
enormously informative and very moving testimony here.
    I know, Mr. Chairman, we are joined by some young people, 
some students, in the back here. Welcome to all of them.
    I am kind of interested in the panel's view about the 
change that has taken place in terms of the profile of those 
that are involved in suicide now. You see, particularly among 
black youth for example, the percentages and the numbers have 
been going up very, very high. How is this thing changing, if 
it has been? I am interested in that.
    And second, I am interested in the parents. We have heard 
from Father Tunkle very moving testimony about how he tried to 
do the best he could. But also, the role of parenting today and 
with these kinds of responsibilities, how parents are going to 
know about it, how they are dealing with it, what is happening 
with parents? Are they spending enough time with their kids and 
trying to understand it? Are they too busy doing other things?
    How much of that is a force or a factor, as well, in terms 
of trying to understand and getting a handle on this?
    First of all, I would be interested in sort of the faces of 
the people that are involved in this and how it has altered or 
changed in the last several years.
    We have seen the statistics. It is 180 percent in the last 
20 years, black youth, for example. I am just interested in why 
this is happening? Are there any things that we ought to 
understand about that? Is that different from some of the 
things that we have talked about today?
    Ms. Gatlin. I think that there is a change among black 
males. Their increased rate of suicide has gone up greatly. 
Females, it is not true. Females, among the African-American 
population, remain very, very low and I think we have a lot to 
learn from them.
    But I think if you take the principle that in the world, 
the places where the highest rates of suicide occur, are those 
in which the people are losing their traditional culture and 
values.
    And then take that to the individual group and our 
communities are being pulled apart. And in some ways perhaps a 
dynamic in African-American males' life is the loss of some of 
their traditional cultural binds. They are left more alone and 
it is a sense of isolation that feeds into suicide so 
frequently.
    Ms. Reizes. Senator, I cannot particularly comment on why 
we have seen changes.
    What I can say is that our experience with our program is 
that the same messages work regardless of race. The message, 
again, should be tied to the idea that suicide is a fatal 
outcome of a mental illness. And that is the most critical 
thing we can say again and again.
    It is very important that that connection be made and that 
the idea that mental illness can be treatable and that this 
does not have to be the way you feel for the rest of your life, 
that we can work with this.
    To answer your question about parents, I think it is 
important not only to involve parents but to assure them that 
they did not do this. They did not cause this. Anymore than 
they cause leukemia, any more than they caused a heart attack. 
You have to empower the parent to feel like they can help their 
child and to try to unburden them somewhat of the blame.
    In our program what we do is we provide what we call a 
parental screening form which is actually a version of the same 
form that the children complete. But it has what we call a 
lower cut-off, meaning that it makes it a little easier for the 
parent to figure out whether or not the signs and symptoms of 
depression or suicide are apparent in their child's behavior or 
attitudes.
    The reason we lower that cut-off is because we do know that 
so often kids know, parents do not, and the friends do not 
tell. So we try to provide a screening form in a way that a 
parent can actually take it to help them think through their 
child's attitudes and behaviors and really involve them in what 
the school is doing. And the schools do that when they send out 
their permission letters and consent letters. So that is one 
way we can hopefully help educate parents.
    Ms. Flynn. If I might just add one other factor we might 
want to consider, we have seen over the past 4 or 5 years, and 
it looks like it is being sustained. a drop in the overall 
suicide rate for youth, which is positive and may, in fact, be 
one indicator of greater access and perhaps some positive 
effect of some of these medications and treatment we were 
talking about.
    We are not seeing that with young African-American males 
and it may reflect a poorer access to health care.
    Senator Kennedy. OK. Father Tunkle?
    Reverend Tunkle. I think another impediment to effective 
suicide prevention is the shame and the stigma which has been 
sort of embedded in our culture regarding suicide. Ironically, 
that shame and stigma originated perhaps in the life of the 
early church where it was seen as a suicide prevention program, 
that early Christians were a little too eager to see themselves 
done in for the sake of Christ. And the church was so alarmed 
at the number of people who were signing up to check out for 
Jesus' sake that they stigmatized it and said if you do this, 
you are going to lose out on the eternal reward.
    So yes, we have made tremendous progress in a couple of 
thousand years, but this stigma still holds on. I think 
sometimes young people have this impediment to stepping forward 
and saying I need help because it would be easier to ask for 
help if I had leukemia than if I had self-destructive thoughts.
    So a hearing like this, anything we can do to open up this 
conversation, is tremendously beneficial and I thank you for 
it.
    Senator Kennedy. Thank you. Thank you, Mr. Chairman.
    Senator DeWine. We have a vote on. This will be a series of 
votes.
    Senator Clinton will ask the last questions. When she is 
done the hearing will be over and I want to thank each and 
every one of you.
    Senator Clinton?
    Senator Clinton. Thank you very much and I really thank 
you, Mr. Chairman, for holding this hearing. And I thank all of 
our panelists.
    I do not have a question so much as a comment. I think the 
work that the panelists have done and the testimony they have 
provided us today certainly gives us a lot to think about, but 
also some pathways to follow.
    I commend you and Senator Dodd for introducing legislation. 
But I think we have to recognize that we are looking at larger 
issues here. Our failure to have mental health parity, our 
failure to fully fund adolescent mental health programs. In 
fact, we seem to have a difficult time even recognizing the 
need for childhood and adolescent mental health treatment.
    Our failure to really require that all of the tests that 
have been done on the serotonin re-uptake inhibitors are put 
into some kind of registry so that people can have access to 
the clinical studies and the information so that they can act 
on it instead of having it just locked away somewhere and be 
pried open and try then to be put to use.
    So I think there is a tremendous opportunity here and I 
hope that those of you who are on the front lines of this 
tragic issue will stay with us and be consistent with us in our 
efforts.
    I would add two other groups that I think deserve to be 
mentioned. There is a consistently high rate of Native American 
adolescent suicide. And there has been a surprisingly high rate 
of suicide among our military forces in Iraq. I think that 
bears some real attention, as well.
    Finally, today we will be voting on I am afraid making 
firearms even more accessible to people who have temporary 
mental health problems, who have depression, who have either 
suicidal or homicidal tendencies that could otherwise be 
reduced or dealt with. But we are going to arm even more of 
them and I think that is a great tragedy that unfortunately we 
do not have to have done but we are barely on the way to doing. 
It will be even more possible for young people to have access 
to weapons to do away with themselves and others, which I think 
is obviously a horrible development.
    But we have to deal with what we are given. We are going to 
need even more help to try to screen and support and treat 
people to avoid those kinds outcomes.
    Thank you very much.
    Senator DeWine. Thank you very much.
    Let me again thank the panel. It has been very, very 
instructive. We have learned a lot and we will try to take the 
information that we have learned today and turn it into some 
very positive action.
    Thank you all very much.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

             Prepared Statement of Reverend Paul D. Tunkle

    I appreciate the opportunity to give testimony before this 
committee. Let me introduce myself, which will explain a great deal 
about my experience and perspective.
    On August 22, 1997, my daughter, Alethea Rose Mary Tunkle, died of 
a self inflicted gun shot wound to the head. She was 22 years old. The 
tragedy and trauma of my child's suicide has become one of the defining 
moments of my life.
    Judy and I have been married 32 years. We have three children. Sam 
is 30, and is a surgery resident in Florida. Elizabeth is 26, and a 
student in San Francisco. Lea was our middle child. I am an Episcopal 
priest serving a congregation in Baltimore. Judy is a psychotherapist.
    First, some background, then some observations for your 
consideration. Lea exhibited psychological problems when she was a 
grade school student. In retrospect, the symptom were of childhood 
depression. Over a 5 year period, on two separate occasions we engaged 
in work with a therapist. On each occasion, Lea was identified as the 
red flag, and we were encouraged to work on our family communications 
skills. Each time we agreed, but asked the therapist to work with Lea 
because of her special problems. On both occasions she was not 
identified as a primary concern. They just missed it, twice.
    In her early teens she was compliant and academically excellent. 
She caused little trouble, and we were content. She was recruited for 
the biochemical engineering program at Rutgers University, and we were 
thrilled. We moved to Louisiana as she began her studies at Rutgers in 
New Jersey. Her progress slowed and her grades began to suffer. I 
called the dean of her school to inquire about her progress. I was told 
that since she was an adult, he could not discuss her grades with me. I 
shared that I was concerned, and he was unable to respond. I told him I 
would fly up, and that Lea and I would make an appointment to see him. 
I called Lea and told her I was coming so we could see her dean and 
visit a psychologist at the university. Between that phone call and my 
scheduled trip, Lea attempted suicide for the first time. She overdosed 
on a large quantity of prescription drugs, some of which she stole from 
her roommates. She left a note which was a clear statement of, ``I'm 
miserable and I want out of here. This is not because you are bad 
parents. Please forgive me.''
    The university was unable to help us, even when I had asked for it. 
Lea was a victim of rape while at college. She found no one who would 
help her. She held onto her shame and guilt, and it added to her 
problems. We were unaware of these events until much later.
    On her first attempt, she was hospitalized. When she came out of 
her coma, she was furious as she realized she was still alive. She 
refused treatment, and we had her involuntarily committed to a 
psychiatric hospital. Our insurance company funded a 72 hour stay. She 
was released into our custody while she was still at serious risk for 
self harm. Our insurance company would not help Lea to get the 
treatment she needed. Lea was willing to stay, and even requested this. 
They denied the benefits, and Judy and I had no financial means to 
enable this to happen on a private pay basis. Lea came home with us for 
a while, and then returned to school. She worked with a therapist, but 
did not improve or remain committed. Each time she was tested, she was 
not diagnosed as clinically depressed, and no meds were prescribed.
    Several months later, Lea attempted again. She got a hotel room and 
assembled the drugs and knives to use. Her college roommate and her 
sister got wind of her plan and traced her. The police came and agreed 
not to arrest her if she would voluntarily go to the hospital. She 
agreed.
    At the hospital in New Brunswick, she waited a long time to be 
seen, was given a cursory exam, and immediately released, while still 
hallucinating from the drugs she had already ingested. She called us 
and we arranged to bring her back with us to Louisiana.
    She came home and was increasingly erratic in her behavior. She had 
a violent rage episode and did some physical damaged to our home. She 
left abruptly, induced her younger sister to leave with her, and flew 
back to New Brunswick. She was operating on credit cards that were 
freely offered to her as a college student. Again, she was out of 
control, and neither our insurance company nor the resources of the 
university seemed to care.
    Finally she came home and slowly declined. We arranged for an 
outpatient treatment program. Lea was asked to leave the program 
because she was non compliant. Of course, her illness made her that 
way, but the program was unable to handle sick people. In the end, she 
went out and purchased a handgun and ammunition. Even though she had 
been hospitalized for psychiatric problems and had two previous suicide 
attempts, she had no impediment to purchasing a handgun. She ended her 
life alone and in desperation.
    When I consider all that could be done for young people like Lea, I 
am moved to reconsider her journey. We need well trained counselors 
available to young people all along their journey. We need teachers who 
have been trained to identify young people at risk and to work with 
parents. We need colleges to have resources in place for the shocking 
number of young people who suffer from depression, anxiety, and who are 
victims of date rape that goes unreported.
    We need not be afraid of the word suicide, nor should we think it 
is contagious. However, it should be noted that a suicide survivor, 
namely one who has lost a loved one to suicide, is nine times more 
likely to die from suicide than the general population. So people like 
me are an already identified risk group. So are siblings of young 
people. So are their classmates and friends. They need to talk about 
their experience, to revisit their trauma, and to feel safe in that 
sharing. Lea had friends who were and continue to be deeply affected by 
her death. They are among the many who can benefit from professional 
help.
    I am an ordained minister. In the congregation I served when Lea 
died, the leaders became so disturbed by her suicide that they asked 
for my resignation. Their basic statement was that if my child had died 
from suicide, my credentials to be their ordained leader had been 
invalidated. The fear and the pain were more than they could stand. 
They decided running away was better than facing the depth of the 
tragedy and growing from it. I sought the help of my bishop, who 
intervened and ruled in my favor. But the lesson is that people with 
good intentions can make things worse when they lack knowledge and 
information and training. Judy and I are now training clergy and lay 
youth leaders in my current diocese on youth suicide prevention skills. 
Survivors such as us have great credibility among those who are willing 
to learn.
    Lea's death would be even more tragic if we could not use its 
lessons to help others. We were not bad parents. She did not have bad 
teachers. Her therapists could have been more knowledgeable and pro 
active. But there is so much we do not understand. One of the best 
things we can do now is open the discussion and the dialogue. We can 
let young people know there are those who will understand and who want 
to help. We can underscore that they need not travel the path of 
despair and depression alone. We can help the general population know 
that suicide is like leukemia. It is a disease that needs compassion 
and treatment, not shame and guilt.
    If Lea could be here, she would say, ``Please stop and listen to 
me. I'm frightened of what is happening to me and I need for someone to 
know and understand. I don't want to die, but I need to know it won't 
be like this forever. Can you help me? Can you love me even though I 
think I want to die? Can you save me from this?"
    How I wish we could have heard her and responded better. How I wish 
she had found those compassionate and understanding voices when she was 
a little child, when she was a teenager, and when she was a college 
student. Maybe through your efforts others won't have to die like Lea. 
We lost not only our daughter, but all the future potential she held 
for a life filled with blessings and joy. Let's do all that we can to 
save our children. As our culture becomes increasingly complex and 
pressured, our children need more help than ever finding their way. 
Let's be part of that helping system, turning them from the darkness 
back toward the light of life. Thank you.

  Response to Questions of Senator Bingaman From Reverend Paul Tunkle

    Question 1. Access to treatment for mental illness is a serious 
problem in this country. Yet there is a reluctance to cover mental 
illnesses at the same level as physical illnesses. How important is 
health insurance parity between mental and physical illnesses in 
reducing the risk for suicidal behavior?
    Answer 1. My daughter could perhaps have been saved if her first 
suicide attempt and subsequent hospitalization were covered. We would 
never think of allowing someone at serious health risk to be released 
from the hospital after 72 hours. It would be seen as irresponsible and 
medically unethical. However, the risks and treatment priorities are 
just as great with mental illness.

    Question 2. The New Freedom Commission on Mental Health and the 
Surgeon General's 1999 Report on Mental Health both identified a 
national shortage of mental health professionals trained to treat 
mental illness in children and adolescents. How can we reduce this 
shortage?
    Answer 2. N/A

    Question 3. Adolescents with mood disorders, such as major 
depression and bipolar disorder, are at high risk for suicide. How 
effective are current treatments for early-onset mood disorders? How 
can we make evidence-based treatments available to more vulnerable 
young people?
    Answer 3. N/A

    Question 4. Substance abuse is also a high-risk factor for suicide. 
What programs are most effective in reducing adolescent substance 
abuse?
    Answer 4. N/A

    Question 5. Teenage suicides are always tragic, but there is a 
consistently high Native American adolescent suicide rate and a recent 
dramatic increase in the African American adolescent suicide rate. Do 
you recommend intense federally supported interventions to address the 
risk factors that result in these statistics?
    Answer 5. N/A

    Question 6. Schools serve as gatekeepers for the early 
identification and referral of young people with mental illness. How 
can we prepare schools to serve more effectively in this role?
    Answer 6. Counselors and teachers would need only modest training 
to be able to identify risk behavior. Once identified, testing and 
referrals would be the way to go. Teachers can see things which parents 
cannot.

    Question 7. Over 1,400 school-based health centers deliver primary 
preventive and early intervention services to more than a million 
children in 45 States. Mental health counseling is the leading reason 
for visits by students and the fastest growing component of school-
based health care. How can we expand the availability of such services?
    Answer 7. Funding and training incentives would enable people to 
move into these areas. If we are now increasingly aware on the health 
risks of obesity and inactivity, both of which are easily observable, 
let's be just as proactive in observing risk behavior in young people's 
mental health condition, and provide the means to address their need.

   Response to Questions of Senator Dodd From Reverend Paul D. Tunkle

    Question 1. Reverend, please let me begin by offering my sympathies 
on the loss of your daughter. I commend your dedication in testifying 
today and in your commitment in helping other youth suicide survivors. 
You mentioned how we cannot be afraid of the word suicide anymore. What 
recommendations can you make to the subcommittee as to how we can work 
to eradicate the stigma of fear associated with suicide?
    Answer 1. It could help if suicide was an illness that was the 
subject of study by students in the ordinary course of science and 
biology classes. The emphasis on illness is analogous to how we have 
progressed away from the fear factor associated with the word, 
``cancer.'' Also, from a linguistic perspective, I use the phrase, 
``died from suicide'' in the same way I would say, ``died from 
leukemia.'' To say, ``committed suicide'' implies an association with 
``committed murder, committed adultery, committed sin.'' Let's leave 
those associations behind us.
    The best antidote to fear is knowledge and discussion without 
judgment.

    Question 2. Reverend, you mentioned that Lea received little or no 
medical, psychological or emotional support from her school. What type 
of support services do you feel should be implemented at colleges and 
universities across this country?
    Answer 2. Colleges need to have the programs for their young people 
to access. However, many young people experiencing depression will not 
seek out help. It would be like asking someone having a heart attack to 
drive themselves to the hospital. Not many can. So I would hope that 
colleges would have methods to evaluate students based on grades and 
professor input. Teachers could also have the means to direct their 
comments and concerns to their dean, who could then in turn refer the 
matter to the counseling department. Lea would have been helped if her 
dean had been willing to recognize that her plummeting grades were a 
sign of a problem, called her in and requested that she work with the 
counseling services of the school. At the least, he could have asked 
her what was going on. Ignoring young people when they begin to 
experience failure can be catastrophic for those young people.

    Question 3. Reverend, I applaud the work you and your wife have 
done in the area of youth suicide postvention. It is rare for us to 
have a discussion on youth suicide. When we do, it is even rarer to 
have a discussion on youth suicide postvention. I feel we oftentimes 
tend to overlook the important needs of families and friends of 
children who have taken their own lives. I believe there should some 
parity between our prevention, early intervention and postvention 
efforts. With that said, how do you feel we can support suicide 
postvention services in this country? Do we need more? If so, where? Do 
we need to make survivors more aware of services that already exist?
    Answer 3. The best model for postvention services I know is the 
Baton Rouge Crisis Intervention Center in Louisiana. Dr. Frank Campbell 
is the director, and he is an excellent resource. He runs a weekly 
postvention support group attended by over 50 people. He also has 
developed the LOSS Team. This group works in conjunction with the 
Parish Coroner. When a suicide death is reported to the coroner, the 
LOSS Team is included in the first respondents on the scene, 
immediately working with the survivors and supporting them in their 
initial shock. From there they help them find their way to the support 
systems of the community. The coroner is a critical component in this 
program's success. Clergy, funeral homes and others can be primary 
referrals to postvention support services. However, the most important 
referral source is the primary care family physician. As soon as 
doctors become aware of the situation, they are best positioned to 
direct those in need to the community services. The American 
Association of Suicidology hopes to have a postvention group in every 
community. Judy and I are part of that network, both in Alexandria, 
Louisiana, and now in Baltimore. Neither community had these services 
before we initiated our groups.

    Question 4. Reverend, your testimony speaks clearly to the 
importance of the family in youth suicide prevention and early 
intervention initiatives. We know that families play a central role, if 
not the central role, in fostering resilience and self-worth in most of 
our young people. We also know that children and young adults can often 
take their lives for reasons that are not easily recognizable to their 
families. With that said, what tools do you feel families can use to 
recognize signs of suicide or the emotional and behavioral disorders 
related to suicide in their children?
    Answer 4. Every parent cares deeply about their children's welfare. 
However, there are some risks that are so fearful to a parent, that 
denial eclipses their better judgment. Schools can again play an 
important role here, offering programs and resources for parents to 
consider. Community education forums would help. In the church I serve, 
the parish is fully aware of Lea's death, and they access me as a 
source of help during times of stress and need with their adolescents. 
If a parent takes a child to the doctor because, ``something is 
wrong,'' I would hope the physician could direct that family to 
resources for counseling. The anti-depressant drugs are not enough. 
Talk therapy is essential to make the holistic kind of impact we seek. 
If the village takes on suicide as a challenge, I believe the village 
can make a huge difference for good.
           Question of Senator Reed for Reverend Paul Tunkle
    You mentioned your frustration in getting your health insurance 
company to cover hospitalization costs after your daughter attempted 
suicide.
    Question. What aspects of dealing with health insurance plans are 
most often cited as barriers to accessing appropriate mental health 
care?
    [Response was not available at print time.]

                  Prepared Statement of Cheryl A. King

    Good morning, Chairman DeWine, and members of the Subcommittee, and 
thank you for inviting me here today. The number of children and 
adolescents who commit suicide in our country is alarming, and I 
applaud you for taking the lead in addressing this tragedy with today's 
hearing.
    I am Dr. Cheryl King, a licensed clinical psychologist and 
Associate Professor of Psychology at the University of Michigan. I 
serve as Director of the Child and Adolescent Depression Program at the 
University of Michigan Depression Center and as Chief Psychologist in 
the Department of Psychiatry at the University of Michigan Medical 
School. I am also a Past President of the American Association of 
Suicidology, a national organization dedicated to understanding and 
preventing suicide, and serve on the Scientific Advisory Board of the 
American Foundation for Suicide Prevention. Over the past 15 years, my 
work has focused on both the clinical and research aspects of youth 
suicide.
    Regrettably, youth suicide is a continuing national tragedy. 
According to the Centers for Disease Control and Prevention (CDC), 
suicide is the third leading cause of death among children and 
adolescents. In 2000, 1,921 young people between the ages of 10 and 19 
ended their lives. More teenagers and young adults die from suicide 
than from cancer, heart disease, AIDS, birth defects, stroke, 
pneumonia, influenza, and chronic disease, combined.
    A series of highly visible legislative, public policy, advocacy, 
and organizational events have created a historic juncture for suicide 
prevention efforts. These were catalyzed in 1999 when The Surgeon 
General's Call to Action to Prevent Suicide stressed the need for 
effective suicide prevention and intervention strategies.
    In 2002, the Institute of Medicine underscored suicide prevention 
as a significant public health problem with the publication, Reducing 
Suicide: A National Imperative. The report urged the implementation and 
enhancement of the National Strategy for Suicide Prevention, which lays 
out a suicide prevention framework for action and guides development of 
an array of services and programs.
    The report of the President's New Freedom Commission on Mental 
Health released last year stressed the urgent need for action on 
suicide prevention. The Commission encourages public education efforts 
to be targeted to distinct and often neglected populations, such as 
ethnic and racial minorities and adolescents.

                       METHODS OF SUICIDAL DEATHS

    Firearms are the most common method of suicide among adolescents in 
the United States. In one study, firearms were present in the homes of 
74.1 percent of completers and 33.9 percent of suicidal inpatients. 
Several more recent control studies also demonstrate a strong link 
between completed suicide and the availability of firearms in the home.
    In 1996, firearms were used by 66.4 percent of male suicide victims 
and by 48.3 percent of female victims (aged 15 to 19). After firearms, 
the most common methods for adolescent males were hanging (including 
instances of strangulation and suffocation, 22.7 percent), gas 
poisoning (3.4 percent), and poisoning that involved solid or liquid 
substances (2.3 percent). Methods of suicides for female victims 
included hanging (29.3 percent), solid or liquid poisoning (12.1 
percent), jumping from heights (3.1 percent), and gas poisoning (2.5 
percent).

             SUICIDE RATES ACROSS GENDER AND RACE/ETHNICITY

    The suicide rate for youth ages 15 to 19 is 8.2 per 100,000, and 
the rate for youth between the ages of 10 and 14 is 1.5 per 100,000. 
The suicide rate for males in the 15- to 19-year age group is markedly 
higher than that for females. From 1980 to 1997, 83.8 percent of all 
suicides among this age group were committed by males.
    There is a gender difference in completed suicides, although it is 
the reverse of what is seen with ideation and attempts. Approximately 4 
to 10 percent of boys versus 10 to 20 percent of girls report a history 
of suicide attempt. Thus, two to three times as many girls as boys 
report having made at least one suicide attempt. At no other time in 
the human life span is the prevalence of suicide attempts as high as 
that documented during adolescence.
    Suicide rates also differ by racial and ethnic group. American 
Indian/Alaska Native adolescents are more than twice as likely to 
commit suicide as any other racial/ethnic group. With 52.9 deaths per 
100,000, adolescent American Indian/Alaska Native males are at four 
times the risk for suicide than are males of any other racial/ethnic 
group. Among high school students, 10.7 percent of all Hispanics and 
14.9 percent of Hispanic females reported attempting suicide in the 
past 12 months. In addition, 30.3 percent of Hispanic female high 
school students reported seriously considering suicide, the highest 
rate of any racial or ethnic group in the country. This compares to 
26.1 percent of Caucasian females and 22 percent of African American 
females.
    During 1981 to 1998, the suicide rate for African American youths 
aged 10 to 19 years increased from 2.9 to 6.1 per 100,000. As of 1995, 
suicide was the third leading cause of death among blacks aged 15 to 
19. However, African American youth have lower suicide rates than 
Caucasian youth, and African American females have the lowest 
adolescent suicide rate.

                     SUICIDAL IDEATION AMONG YOUTH

    It is not uncommon for adolescents to think about suicide. The 1999 
Youth Risk Behavior Surveillance (YRBS, 2000) found that, in the 
previous year, 19.3 percent of high school students nationwide had 
seriously considered attempting suicide, and 14.5 percent had made a 
specific plan to attempt suicide. Every year, 2 million children and 
adolescents attempt suicide, and two-thirds of them are females. Among 
high school students in 1997, 27.1 percent of females seriously 
considered suicide, compared to 15.1 percent of males.
    Suicide ideation includes a broad continuum of suicidal thoughts, 
ranging from thoughts that others (such as parents) might be better off 
if the adolescent were dead to the careful consideration of a specific 
plan for completing suicide. Such thoughts may be expressed 
behaviorally, either in writing or in speech. Suicidal actions include 
the broad domain of self-injurious behavior with some degree of 
suicidal intent. One of the most striking aspects of adolescent 
suicidal behavior is the high prevalence rate for non-lethal suicide 
attempts.
    The 1999 Youth Risk Behavior Surveillance data showed that suicidal 
thoughts tended to peak in the 10th grade. Twenty-two percent of 10th 
graders had seriously considered suicide in the previous 12 months, and 
17.7 percent had made suicide plans.
    Although many youth who report suicidal thoughts or attempt suicide 
do not become suicide victims, these categories overlap substantially. 
For instance, having frequent thoughts of suicide is the best predictor 
of suicide attempts, and many youth who attempt suicide report a 
history of suicidal ideation. Furthermore, greater severity of reported 
suicidal thoughts increases the likelihood of a suicide attempt within 
the next year. Approximately 35 to 45 percent of adolescents who 
complete suicide have a history of suicide attempt.
    And while research tools and opportunities currently exist to 
address the problem of suicide, there continues to be a dramatic 
mismatch in terms of federal dollars devoted to the understanding and 
prevention of suicide contrasted with other diseases of less public 
health impact.

                   RISK FACTORS FOR SUICIDAL BEHAVIOR

    Risk factors for completed suicide and suicidal behavior are 
similar in most respects. There are a few exceptions, however, such as 
the more specific relationship between availability of firearms and 
completed suicide.
    Prior Suicide Attempt. A history of prior suicidal behavior is the 
strongest predictor of future suicidal gestures or self-inflicted harm. 
While these acts are sometimes thought to be manipulative or attention-
seeking, they should not be taken lightly. Youth can be poor judges of 
lethality, and what is believed to be a gesture may be accompanied by 
significant suicidal intent. It also may result in substantial physical 
harm or even suicide because of an error in knowledge or judgment.
    Mental Disorder. Approximately 90 percent of youth suicide victims 
have histories of identifiable mental disorders. The most common types 
are depressive disorders, alcohol or substance abuse, conduct disorder 
or patterns of aggressive behavior, and anxiety disorders. Depressive 
disorders are linked with increased risk for suicide ideation, suicide 
attempts, and completed suicides. Eighty percent of depressed youth 
report significant suicidal ideation, and 32 percent of depressed youth 
report one or more suicide attempts prior to adulthood.
    Substance Abuse. Research demonstrates a clear connection between 
increased severity of suicidal behavior and the presence of alcohol 
abuse and major depression among adolescent inpatients. Retrospective 
studies have found that between 25 and 50 percent of adolescent 
suicides involve the consumption of alcohol, which increases 
impulsivity, impaired judgment, and mood changes. Research also 
documents a threefold increase in suicide attempts among depressed 
youths with comorbid conduct and/or substance use disorders.
    Psychosocial Factors. Environmental or family stress, especially a 
history of neglect or physical, emotional, or sexual abuse, are 
considered significant risk factors for suicidal behavior. 
Interpersonal conflict and loss (i.e., break-ups, deaths) also are risk 
factors. Additionally, hopelessness, impulsivity, aggressive behavior, 
and agitation are psychological characteristics associated with 
increased risk for suicidal behavior.
    Gay, lesbian, and bisexual adolescents are at increased risk for 
suicidal behavior. Recent general population surveys indicate that 
approximately 42 percent of these youth experience suicidal ideation, 
and 28 percent have made one or more suicide attempts during the past 
year. Many of the risk factors in these youth are the same as those for 
heterosexual youth. Problems such as comorbid substance abuse and 
depression, however, are more common among youth who have a homosexual 
orientation. In addition, risk factors such as stigmatization and 
discrimination are specific to those who face negative attitudes within 
society.
    An examination of acculturation issues among immigrants deserves 
our attention. Research suggests that some acculturating Hispanic 
adolescents experience high levels of acculturative stress. These 
adolescents are also at risk for experiencing critical levels of 
depression and suicidal ideation. In fact, a study revealed that 
approximately one quarter of the Hispanic American adolescents 
experienced critical levels of suicidal ideation. The study highlights 
the importance of assessing and treating the depressed and potentially 
suicidal acculturating adolescent within a cultural context. Since the 
Hispanic culture is not entirely homogenous, further research should 
examine variables within more specific Latino subgroups.
    Contagion. Researchers have found that cluster suicides are more 
likely to occur among adolescents and young adults than among 
individuals in other age groups. Approximately 5% of adolescent 
suicides in the United States are cluster-related. When a youth suicide 
occurs, intervention aimed at promoting grief and mourning and 
decreasing guilt, trauma, and social isolation, as well as providing 
psychoeducation aimed at decreasing identification with the suicidal 
behavior, are recommended. Media coverage of suicide may spark suicide 
contagion.
    Availability of the Means. The importance of restricting suicidal 
youth's access to firearms is highlighted by documented associations 
between more restrictive gun control laws and decreases in suicide 
rates. Similarly, potentially lethal drugs (such as prescription or 
over-the-counter sedative drugs) either should be removed from the 
homes of potentially suicidal youth or monitored closely by parents and 
guardians.

                         PATHWAYS TO PREVENTION

    Much still needs to be done to prevent youth suicide. Few 
randomized controlled intervention trials have been conducted with 
suicidal youth, evaluated interventions have shown limited impact on 
suicidal ideation and behavior, and suicidal adolescents' adherence 
with treatment recommendations has generally been poor. We need to 
develop effective strategies to intervene with youth who have reported 
thoughts of suicide or who come to our attention following a suicide 
attempt.
    Effective suicide prevention strategies, however, need not be 
specific to suicide, and, they need not be implemented only in close 
temporal proximity to imminent suicide risk. A comprehensive, strategic 
plan for suicide prevention should include multiple points for 
prevention, maximizing the likelihood of reaching people in need. For 
instance, preventing the onset of some types of disorders may be 
feasible. Alcohol and substance abuse is an example of one such risk 
factor that has been related to a significant portion of suicides 
across the life span. Furthermore, the early recognition of depressive 
disorders, with referral for appropriate treatments, may be an 
effective suicide prevention strategy.
    A goal of suicide prevention strategies is to alter developmental 
trajectories, moving individuals onto healthier pathways fraught with 
less suicide risk. The less specific and proximal these strategies are, 
the more likely it is that a successful prevention effort will require 
the efforts of prevention specialists and advocates in diverse fields. 
These might include violence prevention (firearm availability), general 
mental health (access to services), and prevention of hazardous 
drinking (alcohol/substance abuse education programs). The list of 
possible collaborators for prevention efforts is lengthy. Many of the 
prevention strategies that would feasibly result from unified efforts 
would include societal, public policy, and educational efforts.
    ``Universal'' preventive interventions directed at the entire 
population, including health promotion and educational efforts, would 
be examples of efforts to prevent the onset of a risk factor. These 
might include educational public service announcements, restrictions on 
advertising for alcoholic beverages, school-based health classes 
emphasizing mental health and substance abuse problems or health 
promotion activities. ``Selective'' interventions, directed at 
subgroups with some increased level of risk, might include school-based 
mental health programs for identified ``high risk'' children. School-
based prevention programs are critical in helping children at risk for 
suicide. Because the school is the community institution that has the 
primary responsibility for the education and socialization of youth, 
the school context has the potential to moderate the occurrence of risk 
behaviors and to identify and secure help for at-risk children.
    The Centers for Disease Control and Prevention has demonstrated 
great commitment to reduce youth suicide rates through an array of 
initiatives. These include the expansion of a state public health youth 
suicide prevention program; funding an evaluation of telephone crisis 
services for adolescents; and funding a program to provide information 
on the prevalence of Internet use by teenagers in their attempt to seek 
help for emotional problems.
    The National Institute of Mental Health continues to develop and 
test various interventions to prevent suicide in children and 
adolescents through early diagnosis and treatment of depression and 
other mental disorders and is working to find effective methods to 
evaluate suicidal thinking and behaviors.
    The Center for Mental Health Services of the Substance Abuse and 
Mental Health Services Administration continues to provide critically 
needed mental health promotion and youth suicide prevention services 
primarily through its Children's Mental Health Services Program, 
Community Mental Health Block Grants, Children's State Incentive 
Grants, School-Based Violence Prevention Program, and National Child 
Traumatic Stress Initiative.
    Taking a developmental perspective on the problem of youth suicide, 
it is evident that we must consider multiple pathways to prevention, 
place renewed emphasis on prevention strategies that have their impact 
earlier in the life course or earlier in the course of mental disorder, 
and collaborate more effectively with colleagues and advocates in other 
prevention fields. Meeting our suicide prevention objectives will 
require the unified effort of prevention specialists and advocates in 
the broader mental health, substance abuse prevention, and health 
promotion fields.
    The development and implementation of an overarching strategic plan 
for suicide prevention, including a lifespan continuum of accessible 
prevention options, can be achieved with the shared vision, commitment 
and resources of disciplines and government working with individuals 
and communities.
    Thank you, again, for the opportunity to present this testimony. I 
would be pleased to answer any questions.

       Response to Questions of Senator Dodd From Cheryl A. King

    Question 1. Doctor, I commend your dedication and work in the 
clinical aspects of youth suicide prevention, and I thank you for 
joining us this morning. In your testimony, you speak to the need for a 
``comprehensive, strategic plan for suicide prevention that should 
include multiple points for prevention''--points that include mental 
health promotion, substance abuse prevention, educational initiatives, 
law enforcement initiatives, violence prevention, and childhood 
development. With that said, how can we, as lawmakers, support these 
plans? What do you feel are the resources that States and localities 
need to foster them?
    Answer 1. There are a variety of ways in which lawmakers could 
support the development and implementation of youth suicide prevention 
strategies in States and localities. The bill that you introduced this 
week to support the planning, implementation, and evaluation of 
organized activities involving statewide youth suicide early 
intervention and prevention strategies, bill S. 2175 (108), is a 
tremendous step forward in this direction. You and the cosponsors, 
Senators DeWine, Reid, and Smith, are highly commended for this action.
    Block grants are another possible mechanism. This strategy could 
involve block grants administered through the Department of Education 
(alcohol and drug abuse prevention programs), the Department of Health 
and Human Services (Maternal and Child Health Bureau, Health Resources 
Services Administration, Substance Abuse and Mental Health Services 
Administration), the Department of Justice (Office of Juvenile Justice 
and Detention Programs); or ideally, through a grant program that 
requires collaboration between these agencies at the State and 
community level. Funds could be earmarked for separate youth suicide 
prevention programs or for the integration of youth suicide prevention 
strategies into existing programs and services provided through these 
agencies.
    Suicide prevention programs include those that reduce risk factors 
associated with suicide and those that strengthen protective factors. 
Furthermore, research suggests that programs designed to reduce youth 
suicide risk factors (e.g., depression, bipolar disorder, alcohol/
substance abuse, physical abuse, sexual abuse, school drop-out, and 
family history of suicide) are indicated, as are programs designed to 
strengthen protective factors such as social support, meaningful 
connections with school and adults, and certain life skills. There are 
multiple targets in our efforts to reduce the toll of suicide among 
adolescents.
    Several specific recommendations for ways in which lawmakers can 
support a comprehensive plan for suicide prevention are described 
below:
    (1) A primary recommendation of the President's New Freedom 
Commission for Mental Health is to implement the National Strategy for 
Suicide Prevention (NSSP). One of the recommendations included in the 
NSSP is screening for suicide risk factors in alcohol and other drug 
abuse treatment centers. Research data consistently and overwhelmingly 
point to the heightened suicide risk among those with co-occurring 
alcohol use and mood disorders. Funds could be earmarked for such 
indicated screening.
    (2) Because it has been established that parental psychopathology 
(depression, substance abuse) and a family history of suicide are 
associated with suicidal ideation, suicide attempts, and completed 
suicide in youth, tailored services for parents and families are 
indicated. Funds administered through MCHB, or separately targeted 
funds, could provide the resources needed to screen for and intervene 
in cases of maternal depression and substance abuse. Furthermore, such 
resources could provide for critical postvention services when a 
suicide occurs within a family. Other agencies support child abuse 
prevention programs and domestic violence prevention programs, which 
are also associated with suicide risk.
    (3) Support of a Senate companion bill to H.R. 3593, introduced by 
Congressmen Davis of Illinois and Osborne of Nebraska, is highly 
recommended. This bill proposes to amend the Higher Education Act by 
providing funding to increase access to mental and behavioral health 
services on college campuses. This is extremely critical as more 
students with serious suicide risk factors are attending colleges and 
universities, and fewer of these students have access to mental health 
services in the college community. This absence of services is 
especially tragic during an age span when depression onset is common, 
hazardous drinking is pervasive, and the suicide rate is known to 
increase to an even higher level than exists during adolescence.
    (4) Incentives are recommended for ecological changes on college 
campuses to reduce suicide risk among students. Residence hall staff 
should be trained to recognize signs of risk among students and 
intervene with appropriate support and referrals to campus services. 
Academic policies should provide reasonable support to students who 
need medical leaves for mental illnesses. Campus policies should ensure 
that parents are involved in the support and care of students with 
mental illness whenever clinicians judge this could improve the 
clinical outcome, and that students who demonstrate signs of risk for 
suicide receive comprehensive clinical evaluations.
    (5) The Administrative Branch should appoint an official in one of 
the Departments (probably DHHS) as coordinator of suicide prevention 
initiatives across all Departments who have a stake in the outcome. 
Following The Surgeon General's Call to Action to Prevent Suicide in 
1999, such a Federal Steering Group on Suicide Prevention was 
established but it currently has no mandate. It is recommended that 
such a Federal Steering Group be empowered to coordinate and track 
federally sponsored suicide prevention activities. In keeping with a 
recommendation from the National Strategy for Suicide Prevention, the 
official appointed as coordinator of suicide prevention initiatives 
should inaugurate a public-private partnership to advance 
implementation of the National Strategy. This partnership could make 
funds available for suicide prevention activities, including 
demonstration projects for new initiatives.
    (6) It is recommended that funds be provided to SAMHSA for ongoing 
support of the National Suicide Prevention Technical Resource Center. 
This will enable us to assist each State in developing a suicide 
prevention plan. The Center provides technical assistance and 
consultation, and can assist States in establishing a ``point of 
coordination'' for information about evidence-based suicide prevention 
services within each region or community. It would also be available to 
the public-private partnership (mentioned in #5) as a ``go to'' agency 
for information, data analyses, and technical assistance.
    (7) Health insurance parity between mental and physical illnesses 
is an essential component of a comprehensive effort to reduce youth 
suicide. In the State of Michigan, we are currently working on a 
statewide suicide prevention plan. At planning meetings and open forums 
attended by school personnel, health department personnel, mental 
health professionals, and family survivors of suicide, the most 
commonly raised concern is the absence of resources for many who are 
suicidal and cannot afford adequate treatment.

    Question 2. Doctor, in your testimony you speak of the different 
suicide rates between gender, race and ethnicity groups. Has there been 
research conducted that sheds light on why these differences exist? Are 
there certain social factors at play that might cause children and 
young adults of a certain gender or ethnicity to be more prone to 
suicide?
    Answer 2. Primary risk factors for suicide among adolescents are 
mental or psychiatric disorders along with alcohol and substance use or 
a pattern of hazardous drinking (i.e., binge drinking). The combination 
of a mood disorder (e.g., major depressive disorder, bipolar disorder) 
and substance abuse creates a 50-fold increased risk for completed 
suicide. In fact, research indicates that significant numbers of youth 
suicides occur under the influence of alcohol. Research also indicates 
that problems tend to be interrelated among adolescents. Hazardous 
alcohol use by adolescents is related to suicide as well as to drunk 
driving, physical fights, violent crimes, risky sexual behavior, and 
school performance problems. Thus, population groups with higher than 
average rates of alcohol use and alcohol-related problems (e.g., 
American Indians, Alaskan Natives; males) can be expected to have 
higher than average suicide rates. In addition, groups such as American 
Indians have less access to good health and mental health care.
    Youth who are poorly connected or disconnected from major societal 
support systems (family, school, work) seem to be at high risk for 
suicide if other suicide risk factors are also present. This suggests 
that youth who live in communities with lower rates of social 
connectedness, higher rates of school drop-out, and high rates of 
joblessness (e.g., Native American adolescents) may be at increased 
risk for suicide. For instance, research indicates that suicides often 
take place after a period of absence from school or after dropping out 
of high school or not attending college. Although this withdrawal may 
also relate to a struggle with depression, one study reported that 
school drop-outs were many times more likely than other young people to 
attempt suicide, even after adjusting for other diagnostic and social 
risk factors. Conversely, increased connectedness to major societal 
support systems is a protective factor against suicide. An excellent 
example of this is African American females who have particularly low 
suicide rates relative to other groups nationwide. This low prevalence 
rate is believed to partially reflect the strong sense of community 
among African American females, a group whose support system generally 
includes an extended family of females and involvement in a supportive 
religious community.
    Adolescent girls may be more prone to suicide attempts than 
adolescent boys due to their elevated rate of depression. There is, 
however, no gender difference in the prevalence of medically serious 
attempts, and the prevalence of completed suicide is actually 5-6 times 
higher in boys than in girls. This much higher rate of completed 
suicide among boys is thought to be due to both differences in 
psychopathology and differences in method preferences. In terms of 
psychopathology, suicide is often associated with aggression, 
impulsivity, and alcohol abuse. These problems are each more common in 
males. In terms of method choice, girls tend to favor overdoses. These 
overdoses tend to be less lethal than the methods commonly used by 
boys, which include firearms and hanging. They may be less lethal 
because we have better emergency responses and treatment for overdoses 
than we have for other potentially lethal means for suicide.

    Question 3. Doctor, you mention that there are currently many 
underfunded research tools and opportunities available to address the 
problem of youth suicide. If these tools and opportunities were given 
more support, how could they help us better understand this tragedy? 
How could they further help our prevention initiatives?
    Answer 3. Research is our primary means of developing both (1) a 
comprehensive understanding of youth suicide, and (2) effective 
evidence-based suicide prevention strategies that can be feasibly 
implemented within States and localities.
    Government-sponsored surveillance of suicide risk factors and 
completed suicide among youths and college students is indicated. We 
hear regularly about our nation's economic indicators, yet have little 
information available concerning the well-being of our youth. In fact, 
we know much more about suicide risk factors than we do about the 
prevalence of these risk factors in our nation's youth and college 
students. Several specific recommendations can be made in this area.
    (1) Repeat the College Health Risk Behavior Survey, which was most 
recently conducted in 1995 by the Centers for Disease Control.
    (2) Enhance the Youth Risk Behavior Survey, which is conducted 
every 2 years by the Centers for Disease Control. This survey could be 
improved with additional, more refined questions related to youth 
suicide risk.
    (3) Include measurement of suicide risk factors in federally 
sponsored longitudinal studies of youth. These studies may have a 
primary focus on any of a wide range of outcomes (e.g., delinquency, 
nutritional status, sexually transmitted diseases, homelessness, drug 
use). Inclusion of suicide-related risk and outcomes would provide 
substantial information about the course of suicide risk factors, their 
relations to other indicators of well-being, and developmental pathways 
to suicide. The importance of learning how protective factors can be 
strengthened to mitigate the effects of suicide risk factors could be 
emphasized.
    Establishment of suicide prevention research centers is also 
recommended. Such centers of excellence would enable us to develop more 
sensitive assessment tools for suicide risk, identify how protective 
factors can mitigate suicide risk, and develop evidence-based 
prevention programs and treatments for suicidal youth. They would be a 
national resource for the rapid dissemination of measurement advances 
and evidence-based suicide prevention programs. In parallel with this, 
earmarked research funds are recommended for the efforts of researchers 
to evaluate statewide strategies and policies, and clinical 
interventions for suicidal youth. Incentives to conduct research in the 
area of youth suicide are strongly recommended because of the unique 
difficulties and challenges inherent in conducting research with a high 
risk and vulnerable population.

                  Prepared Statement of Joelle Reizes

    Mr. Chairman and Members of the Committee, I am pleased to be here 
today to discuss a critically important public health issue--teen 
suicide. I am the Director of External Relations for Screening for 
Mental Health, a nonprofit organization based in Wellesley Hills, MA. I 
operate a satellite office in Loveland, OH.
    Screening for Mental Health's mission is to promote mental health 
screening as an integral part of overall healthcare. Our teen suicide 
program is called the SOS High School Suicide Prevention Program. 
According to the National Center for Health Statistics, suicide is the 
third leading cause of death for the 15-24 year age group. Indeed, one 
in eight adolescents between the ages 15-19 will suffer from major 
depression in any given year.
    By way of introduction, I want to pass along a story that was 
related to me just last month by a school counselor from Cape Cod, 
Massachusetts. She ran the SOS program in her school last year. As a 
result, a young man recognized his own symptoms and came to the 
guidance counselor for help. The guidance counselor contacted his 
parents, and together, they got him the therapy he needed. A year 
later, he is doing very well and succeeding in school.
    But, 2 weeks ago, this same young man went to class, sat down in 
his chair, and noticed that the student who had been sitting there 
before him had written on the desk, ``I feel terrible and want to kill 
myself.'' Because he had been through the SOS program, this student 
knew to take this note seriously. He also knew who to go to for help. 
He alerted the school counselor who was able to work with the teacher's 
seating charts to identify the student in need. It turns out this young 
person was actively suicidal. The counselor contacted the parents and 
got the student into the local hospital to be evaluated that same day. 
This potentially life-saving intervention resulted from increased 
awareness achieved through the SOS program.
    SOS provides a mental health checkup, via depression screening. It 
also provides the education teens need to recognize depressive symptoms 
in themselves or others and the power to act when they see these 
symptoms. This means that even if a student is not depressed or 
suicidal at the time of the screening, he or she will know how to 
recognize the symptoms and what to do to get help if it ever does 
develop in the future.
    The main teaching components of SOS are the depression screening 
questionnaire and an educational video with discussion guide. The 
video, entitled Friends for Life, features dramatized vignettes that 
model the wrong and the right ways to react to a friend exhibiting 
suicidal signs. The program helps teens to understand the important 
connection between suicide and undiagnosed, untreated mental illness--
which typically involves depression. It strives to increase help-
seeking behaviors in teens by teaching them to ACT--Acknowledge, Care 
and Tell. Acknowledge that what you are seeing are signs of suicide and 
are serious, C--Tell the person you Care about them and want to help, 
and T--Tell a trusted adult.
    Schools that want to participate in the SOS program register with 
the Screening for Mental Health office. Screening for Mental Health 
then sends each school a huge box of materials, which we call a 
screening kit. This kit contains everything the school needs to 
implement the program, including procedure and training materials for 
school personnel, depression screening forms, the Friends for Life 
video, posters, and a variety of educational brochures--enough 
materials for 500 students. School health professionals and local 
clinicians implement the program, creating a team and setting up 
referral procedures based on local resources.
    Most schools learn about the program through one of several 
professional associations. SOS enjoys the support of the National 
Association of School Psychologists, the American School Counselors 
Association, the National Association of Secondary School Principals 
and many other school-based and mental health organizations. Members of 
these organizations serve on our Advisory Board and in fact, were 
instrumental in the development of the program from its very beginning. 
This is one of the reasons the SOS program is successful--because 
before we created any materials, we involved these groups and asked 
them what they wanted in a suicide prevention program. SOS was designed 
with the input of the very same school nurses, counselors, and school 
psychologists who actually do the work with the students in the schools 
every day.
    A landmark study conducted by, Dr. Robert Aseltine of the 
University of Connecticut Health Center, will be released tomorrow, in 
the American Journal of Public Health. This was a randomized controlled 
study with 2100 students from five high schools that revealed a 40 
percent decrease in suicidal behavior in those exposed to our program. 
This Nation has an over 20 year history with school-based suicide 
prevention programs and yet this is the first time anyone has ever seen 
such a result. This groundbreaking data is part of the reason why the 
SOS program is the only suicide prevention program currently listed on 
SAMHSA's National Registry of Effective Programs.
    SOS is also cost-effective. Our current per child cost is only one 
dollar.
    We hope to grow the SOS program with federal support so we can 
provide the program to as many schools as want it. The program is cost-
effective, flexible, easily reproduced in a variety of school settings, 
and the only program to have evidence of its ability to reduce suicidal 
behavior. We believe it is an important program option for schools 
looking to do suicide prevention programming--but most importantly, we 
believe that our children are worth the investment.
    Thank you very much for your time and attention today, and I'd be 
happy to answer any questions you might have for me.
                                 ______
                                 
                      Screeening For Mental Health,
                                 Wellesley Hills, MA 02481,
                                                    March 12, 2004.
Hon. Mike DeWine,
Chairman,
Subcommittee on Substance Abuse and Mental Health Services,
Washington, DC 20510.
Hon. Edward Kennedy,
Ranking Member,
Subcommittee on Substance Abuse and Mental Health Services,
Washington, DC 20510.

    Dear Mr. Chairman and Ranking Member: I am honored to provide the 
subcommittee with additional information. The responses to the 
questions posed are reflective of my individual opinions along with the 
expertise of Douglas G. Jacobs, MD, Executive Director of Screening for 
Mental Health and Associate Clinical Professor of Psychiatry at Harvard 
Medical School as well as Robert Aseltine, Ph.D., Associate Professor, 
Department of Behavioral Sciences and Community Health, University of 
Connecticut Health Center. Dr. Aseltine is the lead researcher on our 
recently published evaluation paper in the American Journal of Public 
Health. Dr. Jacobs is the Editor of the ``Harvard Medical School Guide 
to Suicide Assessment and Intervention'' and the Chairman of the 
American Psychiatric Association Workgroup that recently created the 
APA's first Practice Guideline for the Assessment and Treatment of 
Patients with Suicidal Behaviors.
    I was truly pleased to be able to participate in the hearing on 
Suicide and Youth and appreciate the subcommittee's interest in this 
important public health topic. If you require anything else, please do 
not hesitate to contact me.
                                                 Sincerely,
                                                  Joelle M. Reizes,
                                                          Director,
                    External Relations Screening for Mental Health.
                                 ______
                                 
        Response to Questions of Senator Dodd From Joelle Reizes

    Question 1. Thank you very much for joining us this morning. In 
your testimony, you say that the main teaching components of the SOS 
Program are a depression screening questionnaire, an educational video, 
and a discussion guide. How are these materials conceptualized? How do 
they interact with one another?
    Answer 1. The program is designed to provide a mental health check-
up (paper and pencil screening form) for every student as well as an 
educational program that informs students about the symptoms of 
depression and suicide, their relationship, and the importance of 
treatment (video and discussion guide). Thus, students can assess their 
own symptoms at the time of the program, but are also empowered to 
identify the symptoms of depression and suicidality in themselves and a 
friend whenever they occur and know how to access help. As you may 
know, depression is an episodic event. This means that a student may 
not have depression at the time of the screening but may develop it 6 
months later. Thus, screening alone is not the answer. Education must 
be a part of the program so that students will know what to do, how to 
identify depression and suicide and how to access help if the symptoms 
develop in themselves or a friend later.
    The two-part program is usually implemented during one classroom 
period by existing school personnel. Most schools provide the program 
to all students the first year, and then simply to the next incoming 
class (e.g. 7th, 8th or 9th graders and transfer students).
    SOS also provides educational material for students as well as for 
school staff, and parents. There is a version of the screening form 
that can be sent home to parents so that they can ``take'' the 
screening for their children. It helps parents assess their child's 
attitudes and behaviors, and identify possible depression or 
suicidality. The most important aspect of the parental screening form 
may be that it helps parents open up a dialogue about these issues with 
their children.

    Question 2. I was pleased to hear that the University of 
Connecticut School of Medicine conducted an evaluation of the SOS 
Program. I was also pleased to learn that the Hartford Public Schools--
an urban school system in my State with a great need for adequate 
mental health services--participated in the evaluation. When designing 
the SOS Program, how do you develop the materials so that they can 
reach children and young adults from all different geographic, racial, 
ethnic, and socioeconomic backgrounds?
    Answer 2. We developed the materials with the hope that they would 
be user friendly to teens from diverse backgrounds by utilizing the 
expertise of school-based professionals on our Advisory Board. The 
vignettes address different issues that relate to a variety of people 
from different backgrounds and the people in the videos discussing 
their individual experiences with suicide and depression come from a 
variety of racial backgrounds. The program has been used and is well-
received by schools in urban, suburban and rural communities.
    Based on the results of our evaluation to date, we are confident 
that our program addresses the needs of children from disadvantaged 
minority backgrounds as well as middle-class white teens. Our 
preliminary work from last year where we expanded this program into 
suburban areas, suggests that this program is equally effective in 
urban and suburban areas. The suicide reduction we saw in the 
evaluation study was independent of race. Please note that the SOS 
program provides Spanish language materials as well as English language 
materials.
    Clarification: Officially, Dr. Aseltine's affiliation is not with 
the School of Medicine. The University of Connecticut Health Center 
holds the School of Medicine and School of Dental Medicine. The 
Department of Behavioral Sciences and Community Health, with which Dr. 
Aseltine is affiliated, is within the Dental School due to longstanding 
historical reasons. However, Dr. Aseltine's specialty is in depression 
and mental health.

       Responses to Questions of Senator Reed From Joelle Reizes

    Question. The New Freedom Commission on Mental Health and the 
Surgeon General's 1999 report on Mental Health both identified a 
national shortage of mental health professionals trained to treat 
mental illness among our youth. Would you agree that the shortage of 
professionals in your community is a barrier to treatment? What has 
been the experience in your community?
    Answer. The shortage of trained mental health professionals is an 
important national issue. Of particular import to teen suicide 
prevention is the shortage of child and adolescent psychiatrists. Many 
communities that would like to conduct suicide prevention and other 
mental health campaigns such as the SOS program or National Depression 
Screening Day hesitate to do so because they do not know who will treat 
the individuals identified by a screening. We refer the subcommittee to 
the American Academy of Child and Adolescent Psychiatry's document 
``AACAP Work Force Data Sheet'' available at http://www.aacap.org/
training/workforce.htm for a summary of this critical public health 
issue. While we recognize that this shortage can be a barrier to 
treatment, a shortage of providers does not reduce the need for 
screening or treatment. Rather, it calls for increased training of 
mental health professionals in this important area.
    Most schools that use the SOS program feel that, even in the face 
of clinician shortages, it is still important to identify young people 
at risk for depression and suicide and work with the students and their 
families. The school professionals can triage those who need emergency 
services while providing alternate counseling to those who have been 
reached at an early enough stage until resources are available.
    We feel that it is important for all mental health professionals to 
be adequately trained in suicide assessment and intervention, with 
information that is most current and based on the best possible science 
and clinical training. The American Psychiatric Association recently 
published a Practice Guideline for the Assessment and Treatment of 
Patients with Suicidal Behaviors. The guideline is intended to help 
reduce individual patient's suicide risk by giving psychiatrists tools 
to assess for risk and formulate treatment strategies. The new 
guideline provides recommendations for assessment and treatment 
interventions based on evidence from research literature and clinical 
consensus. It should be noted that this guideline is designed primarily 
to address practices as they pertain to adult patients, ages 18 and 
over, and are appropriate for our discussions around college mental 
health practices rather than adolescent. There are practice parameters 
for patients under 18, developed by the American Academy of Child and 
Adolescent Psychiatry, www.aacap.org.
    The development process for the new American Psychiatric 
Association guideline required more than 2 years and included review of 
over 34,000 articles from the scientific literature published since the 
1960s. With oversight from APA's Steering Committee on Practice 
Guidelines, early drafts of the guideline were reviewed by more than 
100 experts and APA members, eight professional organizations, and 
numerous APA components. A final draft was reviewed and approved by the 
APA Assembly and Board of Trustees. The guideline has been published as 
a supplement to the November issue of the American Journal of 
Psychiatry and is available on the APA website at http://www.psych.org/
psych_pract/treatg/pg/prac_guide.cfm.
    Screening for Mental Health is currently working to distribute this 
guideline to psychiatric residents across the Nation. It is intended by 
the APA that this guideline will help provide needed training to mental 
health professionals in the treatment of suicidal patients and thereby 
help reduce the barriers to treatment.

      Response to Questions of Senator Bingaman From Joelle Reizes

    Question 1. Access to treatment for mental illness is a serious 
problem in this country. Yet there is a reluctance to cover mental 
illnesses at the same level as physical illnesses. How important is 
health insurance parity between mental and physical illnesses in 
reducing the risk for suicidal behavior?
    Answer 1. Mental health parity is needed, quite simply, because 
mental illnesses should be treated equally as other illnesses. There is 
no other situation in which we would discriminate against a person 
because they have an illness that involves one body part or organ, 
rather than another. And yet, by not offering parity, we routinely do 
this to patients with mental disease. The reduction of suicidal 
behavior turns on early identification and adequate treatment. Adequate 
treatment is predicated on the idea of access to mental health care, 
for which parity is a necessary precursor. This is an especially 
critical issue for the 16-17 percent of Americans under age 65 without 
health insurance, as well as for the underinsured. In 2002 16.7 percent 
of American children were living in poverty, with rates of over 50 
percent for Hispanic and African American children. In 2001 11 percent 
of children had no health insurance and Hispanic and Native American 
children are even less likely to have health insurance than their 
peers. Access to mental health services is further compromised for 
these populations by a lack of parity in health insurance and coverage 
for mental illness. [All stats from U.S. Department of Health & Human 
Services, Centers for Disease Control and Prevention, National Center 
for Health Statistics]

    Question 2. The New Freedom Commission on Mental Health and the 
Surgeon General's 1999 Report on Mental Health both identified a 
national shortage of mental health professionals trained to treat 
mental illness in children and adolescents. How can we reduce this 
shortage?
    Answer 2. We defer to our colleagues at the American Academy of 
Child and Adolescent Psychiatry and the American Psychiatric 
Association on this issue. We refer the subcommittee to the American 
Academy of Child and Adolescent Psychiatry's document ``AACAP Work 
Force Data Sheet'' available at http://www.aacap.org/trig/workforce.htm 
for a summary of this topic. As noted in the response to Senator Reed, 
the shortage of trained professionals does not reduce the need for 
screening mechanisms or treatment. We believe the answer lies in 
continuing outreach and education efforts to professionals and the 
public to both help train professionals and identify those in need of 
help.

    Question 3. Adolescents with mood disorders, such as major 
depression and bipolar disorder, are at high risk for suicide. How 
effective are current treatments for early-onset mood disorders? How 
can we make evidence-based treatments available to more vulnerable 
young people?
    Answer 3. As we know, the efficacy of pharmaceutical treatments is 
under investigation now. We hope that the broad examination will shed 
light on this subject and that the benefits and risks will be weighed 
appropriately. In addition, a substantial body of literature supports 
the efficacy of psychotherapy in the treatment of specific disorders 
that carry with them an increased risk for suicide, especially non-
psychotic major depressive disorders. Specifically, interpersonal 
therapy and cognitive behavioral therapy have been found effective in 
clinical trials of adults with major depression.
    There is no single answer to preventing suicide; therefore, 
evidence-based prevention activities and treatments must be seen as 
part of an overall continuum of identification and care. Congress can 
urge schools, colleges, and communities to view suicide prevention as 
an important public health issue and encourage, through funding 
channels, the further training of mental health clinicians, adequate 
mental health treatment resources such as in-patient care, partial day 
hospitalization, outpatient counseling, pharmacy benefits and mental 
health parity.
    Also, comprehensive, systematic screening services must be an 
integral component of any suicide prevention initiative. Screening 
leads to early identification of the most common risk factor for 
suicide--mental illness. Research clearly shows that the earlier we 
identify a disorder, the better the chance we have of positive 
outcomes.

    Question 4. Substance abuse is also a high-risk factor for suicide. 
What programs are most effective in reducing adolescent substance 
abuse?
    Answer 4. We cannot comment on the efficacy of adolescent substance 
abuse programs. However, the strength of the association between 
alcohol and suicide in the SOS research data is startling: those 
reporting that they have used alcohol when feeling down are almost 6 
times more likely to report a suicide attempt during the past year and 
over 4 times more likely to report a lifetime attempt than are those 
who have not used alcohol when feeling down. Similarly, those reporting 
an episode of bingeing in the past 12 months are almost 3 times more 
likely to have attempted suicide in the past year and 4.5 times more 
likely to have ever attempted suicide than those who have not had an 
episode of binge drinking.

    Question 5. Teenage suicides are always tragic, but there is a 
consistently high Native American adolescent suicide rate and a recent 
dramatic increase in the African American adolescent suicide rate. Do 
you recommend intense federally supported interventions to address the 
risk factors that result in these statistics?
    Answer 5. Additional research is needed to identify the risk 
factors that are unique to these populations. Racial and ethnic 
differences in culture, religious beliefs and societal position may 
influence not only rates of suicide but also beliefs about and views on 
death and suicide. It is important to develop interventions that are 
culturally sensitive and that address issues that may be specific to 
certain ethnic minority populations including African American and 
Native American teens.

    Question 6. Schools serve as gatekeepers for the early 
identification and referral of young people with mental illness. How 
can we prepare schools to serve more effectively in this role?
    Answer 6. We need to provide schools with the tools they need to do 
the job of early identification and referral. The SOS program serves 
this very need. It has been recognized by school professional 
organizations as the program of choice, including the National 
Association of School Psychologists, National Association of Secondary 
School Principals, American Counseling Association, American Academy of 
Nurse Practitioners, American School Counselors Association, and the 
National Association of Social Workers, among others.
    The SOS materials serve to educate faculty and staff and parents, 
as well as students. By providing schools with a training manual and 
video for staff, the screening and educational materials and videos for 
students, and parent resources we provide schools with everything they 
need to implement the program. We hope to gain Federal support for SOS 
so that we can provide the program to any school that wants it.

    Question 7. Over 1400 school-based health centers deliver primary 
preventive and early intervention services to more than a million 
children in 45 States. Mental health counseling is the leading reason 
for visits by students and the fastest growing component of school-
based health care. How can we expand the availability of such services?
    Answer 7. As you and your colleagues have aptly noted there is a 
shortage of professionals trained specifically in child and adolescent 
mental health. In order to expand the availability of such services we 
must expand the base of professionals who are qualified to treat 
suicidal teens. Here again we defer to colleagues at the American 
Academy of Child and Adolescent Psychiatry. In general, however, 
school-based health centers can be an important resource in meeting 
mental health needs, both by identifying those in need and referring 
out for specialized treatment, especially in hard to reach populations 
and for the under and uninsured. Expanding such clinics will require 
both funding and training efforts.

                   Prepared Statement of Laurie Flynn

    Good Morning Mr. Chairman and Members of the Subcommittee; as 
Director of the Carmel Hill Center for Early Diagnosis and Treatment 
within the Division of Child and Adolescent Psychiatry at Columbia 
University, I am honored to participate as a witness at today's hearing 
on youth suicide prevention. The Carmel Hill Center administers the 
Columbia University TeenScreen Program, a mental health screening and 
suicide prevention initiative for youth.
    The issue of youth suicide prevention is personal to me; my 
daughter made a suicide attempt during her senior year of high school. 
She had deteriorated inexplicably and rapidly, moving quickly from 
severe stress to depression with few warning signs. At the time, there 
was no reliable way for youth to be screened for mental illness or 
suicidal tendencies and parents had no reliable way of knowing their 
child was in danger. Thankfully my daughter was successfully treated 
and went on to college and graduate school. Last year she was married. 
My family's story has a happy ending, but thousands of parents and 
teens are not so fortunate.

   THE EVIDENCE BASE FOR MENTAL HEALTH SCREENING AS A MEANS OF YOUTH 
                           SUICIDE PREVENTION

    Since my daughter was first treated for mental illness, evidence-
based youth mental health screening programs have been researched, 
developed, proven to work, and made available for use. These suicide 
prevention initiatives, which include not only the Columbia University 
TeenScreen Program but also other programs such as the Signs of Suicide 
Program developed by our colleagues at Screening for Mental Health, 
Inc., have undoubtedly helped improve, if not saved, the lives of 
thousands of teens. Had the TeenScreen Program been available in my 
daughter's high school, I most likely would have had a year or more 
warning that she needed help.
    There exists a growing body of scientific research that has found 
screening to be an effective way to find those who are suffering from 
mental health problems and are at risk for suicide. Screening provides 
a way to find these youth before their lives have been permanently 
derailed by related poor academic achievement, substance use, self 
injury and suicide attempt. Screening is especially important because 
many conditions, especially adolescent depression, do not always 
exhibit easily identifiable symptoms. Universal screening, when linked 
with referral to appropriate services, can significantly reduce the 
devastating impact of mental health problems on young lives.
    The move to offer mental health screening to every teen in the 
United States is based on the findings of a psychological autopsy study 
published in 1996 by Dr. David Shaffer, Chairman of the Department of 
Child and Adolescent Psychiatry at Columbia University. The study 
provided information about teenagers who commit suicide and how 
suicides could be prevented, revealing that teen suicide is not the 
unpredictable event we had once thought it to be. In fact, teens that 
commit suicide suffer from a very specific range of mental illnesses. 
Dr. Shaffer found that 91 percent of the teens that committed suicide 
had a psychiatric disorder at the time of their deaths. This finding 
has now been replicated in several national and international studies. 
In Dr. Shaffer's study, the majority of boys who committed suicide 
suffered from depression, abused alcohol or drugs, and/or had made a 
prior suicide attempt. Most girls who committed suicide either suffered 
from depression or had made a prior suicide attempt (Shaffer et al., 
1996a).
    The original study of the TeenScreen Program on 2,004 high school 
students revealed the program's unique ability to uncover youth at risk 
for suicide, but unknown to have problems and not receiving 
professional help for them (Shaffer et al, 1996b). Only 31 percent of 
those with major depression, 26 percent of those with recent suicide 
ideation, and 50 percent of those who had made a past suicide attempt 
were known by school personnel to have significant problems and 
receiving help. This indicates that the majority of students who are 
suffering from a mental illness and are at risk for suicide are 
currently not detected.
    Dr. Shaffer hypothesized that if youth were screened for these 
disorders and those found to be at risk were treated, most suicides 
could be prevented. As a result of Dr. Shaffer's research, the Columbia 
University TeenScreen Program was developed.

              THE COLUMBIA UNIVERSITY TEENSCREEN PROGRAM

    The TeenScreen Program has a simple purpose: to screen youth for 
mental illness and suicide, identify those who are at risk, and link 
them to appropriate treatment. In 1999, we were able to take the 
available research and apply it in the real world with the launch of 
the national TeenScreen Program. As part of our initiative to ensure 
that every teenager receives a mental health screening before leaving 
high school, we have trained 108 screening sites in 34 states, Guam, 
Canada and Panama. We currently have over 200 sites in development. In 
2003, we were able to screen approximately 14,200 teens at these sites; 
among those students, we were able to identify approximately 3,500 
youth with mental health problems and link them with treatment. This 
year, we believe we will be able to identify close to 10,000 teens in 
need, a 300 percent increase over last year.
    The TeenScreen Program works by creating partnerships with 
communities across the nation to implement early identification 
programs for suicide and mental illness in youth. We work with 
communities to develop screening programs that are based on the 
TeenScreen Program, yet adaptable to accommodate the specific needs and 
resources of each community. Most screening programs take place in 
schools, but the program can also be implemented in residential 
treatment facilities, foster care settings, clinics, shelters, drop-in 
centers and other settings that serve youth.
    Once a screening partner has been identified, we ask that the 
potential screening site complete some basic requirements. The site 
must submit a plan for screening youth and agree to identify a site 
coordinator, agree to screen a minimum of 200 youth per year, commit to 
routinizing screening in their community, and provide biannual 
reporting of screening results. We do not require data collection for 
research purposes, and we work with potential sites through the 
application process to help them fulfill each requirement to the best 
of their ability. In fact, many of our current sites began screening as 
part of a 1-year pilot and, once they felt comfortable with the process 
and obtained further community resources and support, have since 
advanced to screening routinization.
    It is important to note that we require both parental consent and 
participant assent before a youth can take part in the screening 
process, thus making screening a completely voluntary activity.
    In the first stage of the actual screening process, all youth who 
consent to screening and obtain parental consent complete the 
Diagnostic Predictive Scales (DPS). The DPS is a 10-minute self-
administered questionnaire that screens for social phobia, panic 
disorder, generalized anxiety disorder, major depression, alcohol and 
drug abuse, and suicidality.
    Youth who report no mental health problems on the DPS are dismissed 
from the screening, and youth who require further attention are 
advanced to the second stage where they are assessed by a mental health 
clinician to determine if further evaluation or treatment would be 
beneficial. If professional services are recommended, the youth and his 
or her family are assisted with the referral process.
    At a time of budget shortfalls at both the federal and state 
levels, I am aware that the subcommittee is particularly interested in 
the costs associated with our screening program. I am happy to report 
that as part of our new campaign to ensure that every teenager receives 
a mental health check-up before leaving high school, we are offering 
400 communities across the nation free individually tailored screening 
projects, including free screening instruments, materials, and 
software; free pre-training consultation; free training; and free post-
training technical assistance.
    Most sites incur a minimal cost for implementing a screening 
program. The primary cost associated with screening is staff; other 
costs include computers and supplies. Many schools and communities can 
implement their programs at no additional cost by utilizing resources 
that are already in place (e.g., the school social worker conducts the 
screening and uses the school's computer lab to do so) or by securing 
volunteers and interns to staff the program. Schools that do not have 
these resources in place have been able to find grants to support the 
screening staff, which can be as small as one person, and supply needs. 
Because the program is flexible and can be implemented in a variety of 
ways, it is able to fit into any budget.

                             STATE EFFORTS

    Through our outreach efforts and community partnerships, we have 
been enormously pleased to work with several states that have taken the 
initiative to implement statewide youth mental health screening and 
suicide prevention strategies. Among these states are Ohio, Florida, 
Nevada, and New Mexico; in addition, recent activity in Pennsylvania 
and Iowa have put those states on the path to a statewide strategy.
    For example, in the Chairman's home state of Ohio, we have been 
fortunate to work with Mike Hogan, PhD, Director of the Ohio Department 
of Mental Health, Chair of the President's New Freedom Mental Health 
Commission, and a member of our National Advisory Council. In February 
2002, Commissioner Hogan initiated a statewide TeenScreen effort by 
soliciting five county mental health boards to be part of a pilot 
program. Over the next 10 to 18 months, the development of these 
screening sites was supported by staff at the TeenScreen Program as 
well as through a grant of $15,000 from the Department of Mental Health 
to each mental health board who is participating in the pilot program 
(Cuyahoga County, Clermont County, Butler County, Stark County, and 
Wayne/Holmes Counties).
    In Senator Ensign's home state, the Nevada Department of Education 
recently announced plans to create a new office within the department, 
the Center for Health and Learning. Our partnership with Nevada began 2 
years ago in the Clark County Health District, which maintains 3 
school-based health centers serving ten schools in Las Vegas and North 
Las Vegas. During this time, health district staff has used the 
TeenScreen Program in 3 of the area schools. Due to the success of the 
program in Clark County, and through the continuous outreach and 
collaborative efforts of the county's health district staff, the Nevada 
Department of Education has taken an interest in the TeenScreen 
Program, resulting in the creation of the Center for Health and 
Learning. The development of the Center has been led by Gary Waters, 
State School Board President, and strong supporter of the TeenScreen 
Program. The Center will, among other activities, be responsible for 
setting up a statewide program to oversee the TeenScreen Program in 
interested schools and districts. The Center's oversight will include 
the development, start-up, and implementation of TeenScreen sites as 
well as ongoing support, including planning support, coordination of 
provider services, and quality assurance guidance, for these new sites.
    In New Mexico, home to Senator Bingaman, a collaborative 
relationship with the New Mexico Department of Health's Office of 
School Health and the University of New Mexico's Department of 
Psychiatry has led to successes on many fronts. Our partnership in the 
state began two and a half years ago with a TeenScreen Program pilot in 
5 school-based health centers (including Silver City SBHC, Ruidoso 
SBHC, Acoma-Laguna SBHC, and Bernalillo SBHC). This pilot has led to 
the stationing of a TeenScreen Program Western Regional Coordinator in 
Albuquerque, integration of the TeenScreen Program into several Robert 
Wood Johnson funded research grants, and the adoption of screening by 
several frontier schools, including Newcomb, Clovis, and Lovington. 
Youth mental health screening is also at the forefront of issues to be 
included in New Mexico's behavioral health restructuring plan, and have 
a great deal of support across state agencies. As the Senator is aware, 
recent suicides in Pojoaque schools have prompted that community and 
others to seek out solutions that better address the unique challenges 
that New Mexico communities face, and the TeenScreen Program is one of 
the approaches being considered.
    In Iowa, home to a member of the full committee, Senator Harkin, a 
tragedy occurred just this past October. A student at Lincoln High 
School in Des Moines committed suicide, and subsequently parents and 
school officials became suspicious of a suicide pact. In response to 
the suicide and the suspected suicide pact, and with the help of former 
Governor Terry Branstad, a member of our National Advisory Council, 
TeenScreen Program staff offered our assistance and our program to 
Lincoln High School and the Des Moines school district. This incident 
coincided with a groundswell of interest in screening from school 
social workers, most of who had heard about TeenScreen at a conference, 
and in the State Department of Education. Ultimately, we were able to 
convene two important meetings; the first was with representatives of 
the State Department of Education and school social workers from around 
the state; the second was with the principal of Lincoln High School, 
members of the school board, and representatives of the Des Moines 
School District, among other attendees. As a result of these two 
meetings, we are on our way to implementing youth mental health check-
ups not only in the Des Moines School District, but across the state as 
part of a statewide TeenScreen Program pilot.
    In Florida, our partnership is an example of the relationship 
between youth suicide, mental illness, and substance abuse prevention. 
TeenScreen Program staff has been working with Governor Jeb Bush to 
help achieve his goal of reducing suicides in the state. We have 
specifically collaborated with Jim McDonough, Director of the Office of 
Drug Control and the state Suicide Prevention Talk Force. In 
partnership with the University of South Florida we are piloting 
district wide mental health screening of 9th graders in Hillsborough 
and Pinellas counties. Staff has met with mental health professionals 
and community leaders, elected officials, advocates, the business 
community, and family organizations to build a base of support for 
media outreach and awareness.

             THE CASE FOR EXPANDED MENTAL HEALTH SCREENING

    Research has established that evidence-based screening programs are 
one of the most effective means of youth suicide prevention. Research 
has also shown that one of the best times to catch youth at risk of 
suicide is in high school, with suicide rates among teens rising 
dramatically around age 14 to 15. While we are proud to have trained 
108 screening sites in the use of the TeenScreen Program, only a 
fraction of our nation's secondary schools currently offer students a 
mental health screening.
    The need for increased availability of youth mental health 
screening is evidenced by the fact that close to 750,000 teens are 
depressed at any one time, and an estimated 7-12 million youth suffer 
from mental illness. While treatments are available for these severely 
disabling disorders, sadly, most children do not receive the treatment 
they need. Among teens that are depressed, 60-80 percent go untreated. 
Among all teens with mental illness, two out of three do not receive 
treatment.
    It has been established that the failure to adequately care for the 
mental health of our youth is connected to youth suicide. Suicide 
continues to be the third leading cause of death among our youth. In 
fact, more adolescents die by suicide as die from all natural causes 
combined. This does not even take into consideration the 19 percent of 
teens who contemplated suicide, the 9 percent who made a suicide 
attempt, and the 3 percent who made an attempt requiring medical 
attention, as identified by the CDC in 2001.
    The good news is that in the past year, there has been a wave of 
support for youth mental health screening, led by the final report of 
the President's New Freedom Commission on Mental Health. One of only 6 
reported goals of the commission is that ``Early Mental Health 
Screening, Assessment, and Referral to Services Are Common Practice.'' 
The commission found that among children such screening, assessments, 
and referrals ``can prevent mental health problems from worsening.'' 
The commission's final report also states that ``schools are in a key 
position to identify mental health problems early and to provide a link 
to appropriate services.''
    I am especially pleased to report that the commission named the 
Columbia University TeenScreen Program a model program for early 
intervention.

              NATIONAL SUPPORT FOR MENTAL HEALTH SCREENING

    In addition to the endorsement by the President's New Freedom 
Commission on Mental Health, to date, 21 national mental health, 
education, and other organizations have endorsed the goal of offering 
every American teen receives a mental health check-up before high 
school graduation. A list of these organizations has been provided for 
committee members.
    We have also found success in Congress and among state legislators. 
Language in fiscal year 2004 omnibus appropriations bill calls on the 
Federal Government to report on what it is doing to encourage mental 
health check-ups for youth, including school based screening. We see 
this as a first step towards identifying one or more federal funding 
streams in the Department of Health and Human Services and the 
Department of Education to support screening.
    Last September, Congresswoman Rosa DeLauro introduced the 
Children's Mental Health Screening and Prevention Act, H.R. 3063, 
bipartisan legislation to fund a federal demonstration program 
encouraging diverse sites to implement and evaluate youth mental health 
screening. The legislation, which currently has 37 cosponsors in the 
House but no companion legislation in the Senate, would authorize up to 
$7.5 million a year to enable up to 10 interested communities to 
participate. At the state level, the Pennsylvania, Georgia, and 
Illinois state legislators have introduced resolution specifically 
encouraging the use of mental health screening as a means of 
identifying youth at risk for suicide. In Pennsylvania, this resolution 
was followed-up by a joint hearing on youth suicide prevention at which 
we were honored to testify.

                    CHALLENGES FOR THE SUBCOMMITTEE

    The challenge to the subcommittee is clear. There now is a proven 
way to find young people before they make an attempt on their lives. 
Families are counting on your leadership.
    Fortunately, the subcommittee, the committee, the Senate, the 
Congress, and the entire federal government are in a position to ensure 
that every teen in America is offered a mental health screening as a 
means of suicide prevention. More leadership is needed, not necessarily 
more money. Our experience shows that the government can support youth 
mental health screening by redirecting existing resources. For example, 
state and local education agencies can use Safe and Drug Free Schools 
and Communities dollars to support school-based mental health services 
and suicide prevention activities. Both the federal and state 
governments must do a better job of encouraging local school districts 
to include mental health check-ups in their grant applications.
    Looking back at the example set by Nevada, I would encourage the 
Federal Government to support the appointment of a state leader on 
suicide prevention. Currently, suicide prevention activities are 
administered by a myriad of state agencies and councils, sometimes in 
coordination with mental health services, sometimes in coordination 
with health services such as injury and violence prevention, and 
sometimes in coordination with education services. This leader can be a 
person currently working on youth suicide prevention at the state 
level, but who would now be responsible for coordinating and 
disseminating available information on youth suicide prevention and 
youth mental health screening.
    Finally, Congress will soon consider reauthorization of the 
Substance Abuse and Mental Health Services Administration. I know the 
subcommittee joins me in thanking the agency for their leadership on 
the issue of youth suicide prevention. I encourage Congress to ensure 
that the agency has the resources it needs to continue its work and to 
increase its support of youth mental health screening.
    I am grateful for the subcommittee's leadership on and support for 
youth suicide prevention and am ready to work with you to ensure that 
all children are on the path to lead happy and healthy lives.
    I would be more than happy to take any questions from the 
subcommittee members.

                              BIBLIOGRAPHY

    Shaffer, D., Gould, M., Fisher, P., Trautman, P., Moreau, D., 
Kleinman, M., & Flory, M. (1996). Psychiatric diagnosis in child and 
adolescent suicide. Archives of General Psychiatry; 53: 339348.
    Shaffer, D., Wilcox, H., Lucas, C., Hicks, R., Busner, C., & 
Parides, M.S. (1996). The development of a screening instrument for 
teens at risk for suicide. Poster presented at the 1996 meeting of the 
American Academy of Child and Adolescent Psychiatry; New York, NY.
    Lucas, C. (2001). The Disc Predictive Scales (DPS): Efficiently 
Screening for Diagnosis. Journal of American Academy of Child and 
Adolescent Psychiatry; 40(4): 443-449.



      Response to Questions of Senator Bingaman From Laurie Flynn

    NOTE: In order to ensure full and final scientific review, Laurie 
Flynn will provide additional information and research references to 
Senator Bingaman in the coming week.

    Question 1. Access to treatment for mental illness is a serious 
problem in this country. Yet there is a reluctance to cover mental 
illnesses at the same level as physical illnesses. How important is 
health insurance parity between mental and physical illnesses in 
reducing the risk for suicidal behavior?
    Answer 1. There is no known research that documents that lack of 
access to mental health treatment increases an individual's risk for 
suicidal behavior; we know, however, that the lack of health insurance 
parity creates a barrier to effective treatment for those at risk. One 
of the things that we do in our own program, the TeenScreen Program, is 
work with screening sites to ensure that the necessary and appropriate 
treatment is available in the community for youth found to be at risk 
and in need of mental health services.

    Question 2. The New Freedom Commission on Mental Health and the 
Surgeon General's 1999 Report on Mental Health both identified a 
national shortage of mental health professionals trained to treat 
mental illness in children and adolescents. How can we reduce this 
shortage?
    Answer 2. While this is not an area which we have studied, we are 
appreciative of Senator Bingaman's sponsorship of S. 1223, the Child 
Health Care Crisis Relief Act. TeenScreen Program staff has heard 
anecdotes from our rural screening sites that the lack of mental health 
professionals in these areas has reached a critical mass.

    Question 3. Adolescents with mood disorders, such as major 
depression and bipolar disorder, are at high risk for suicide. How 
effective are current treatments for early-onset mood disorders? How 
can we make evidence-based treatments available to more vulnerable 
young people?
    Answer 3. A limited number of randomized controlled trials have 
shown that SSRIs, cognitive-behavioral therapy, and interpersonal 
therapy are all effective in depressed children and teens; more 
research needs to take place to better match treatments to children.
    Treatments, however, are only effective if youth in need are 
identified and referred for treatment. Former Surgeon General David 
Satcher reported that 1 in 10 American children under the age of 18 has 
a mental illness severe enough to cause impairment. Sadly, while 
treatments are available, not all youth receive the care they need, and 
many of those suffering from depression or another mental disorder make 
a suicide attempt. According to the Centers for Disease Control, in 
2001 suicide was the third leading cause of death for youth age 15-19, 
with more adolescents committing suicide than dying from all natural 
causes combined. The TeenScreen Program is an effective means of 
identifying youth at risk for mental illness and suicide and linking 
them to treatment, especially those silent sufferers who are not known 
to be ill and who might otherwise go without the care they need.

    Question 4. Substance abuse is also a high-risk factor for suicide. 
What programs are most effective in reducing adolescent substance 
abuse?
    Answer 4. While no rigorous, scientific studies have been conducted 
to compare substance abuse prevention programs, we do know that 
depression and substance abuse are frequently co-morbid; together, 
these disorders create a severely increased risk factor for suicide, 
particularly in adolescent males. In fact, almost all adolescent males 
who commit suicide suffer from depression and substance abuse 
disorders.

    Question 5. Teenage suicides are always tragic, but there is a 
consistently high Native-American adolescent suicide rate and a recent 
dramatic increase in the African-American adolescent suicide rate. Do 
you recommend intense federally supported interventions to address the 
risk factors that result in these statistics?
    Answer 5. In our work with the Native American and African-American 
communities, we have seen that these populations appear to be at high 
risk for suicide and may be committing suicide more frequently than 
other populations. Specifically, we have worked with a number of 
Native-American schools in New Mexico, through a partnership with the 
New Mexico Department of Health's Office of School Health and the 
University of New Mexico's Department of Psychiatry, and throughout the 
western United States, as well in the African-American community in New 
York and other urban areas of the country. One thing the government can 
do is make funding available, particularly in high risk and high impact 
communities, to accelerate the implementation of mental health 
screening so that at risk youth are identified and connected to 
treatment at an earlier point in their lives.

    Question 6. Schools serve as gatekeepers for the early 
identification and referral of young people with mental illness. How 
can we prepare schools to serve more effectively in this role?
    Answer 6. Youth mental health screening is one of the most 
effective means of early identification and referral of young people 
with mental illness in schools. Many schools, however, do not have the 
existing time, staff, or resources to implement screenings without 
outside support or consultation. In addition, Federal support for youth 
suicide prevention and school-based mental health services is scattered 
among many agencies and many programs. The Federal Government should 
fund a national coordinating center on youth mental health screening to 
provide training, technical assistance, and ongoing support to schools 
and to help States and national organizations develop screening 
efforts.

    Question 7. Over 1,400 school-based health centers deliver primary 
preventive and early intervention services to more than a million 
children in 45 States. Mental health counseling is the leading reason 
for visits by students and the fastest growing component of school-
based health care. How can we expand the availability of such services?
    Answer 7. Although mental health counseling is the leading reason 
for visits by students, most school-based health centers do not have 
full time mental health counselors and thus cannot adequately meet the 
mental health needs of the students. Additional resources targeted 
towards mental health counseling needs to be provided to school-based 
health centers. Specifically, both the Department of Health and Human 
Services and the Department of Education should ensure that all School-
Based Health Centers have a professionally staffed mental health 
component, including a mental health screening tool in order to help 
staff make the best use of limited resources.

        Response to Questions of Senator Dodd From Laurie Flynn

    NOTE: In order to ensure full and final scientific review, Laurie 
Flynn will provide additional information and research references to 
Senator Dodd in the coming week as needed.

    Question 1. Thank you very much for joining us. You said that 
``universal screening, when linked with referral to appropriate 
services, can significantly reduce the devastating impact of mental 
health problems on young lives.'' What other services has the 
TeenScreen Program worked in conjunction with? Are these school-based 
services, community-based services, or a mixture of both? Has 
TeenScreen been incorporated into any statewide youth suicide early 
intervention and prevention strategy?
    Answer 1. While our national TeenScreen office has not formally 
worked in conjunction with other services, many of our sites throughout 
the country have. Every community that implements the TeenScreen 
Program does so in their own way and many of the screening programs are 
done in collaboration with a variety of other services provided in the 
school and in the community such as advocacy services, mental health 
awareness and educational services, and drug and alcohol prevention 
services. In addition, community partnerships have been formed at the 
local level with chapters of the National Alliance for the Mentally 
Ill; mental health associations; crisis lines; University departments 
of psychology, psychiatry, and social work; and family service 
associations; to name a few, to carry out screening.
    TeenScreen is fortunate to be working in conjunction with several 
statewide youth suicide prevention strategies. In New York, another 
staff member of the TeenScreen Program and I are members of the New 
York State Suicide Prevention Council at the New York State Office of 
Mental Health. We are actively involved in the writing of the New York 
State suicide prevention plan.
    In Oregon, TeenScreen has been noted in ``The Oregon Plan for Youth 
Suicide Prevention: A Call to Action,'' prepared by the Oregon 
Department of Human Services. One of the plan's eight strategies is to 
``implement screening and referral services,'' and the TeenScreen 
program is listed as a ``promising screening instrument.''
    In Florida, our partnership is an example of the relationship 
between youth suicide, mental illness, and substance abuse prevention. 
TeenScreen has been working with Governor Jeb Bush to help achieve his 
goal of reducing suicides in the State. We have specifically 
collaborated with James McDonough, Director of the Office of Drug 
Control and the State Suicide Prevention Task Force. In partnership 
with the University of South Florida we are piloting district-wide 
mental health screening of 9th graders in two counties. Staff has met 
with mental health professionals and community leaders, elected 
officials, advocates, the business community, and family organizations 
to build a base of support for media outreach and awareness.
    In Nevada, the Department of Education recently announced plans to 
create a new office within the department, the Center for Health and 
Learning. The Center will, among other activities, be responsible for 
setting up a statewide program to oversee the TeenScreen Program in 
interested schools and districts. The Center's oversight will include 
the development, start-up, and implementation of TeenScreen sites as 
well as ongoing support, including planning support, coordination of 
provider services, and quality assurance guidance, for these new sites.
    In New Mexico, we have had a collaborative relationship with the 
New Mexico Department of Health's Office of School Health and the 
University of New Mexico's Department of Psychiatry has led to 
successes on many fronts. Due to our success in the State, youth mental 
health screening is at the forefront of issues to be included in New 
Mexico's behavioral health restructuring plan, and have a great deal of 
support across State agencies.
    In Ohio, we have been fortunate to work with Mike Hogan, Ph.D., 
Director of the Ohio Department of Mental Health, Chair of the 
President's New Freedom Mental Health Commission, and a member of our 
National Advisory Council. In February 2002, Commissioner Hogan 
initiated a statewide TeenScreen effort by soliciting five county 
mental health boards to be part of a pilot program. Over the next 10 to 
18 months, the development of these screening sites was supported by 
staff at the TeenScreen Program as well as through a grant of $15,000 
from the Department of Mental Health to each mental health board who is 
participating in the pilot program.
    In Connecticut, we have worked in Wilton, Bridgeport, and most 
recently New Haven; I would be more than happy to discuss this work 
with you or your staff in detail at your convenience.

    Question 2. You mentioned that TeenScreen can be implemented in 
other youth-oriented settings besides schools, such as residential 
treatment facilities, foster care settings, clinics, shelters, and 
drop-in-centers. Has TeenScreen been implemented in any of these 
settings? If so, how does it compare with the school-based programs?
    Answer 2. Yes, TeenScreen has been successfully implemented in all 
of these settings. The model is always a bit different as the staffing 
and resources at each setting vary so much, however, the same 
fundamental process is used.
    In clinical settings or drop-in centers (for example, a community, 
family, and youth clinic), youth are given the opportunity to be 
screened at intake, whether they come in for a routine physical, a 
broken wrist, or a mental health issue.We have several TeenScreen 
programs within Covenant House, which is a shelter for runaway and 
homeless youth. At Covenant House, screening is part of the intake 
process and this enables the shelter staff to immediately identify and 
address the needs of the youth who are suicidal. It also enables them 
to identify youth who have other mental health needs so that they can 
be further assessed and appropriately treated during their stay at the 
shelter.
    We have also worked closely with Father Flanagan's Girls and Boys 
Town in Nebraska, where a version of the TeenScreen Program is 
administered at intake to every youth who enters the program. In 
addition, we are proud to have Fr. Val J. Peter, Executive Director of 
Girls and Boys Town, as a member of our National Advisory Council.
    These ``modified'' screening programs, used at other settings, are 
no more or less effective than our school-based programs. We are trying 
to meet the kids where they are, making schools the most obvious choice 
to implement screening. Wherever kids show up, however, be it shelters, 
pediatrician's offices, or otherwise, they should have the opportunity 
to be assessed for mental health problems and linked with appropriate 
services.
Response to Questions of Senator Reed From Laurie Flynn and Cheryl King
    For Laurie Flynn: A number of panelists and Senator Clinton 
referred to difficulties in accessing treatment for mental illnesses as 
a serious problem in this country.
    Question 1. What are the factors involved in creating this 
inability to access care?
    Answer 1. There are many widely discussed difficulties in accessing 
treatment for mental illness, among them a lack of mental health 
providers, lack of insurance coverage, and a continued stigma against 
mental illness and mental health care. To the list, however, should be 
added accurate diagnosis. Without a complete overview of their mental 
health, teens can receive incomplete care and the limited resources of 
the delivery system can be misalllocated. While our nation's mental 
health professionals are doing a fantastic job at caring for our youth, 
most children and teens with mental health problems are not even known 
to be suffering. Early identification and prevention of youth mental 
illness, through screening, is one of the best ways to ensure that all 
youth receive a complete mental health overview.

    Question 2. There is a reluctance to cover mental illnesses at the 
same level as physical illnesses. How important is parity between 
mental and physical illnesses in improving access to services and 
reducing the risk for suicidal behaviors?
    Answer 2. There is no known research that documents that lack of 
access to mental health treatment increases an individual's risk for 
suicidal behavior; we know, however, that the lack of health insurance 
parity creates a barrier to effective treatment for those at risk. One 
of the things that we do in our own program, the TeenScreen Program, is 
work with screening sites to ensure that the necessary and appropriate 
treatment is available in the community for youth found to be at risk 
and in need of mental health services.

    Question 3. Teenage suicides are always tragic but there is a 
consistently high rate among Native-American and African-American male 
adolescents as well as an apparent dramatic increase in the rate for 
military members returning from Iraq. What data is available regarding 
the etiology or methods for preventing these unnecessary deaths?
    Answer 3. In our work with the Native-American and African-American 
communities, we have seen that these populations appear to be at high 
risk for suicide and may be committing suicide more frequently than 
other populations. Specifically, we have worked with a number of 
Native-American schools in New Mexico, through a partnership with the 
New Mexico Department of Health's Office of School Health and the 
University of New Mexico's Department of Psychiatry, and throughout the 
western United States, as well as in the African-American community in 
New York and other urban areas of the country. One thing the government 
can do is make funding available, particularly in high risk and high 
impact communities, to accelerate the implementation of mental health 
screening so that at risk youth are identified and connected to 
treatment at an earlier point in their lives.
    We don't yet have complete information about the suicide risk for 
military members returning from Iraq as not enough research has been 
done to look at protective factors and long-term outcomes. We are 
hearing anecdotes about the impact of ongoing conflict on the families 
at home, especially give the growing reliance on our National Guard. No 
known programs are in place to address the dislocation of family and 
distress caused by the call up of civilians in the National Guard and 
military reserve. We need to offer a mental health screening to 
children from military families to address their emotional state. We 
should also be offering mental health screening in military-base 
schools around the world. There is a real need for the Department of 
Defense to address this.

    Question 4. What do you think can be done at a Federal level to 
alleviate this situation?
    Answer 4. Overall, the government needs to fund efforts to offer 
all youth mental health screening; we cannot treat teens unless we know 
they are in need. In addition, the government can increase funding for 
suicide prevention research. There is still a lot to be learned.

    For Dr. King: Question 1. What is the current data regarding 
firearm-related suicides?
    Answer 1. The latest research shows that, for young people 15-24 
years old, suicide is the third leading cause of death, behind 
unintentional injury and homicide. From 1980-1997, the rate of suicide 
among persons aged 15-19 years increased by 11 percent and among 
persons aged 10-14 years by 109 percent. From 1980-1996, the rate 
increased 105 percent for African-American males aged 15-19. Among 
persons aged 15-19 years, firearm-related suicides accounted for more 
than 60 percent of the increase in the overall rate of suicide from 
1980-1997. Firearms are the most common method used in completed 
suicides among both adolescent boys and girls in our Nation.
    Psychological research demonstrates that important risk factors for 
attempted suicide in youth are depression, alcohol (or other drug use), 
and aggressive or disruptive behaviors. Children are most frequently 
injured by firearms when they are unsupervised and out of school. These 
shootings tend to occur in the late afternoon, peaking between 4 p.m. 
and 5 p.m., during the weekend, and during the summer months and the 
holiday season.

    Question 2. Where are the youngsters getting these guns from?
    Answer 2. According to a recent study at the University of North 
Carolina, most teens that commit suicide do so with a gun they find in 
the home. Among the findings was that 36 percent of people reporting 
gun ownership and younger children in the home admitted to keeping 
their firearms loaded. Forty-five percent did not store their guns 
locked, and 57 percent failed to store them in a locked compartment. 
Among all ages in this country, 53 percent of all firearm deaths in 
1998 were suicides.

    Question 3. What kind of education and coordination can bring this 
under control?
    Answer 3. The availability of firearms is a risk factor for youth 
suicide. Firearm-specific suicide prevention efforts should be directed 
toward education concerning firearm safety (safe storage) and the 
development of mechanisms for preventing the impulsive or dangerous use 
of firearms by youth (e.g., computerized coded locks). These prevention 
efforts must be combined with strategies that address the mental, 
alcohol/substance use and other disorders associated with suicidal 
incidents. We need to develop and coordinate safe and effective 
programs in educational settings for youth that address adolescent 
distress, crisis intervention and incorporate peer support for seeking 
help. It is essential that we develop and implement strategies to 
reduce the stigma associated with mental illness, substance abuse, and 
suicide and with seeking help for such problems.

          Response to Questions of Senator Bingaman From Panel

    Question 1. Access to treatment for mental illness is a serious 
problem in this country. Yet there is a reluctance to cover mental 
illnesses at the same level as physical illnesses. How important is 
health insurance parity between mental and physical illnesses in 
reducing the risk for suicidal behavior?
    Answer 1. Certainly the widespread use of arbitrary and 
discriminatory limits on mental health benefits in group health plans 
contributes to suicide in this Nation. Demand-side restraints such as 
50 percent coinsurance for using one's outpatient mental health 
benefits (vs. 20 percent for medical/surgical benefits) and day and 
visit limits on inpatient and outpatient care discourage early 
intervention. Untreated mental disorders may cascade into serious 
illness and suicidal intentions. For this reason virtually every 
national organization dedicated to suicide prevention has endorsed the 
Paul Wellstone Mental Health Equitable Treatment Act.

    Question 2. The New Freedom Commission on Mental Health and the 
Surgeon General's 1999 Report on Mental Health both identified a 
national shortage of mental health professionals trained to treat 
mental illness in children and adolescents. How can we reduce this 
shortage?
    Answer 2. In addition to Federal passage of the Campus Care and 
Counseling Act and the Child Healthcare Crisis Act, both of which have 
training components for mental and behavioral health professionals that 
work with children, the Graduate Psychology Education (GPE) Program 
warrants continued and expanded Federal support.
    The GPE Program, established in fiscal year 2002, is the first and 
only Federal program dedicated to psychology education and training. 
Housed in the Bureau of Health Professions (Health Resources & Services 
Administration), it provides Federal funding to universities and 
training sites (i.e., health science centers, children's hospitals, 
V.A. hospitals) to train psychologists with an interdisciplinary 
approach for specializing with underserved populations, especially 
children and adolescents. The psychologists, while being trained with 
other health professionals such as social workers, psychiatrists, 
physicians, nurses, occupational therapists, provide free health care 
in underserved communities, primarily rural or inner city. The training 
for children's services includes violence prevention in preschool 
children, treating neurologically impaired children, preventing child 
abuse, dealing with children's learning problems, and treating 
depression and suicidal tendencies in teenagers. The psychologists who 
are trained through this funding and develop expertise in treating 
youth, will be placed in the underserved communities upon graduation 
and licensing.

    Question 3. Adolescents with mood disorders, such as major 
depression and bipolar disorder, are at high risk for suicide. How 
effective are current treatments for early-onset mood disorders? How 
can we make evidence-based treatments available to more vulnerable 
young people?
    Answer 3. Several evidence-based treatments are available for 
early-onset major depression. These include certain types of 
psychotherapy and antidepressant medication. In fact, a combination 
treatment of medication, short-term psychotherapy, and parental 
education is often recommended for youth because of the concomitant 
interpersonal, family, and/or school difficulties. These difficulties, 
as well as self-defeating behaviors and negative patterns of thinking, 
are addressed to improve functioning and avoid long-term negative 
consequences. Some youth require more prolonged treatment because of 
the severity of their illness or the presence of co-occurring alcohol/
drug abuse or other disorders. Persons with one episode of major 
depressive disorder are at risk for recurrence.
    Bipolar disorder is a chronic and severe illness, which requires 
long-term medication treatment (continuous). Youth with bipolar 
disorder can, however, usually be stabilized with appropriate 
treatment. A strategy that combines medication and psychosocial 
treatment is recommended to manage the disorder and its associated 
psychosocial impairment. Medications known as ``mood stabilizers'' are 
usually prescribed, with other medications added as necessary, 
generally for shorter periods. The psychosocial treatment may address 
healthy daily living patterns, coping and stress management, self-
awareness of mood changes, and the importance of medication treatment 
adherence.
    A physician may prescribe to youth a medication that has been FDA-
approved for use in adults, but not children. Such ``off-label'' use is 
based on medication knowledge and clinical experience, and occurs 
because only a small number of medication treatments for early-onset 
mood disorders have been systematically studied--in terms of safety and 
efficacy--in youth. The FDA has, however, been recommending appropriate 
studies in youth and encouraging drug manufacturers to conduct such 
studies. A current FDA investigation is addressing the appropriate use 
of antidepressants in children and adolescents.
    Health insurance parity between mental and physical illnesses would 
enable us to take the biggest step toward making evidence-based 
treatments more available to vulnerable young people. Many families do 
not have sufficient resources to provide their children with adequate 
treatments. This is particularly true with early-onset bipolar disorder 
and severe forms of major depressive disorder that require more 
intensive and ongoing treatments. It is recommended that such parity be 
provided for evidence-based treatments. It is also recommended that 
incentives be provided for advanced professional training in the area 
of children's mental health, and that Federal funds be earmarked for 
the further development and improvement of evidence-based treatments 
for early-onset mood disorders.

    Question 4. Substance abuse is also a high-risk factor for suicide. 
What programs are most effective in reducing adolescent substance 
abuse?
    Answer 4. The Substance Abuse and Mental Health Services 
Administration (SAMHSA) of the U.S. Department of Health has 
established many model programs that have been found to be effective in 
reducing adolescent substance use. In fact, both SAMHSA and the 
Department of Education maintain registries of effective programs. Many 
of the programs target not only the youth, but their families as well. 
Effective programs incorporate various settings (i.e., school, home, 
community) and target reducing risk factors and increasing the presence 
of protective factors. Three model programs will be highlighted for 
their effectiveness in reducing substance use among youth.
    The Brief Strategic Family Therapy program, developed at the 
University of Miami, is a short-term, problem focused therapeutic 
intervention targeting children and adolescents 6 to 17 years old, that 
improves behavior by reducing drug use and its associated behavior 
problems. It also alters family member's behaviors that are linked to 
protective and risk factors. Outcomes of this program include 75 
percent reduction in marijuana use, 42 percent improvement in conduct 
problems, 58 percent reduction in association with antisocial peers as 
well as improvements in family functioning, youth self-control, and 
family communication skills.
    The Across Ages program, developed at Temple University, is a 
school- and community-based drug prevention program for youth 9 to 13 
years old that pairs older adult mentors (age 55 and above) with youth 
making the transition to middle school. Outcomes of this community-
based intervention include decreased alcohol and tobacco use, increased 
knowledge about and negative attitude toward drug use, increased school 
attendance, as well as lasting relationships with nurturing and 
mentoring adults.
    The Families That Care--Guiding Good Choices program, developed at 
the University of Washington, Seattle, is a multimedia program that 
gives parents of children in grades four through eight (8 to 13 years 
old) the knowledge and skills needed to guide their children through 
early adolescence. Outcomes of the program include reduced substance 
use 2 years after the intervention was completed, significantly lower 
rates of increase in initiation of drinking to drunkenness and 
marijuana use over a 4-year period, less drinking in the past month 
(relative reduction of 40.6 percent) and increased parent communication 
of substance abuse rules and consequences.
    Many effective programs are solidly evidence-based. Policies that 
encourage the implementation of effective programs, the dissemination 
of such programs to all localities, and the adaptation of model 
programs to achieve maximal effectiveness in differing locations, 
cultures, and racial and ethnic groups are recommended.

    Question 5. Teenage suicides are always tragic, but there is a 
consistently high Native-American adolescent suicide rate and a recent 
dramatic increase in the African-American adolescent suicide rate. Do 
you recommend intense federally supported interventions to address the 
risk factors that result in these statistics?
    Answer 5. Federally supported interventions to reduce the high 
suicide rates among racial and ethnic minorities, particularly among 
American Indian and Alaskan Native adolescents, are critically needed. 
American Indian/Alaska Native adolescents are more than twice as likely 
to commit suicide as any other racial/ethnic group. During 1981 to 
1998, the suicide rate for African-American youths aged 10 to 19 years 
increased from 2.9 to 6.1 per 100,000 (with increase occurring among 
males). This is a tragic increase within a relatively short period of 
time. Although African-American males continue to have lower suicide 
rates than Caucasian males, the gap between these two suicide rates has 
closed significantly. Among high school students, 11 percent of all 
Hispanics and 15 percent of Hispanic females reported attempting 
suicide in the past 12 months. These attempts are associated with 
substantial distress and impairment, but do not seem to be associated 
with a higher rate of completed suicide.
    These staggering statistics show the strong need for evidence-based 
interventions at the Federal level that would address some of the risk 
factors associated with youth suicide. Primary risk factors to address 
among racial and ethnic minorities are alcohol and other substance 
abuse, depression, acculturative stress, school drop-out and other 
social problems (i.e. high unemployment), and availability of evidence-
based health care. Programs establishing quality screening and early 
intervention in readily accessible, low-stigma settings are of critical 
importance. These intervention programs need to be implemented within a 
cultural context.

    Question 6. Schools serve as gatekeepers for the early 
identification and referral of young people with mental illness. How 
can we prepare schools to serve more effectively in this role?
    Answer 6. Given schools' day-to-day contact with children from an 
early age, they are ideally suited to identify children with mental 
health problems and to provide needed services or community referral, 
as appropriate. However, due to limited resources, schools too often 
fail to identify children in need of mental health intervention until 
the situation reaches crisis stage. Training school personnel to 
recognize mental health problems early on and providing screening 
programs to identify children at risk would allow for early 
intervention when children are younger and/or when problems are less 
acute.
    Developmental, environmental, and cultural issues would need to be 
addressed in the training and screening programs. An educated school 
environment--with students, teachers, and others aware of the signs of 
depression and suicide risk--offers a safety net in terms of the 
recognition and referral of ``at risk'' students. It is also critical 
to increase the number of school-based mental health professionals, 
including counselors, psychologists, social workers, and nurses, to 
meet the increased need for student mental health services and to refer 
to community providers, when appropriate.

    Question 7. Over 1400 school-based health centers deliver primary 
preventive and early intervention services to more than a million 
children in 45 States. Mental health counseling is the leading reason 
for visits by students and the fastest growing component of school-
based health care. How can we expand the availability of such services?
    Answer 7. Mental health counseling is a vital component of school-
based health care, but is not available to many students. The critical 
role played by school mental health services is conveyed in the final 
report of the President's New Freedom Commission on Mental Health: 
``Clearly, strong school mental health programs can attend to the 
health and behavioral concerns of students, reduce unnecessary pain and 
suffering, and help ensure academic achievement.'' By locating mental 
health services in schools, it is also possible to overcome many 
barriers to care, including lack of health insurance, transportation 
difficulties, language differences, and stigma, which are often faced 
by low-income and non-English speaking families, in particular.
    School health programs should be established in all States and 
territories and in the 25 largest local educational agencies. The 
availability of such services can be increased through greater 
financial support for such Department of Education programs as Title I 
and the Elementary and Secondary School Counseling Program and 
Medicaid, as well as through targeted initiatives that might be offered 
by the Center for Mental Health Services of the Substance Abuse and 
Mental Health Services Administration.
    According to the Centers for Disease Control and Prevention, it is 
vital to extend the eight components of school health (which include 
``Counseling, Psychological and Social Services'') to all American 
children through coordinated school health programs, in keeping with 
the goals of the Nation's key national health planning effort, Healthy 
People 2010.
                                 ______
                                 
      An Outcome Evaluation of the SOS Suicide Prevention Program

             (In press, American Journal of Public Health)

                             Robert H. Aseltine, Jr., Ph.D.
             Department of Behavioral Sciences and Community Health
                            University of Connecticut Health Center
                                       Robert DeMartino, MD
                                  Center for Mental Health Services
            Substance Use and Mental Health Services Administration

    MAILING ADDRESS FOR REPRINTS: Robert H. Aseltine, Jr., Ph.D., 
Department of Behavioral Sciences and Community Health, MC 3910, 
University of Connecticut Health Center 263 Farmington Avenue, 
Farmington, CT 06030-3910, Tel: (860) 679-3282 Fax: (860) 679-1342 
[email protected]

                            ACKNOWLEDGEMENTS

    Support for this project was provided by the Center for Mental 
Health Services/Substance Abuse and Mental Health Services 
Administration and by a grant from the Robert Leet and Clara Guthrie 
Patterson Trust. We would like to thank Barbara Kopans, Amy Bloom, and 
Gene Wallenstein for assistance in carrying out this study, and Douglas 
Jacobs and Ross Baldessarini for helpful comments on earlier drafts of 
this manuscript.

                          AUTHOR CONTRIBUTIONS

    R. Aseltine conceived of the study and took primary responsibility 
for the analysis of data and writing of this manuscript. R. DeMartino 
contributed to the design of the study, the interpretation of the data, 
and reviewed drafts of this manuscript.

                     HUMAN PARTICIPANT PROTECTIONS

    The procedures used to collect these data were approved by the 
University of Connecticut Health Center's Institutional Review Board.
  an outcome evaluation of the sos suicide prevention program abstract
    Objectives. This study examined the effectiveness of the Signs Of 
Suicide prevention program in reducing suicidal behavior.
    Methods. 2,100 students in five high schools in Columbus, Georgia 
and Hartford, Connecticut were randomly assigned to intervention and 
control groups. Self-administered questionnaires were completed by 
students in both groups approximately 3 months after program 
implementation.
    Results. Significantly lower rates of suicide attempts and greater 
knowledge and more adaptive attitudes about depression and suicide were 
observed among students in the intervention group. The modest changes 
in knowledge and attitudes partially explained the beneficial effects 
of the program on suicide attempts.
    Conclusions. SOS is the first school-based suicide prevention 
program to demonstrate significant reductions in self-reported suicide 
attempts in a study utilizing a randomized experimental design.
    Keywords: Suicide, depression, prevention, adolescents, evaluation, 
screening.

    Suicide among young people is one of the most serious public health 
problems facing the United States. According to the National Center for 
Health Statistics, the suicide rate for youth and young adults aged 15-
24 has tripled since 1950, and suicide is now the third leading cause 
of death in this age group.\1\,\2\ Although it is difficult 
to obtain reliable estimates because of the accompanying stigma, the 
incidence of suicide attempts among adolescents may exceed 10% over a 
6-12 month period.\3\,\4\
    A number of diverse approaches to suicide prevention have been 
introduced into high school curricula in the past 15 
years.\5\,\6\,\7\ Few, however, have been 
subjected to rigorous evaluation, and those that have been 
scientifically evaluated have produced mixed results. On the positive 
side, a suicide awareness curriculum developed by Spirito and 
colleagues yielded a significant increase in knowledge concerning 
suicide and small but statistically significant reductions in the use 
of maladaptive coping strategies among ninth grade students.\8\ 
Similarly, increases in personal control, problem-solving coping, self-
esteem and family support and decreases in depression were observed 
among at-risk high school students who were exposed to brief supportive 
counseling interventions developed by Randell et a1.\9\ These modest 
successes are overshadowed, however, by several other studies that have 
failed to observe any effects of such interventions on students' 
attitudes or behaviors.\10\,\11\
    A relatively new approach to reducing the incidence of suicide 
among adolescents is found in SOS: Signs of Suicide. This school-based 
prevention program incorporates two prominent suicide prevention 
strategies into a single program, combining a curriculum that aims to 
raise awareness of suicide and its related issues with a brief 
screening for depression and other risk factors associated with 
suicidal behavior.\12\ In the didactic component of the program, SOS 
promotes the concept that suicide is directly related to mental 
illness, typically depression, and that it is not a normal reaction to 
stress or emotional upset.\13\-\17\ Youths are taught to 
recognize the signs of suicide and depression in themselves and others 
and the specific action steps needed to respond to those signs. The 
objective is to make the action step--ACT--as instinctual a response as 
the Heimlich maneuver and as familiar an acronym as ``CPR.'' ACT stands 
for Acknowledge, Care, and Tell. First, ACKNOWLEDGE the signs of 
suicide that others display and take them seriously. Next, let that 
person know you CARE about him or her and that you want to help. Then, 
TELL a responsible adult.
    The program's teaching materials consist of a video (featuring 
dramatizations depicting the signs of suicidality and depression, 
recommended ways to react to someone who is depressed and suicidal, as 
well as interviews with real people whose lives have been touched by 
suicide) and a discussion guide. Students are also asked to complete 
the Columbia Depression Scale, a brief screening instrument for 
depression derived from the Diagnostic Interview Schedule for 
Children.\10\ The screening form is scored by the students themselves; 
a score of 16+ on the CDS is considered a strong indicator of clinical 
depression, and the scoring and interpretation sheet accompanying the 
screening form encourages students with such scores to seek help 
immediately. Each school provides a description of the resources 
available to students who wish to seek assistance.
    In sum, the SOS program aims to reduce suicidal behavior among 
adolescents through two primary mechanisms. First, the educational 
component of the program is expected to reduce suicidality by 
increasing students' understanding and recognition of depressive 
symptoms in themselves and others, and by promoting more adaptive 
attitudes toward depression and suicidal behavior. Second, the self-
screening component of the SOS program helps students to assess and 
evaluate the depressive symptoms and suicidal thoughts they might be 
experiencing and prompts them to seek assistance in dealing with these 
problems. Such help-seeking need not be limited to referral for 
treatment by a mental health professional, which is likely to be 
constrained by such factors as the availability and accessibility of 
providers, health insurance coverage, and social stigma, but should 
also be manifested in help-seeking directed at the ``indigenous trained 
caregivers'' in the school environment (teachers, guidance counselors), 
as well as loved ones.\18\
    In addition to its use of multiple suicide prevention strategies, 
the SOS program offers other potential advantages. First, the focus on 
peer intervention is developmentally appropriate for the target age-
group.\19\,\7\,\20\ During adolescence peers 
become the primary sphere of social involvement and emotional 
investment for most youths.\21\,\22\ By teaching youths to 
recognize the signs of depression and empowering them to intervene when 
confronted with a friend who is exhibiting these symptoms, SOS 
capitalizes on a key feature of this developmental period. Second, the 
program can be implemented on a school-wide basis by health educators 
with relative ease. Data from schools offering the SOS program during 
the 2001-2002 school year indicate that it can be implemented with 
minimal staff training and does not unduly burden teaching, counseling, 
or administrative staff.\23\ Other suicide prevention programs that 
include mental health screening can be costly, difficult, and time-
consuming to implement.\13\
    This article presents data from an outcome evaluation of the SOS 
program conducted during the 2001-2002 school year in five high schools 
in Hartford, Connecticut and Columbus, Georgia. The primary goal of 
this research was to assess the short-term impact of the program on 
suicidal behavior, help-seeking, and knowledge of and attitudes toward 
depression and suicide in a diverse student population.

                                METHODS

    This study involved 2,100 public school students in three high 
schools in Hartford, CT and two high schools in Columbus, GA. As 
indicated by the demographic profile of the sample (Table 1), these 
schools provide a racially mixed and economically diverse sample of 
youths. The three Hartford schools (N = 1435) are dominated by 
economically disadvantaged youth from diverse racial and ethnic 
backgrounds: approximately 59% of the Hartford sample was of Latino 
origin and 20% of students were Black. Twenty percent of Hartford 
students have been placed in a remedial English or bilingual program 
during high school. In contrast, the racial backgrounds of students in 
the Columbus, GA schools (N = 665) are predominately White and Black, 
with most of these students living in working- to middle-class 
families. 



    The experimental design consists of randomized treatment and 
control groups and post-test only data collection. In 4 of the 5 
participating schools, students were randomly assigned to health (in 
Hartford) and social studies (in Columbus) classes by a computerized 
scheduling program. (Only freshmen classes were eligible to participate 
in the Columbus sites). Because the semester in which students were 
assigned to these half-year classes was determined randomly, all 
students taking these classes during the first half of the school year 
were assigned to the treatment group and received the program over a 2-
day period from October through November 2001. Students taking these 
classes during the second half of the school year were assigned to the 
control group and did not receive the program until after the 
evaluation was completed. The one exception to this, a technical-
vocational high school in Hartford; clusters students in health classes 
according to their major area of study, and class composition does not 
change at midyear. For this school random assignment of classes to 
intervention and control conditions was achieved using a coin flip. 
Because the same teachers and same classrooms were used for both 
intervention and control conditions in all 5 schools, a number of 
potential concerns associated with the assignment of classrooms to 
experimental conditions were minimized.\24\
    Students in both the treatment and control groups were asked to 
complete a short questionnaire in a group setting during class time 
approximately 3 months following the implementation of the program. 
Trained interviewers from the University of Connecticut's Center for 
Survey Research and Analysis and Columbus State University read aloud 
the questions to each class, and students recorded their confidential 
written responses on the anonymous questionnaires. Parents were 
notified in writing about the objectives of the study and were invited 
to contact their respective schools with questions or to withdraw their 
child from the study. The procedures used to collect these data were 
approved by the University of Connecticut Health Center's Institutional 
Review Board. Questionnaires were completed by 2,100 of the 2,258 
students eligible for the study (Control N = 1073, Treatment N = 1027), 
resulting in an overall response rate of 93%.
Measures and Instruments
    The questionnaire included items relevant to three specific classes 
of outcomes: (1) self-reported suicide attempts and suicidal ideation; 
(2) knowledge and attitudes about depression and suicide; and (3) help-
seeking behavior. The primary endpoint for this study is a single-item 
measure of self-reported suicide attempts taken from the CDC's Youth 
Risk Behavior Survey (YRBS): ``During the past 3 months, did you 
actually attempt suicide (yes or no).'' \4\ Suicidal ideation was also 
assessed with a question taken from the YRBS: ``During the past 3 
months, did you ever seriously consider attempting suicide (yes or 
no).'' The measures of knowledge and attitudes about depression and 
suicide were adapted from instruments previously used to evaluate 
school-based suicide prevention programs.\8\,\10\ Knowledge 
of depression and suicide consisted of 10 true-false items that reflect 
the central themes of the SOS program (e.g., ``People who talk about 
suicide don't really kill themselves''; ``Depression is an illness that 
doctors can treat''). Scores on this variable reflect the number of 
correct answers. The measure of attitudes toward depression and suicide 
was an 8 item summary scale assessing attitudes toward suicidal people 
and suicidal behaviors (e.g., ``If someone really wants to kill him/
herself, there is not much I can do about it''; ``If a friend told me 
he/she is thinking about committing suicide, I would keep it to 
myself''). Responses to these questions ranged from ``strongly 
disagree'' to ``strongly agree'' on a five point scale, with higher 
values indicating more adaptive attitudes about depression and suicide 
(Cronbach's alpha = .74). Three separate questions were used to assess 
help-seeking behavior. Students were asked whether in the past 3 
months, ``. . . you received treatment from a psychiatrist, 
psychologist, or social worker because you were feeling depressed or 
suicidal (yes or no)'', whether ``. . . you talked to some other adult 
(like a parent, teacher or guidance counselor) because you were feeling 
depressed or suicidal (yes or no)'', and whether ``. . . you talked to 
an adult about a friend you thought was feeling depressed or suicidal 
(yes or no).''
    Subjects with missing values on any variable in a particular 
analysis were excluded from that analysis. Although 84 youths assigned 
to the treatment group did not actually participate in either of the 
central elements of the program (the video and depression screening) 
due mainly to absences from school, they were retained in the analysis 
in order to estimate ``intention to treat'' effects. After exclusions 
for missing data, the effective sample size for these analyses ranged 
between 1,894 and 1,912.
    Descriptive statistics for all dependent variables used in this 
analysis are presented in Table 2, separately by treatment status. 



                                RESULTS

Comparability of Treatment and Control Groups
    Preliminary analyses were conducted to assess the comparability of 
treatment and control groups in terms of race/ethnicity, gender, grade, 
and ESL status. Chi-square tests revealed no differences in the 
composition of treatment and control groups by race or gender. However, 
significant differences were observed for grade (chi-square = 23.6, df 
= 3) and ESL status (chi-square = 7.8, df = 1). Concerning grade, 10th 
grade students were slightly more likely to be assigned to the 
treatment group (e.g., 58% of 10th grade students were in the treatment 
group versus an expectation of 50%), while freshmen were slightly less 
likely to be assigned to the treatment group (44% in treatment). 
Concerning linguistic status, only 40% of those who had taken ESL or 
bilingual classes during high school were assigned to the treatment 
group.

Assessing the Effects of the SOS Program
    To account for the assignment of classrooms to experimental 
conditions, multivariate analyses of program effects were performed 
using HLM 5.\25\ HLM was developed to address generic problems in the 
analysis of hierarchical data structures, that is, data in which 
characteristics of one unit of analysis (e.g., individuals) are nested 
within, and vary among, larger units (e.g., social groups or contexts). 
In this analysis the effect of exposure to the SOS program on each 
outcome variable was estimated in a two-level HLM model, where students 
(the level 1 unit of analysis) were nested with classrooms (the level 2 
unit of analysis). The basic level 1 model for these outcomes was:

Yij=B0j+B1jFEMALEij+B2-
   5jRACEij+B6jESLij+B7-
                  9jGRADEij+eij

where Y represents the predicted value on each outcome variable 
for each individual i in classroom j; FEMALE, RACE, and ESL represent a 
series of dummy variables for the demographic control variables 
included in the analysis; and e represents random error. To reduce the 
error variance in the outcome measures and control for differences in 
the composition of the treatment and control groups,\26\ all level 1 
models include dummy variables for race/ethnicity (Black non-Hispanic, 
Hispanic, Multiethnic, Other Race vs. White non-Hispanic), gender 
(Female vs. Male), grade (10th, 11th, 12th vs. 9th), and ESL status 
(ESL vs. no ESL).
    Because exposure to the SOS program was determined at the classroom 
level, treatment effects were assessed for each outcome by inserting a 
dummy variable for exposure to the program into the level 2 equation 
for the level 1 intercept term:
B0j=G00+G01TREATMENTj+U0
                                   j
The random error in this equation (U0j) represents residual 
variability in treatment effects across classrooms. All demographic 
control variables were modeled as fixed effects (i.e., B1j = 
G10). 



    The effects of the SOS program on students' knowledge of and 
attitudes toward depression and suicide, help-seeking behavior, and 
suicidal ideation and self-reported suicide attempts are presented in 
Table 3. For the analysis of attitudes and knowledge, this table 
presents coefficients from a standard two-level HLM analysis; for help-
seeking behavior, suicidal ideation, and suicide attempts, coefficients 
are derived from nonlinear two-level HLM models using the logit link 
function. The top row in Table 3 presents the effects of exposure to 
the SOS program on the various outcome measures included in this study. 
First and most importantly, the coefficients presented in column 1 of 
Table 3 indicate that exposure to the SOS program was associated with 
significantly fewer self-reported suicide attempts. The coefficient for 
the effect of the program on attempts is ^.467, which when converted to 
an odds ratio indicates that the youths in the treatment group were 
approximately 40% less likely to report a suicide attempt in the past 3 
months relative to youths in the control group (i.e., OR = e^.\467\ = 
.628). The magnitude of the difference between the treatment and 
control groups is also indicated in the descriptive statistics 
presented in Table 2, as the rate of self-reported suicide attempts 
among students in the control group was 5.4% compared to only 3.6% 
among students in the treatment group.
    Similarly, exposure to the SOS program resulted in greater 
knowledge of depression and suicide and more adaptive attitudes toward 
these problems (columns 3 and 4). The effects of the program on 
knowledge and attitudes were modest in magnitude, resulting in effect 
sizes of slightly more than a third of a standard deviation (e.g., 
knowledge: .689/1.98 =.35). The effects of the SOS program on both 
attitudes and knowledge remained statistically significant at the .0071 
and .0083 levels, respectively, when Holm adjustments were applied to 
correct for multiple tests involving these secondary 
endpoints.\27\\28\ In contrast, the effects of the SOS  
program on help-seeking behavior did not achieve statistical 
significance. The negative coefficients for treatment effects in 
columns 3, 4, and 5 of Table 3 indicate that the treatment group was 
slightly less likely than the control group to seek help for emotional 
problems, but these effects did not achieve statistical significance at 
either a nominal or corrected .05 alpha level. Finally, although the 
descriptive statistics in Table 2 indicate lower levels of suicidal 
ideation among the treatment group, this difference fell short of 
statistical significance at the .05 level in the full multilevel model 
(column 2 of Table 3).
    Concerning the impact of the demographic control variables on these 
outcomes, the patterns observed in Table 3 are consistent with those 
observed in national data from the 1999 Youth Risk Behavior Surveys.\4\ 
The female coefficients in these models indicate that girls had 
significantly greater knowledge and more constructive attitudes about 
depression and suicide, were more likely to seek help when depressed 
and to intervene on behalf of friends, and were significantly more apt 
to report suicidal ideation and suicide attempts in the past 3 months 
than are boys.\29\ Students in high school ESL programs had less 
accurate knowledge about depression and suicide, and had a higher 
prevalence of self-reported suicide attempts. However, ESL status was 
positively related to help-seeking, as students in these programs were 
more likely to seek treatment or talk with an adult when feeling 
depressed.
    Significant effects of race/ethnicity on knowledge of depression 
and suicide, two of the help-seeking outcomes, and suicidal ideation 
and self-reported suicide attempts were also observed. Whites tended to 
be more knowledgeable about depression and suicide than those in other 
race and ethnic categories. However, Black students reported lower 
rates of suicidal ideation and suicide attempts than Whites and were 
less likely to seek professional help for these problems, both of which 
are consistent with previous epidemiologic research showing lower rates 
of suicidal ideation and depression among Blacks.\1\,\4\ A 
reparameterization of the models presented in Table 3 (by including a 
dummy variable for White racial status and removing the Black term) 
indicated that Blacks also had significantly lower rates of suicidal 
ideation, self-reported suicide attempts, and professional help-seeking 
than Hispanics. Finally, differences in these outcomes by grade did not 
exceed what would be expected by chance (only 1 significant effect out 
of 21 contrasts).
    Finally, the intraclass correlation coefficient for each outcome 
variable is presented in the bottom row of Table 3. The coefficients 
range from nearly 0 for self-reported suicide attempts, suicidal 
ideation, and talking to an adult about a troubled friend, to a high of 
.07^.09 for the measures of knowledge and attitudes. These coefficients 
indicate that there is a high degree of independence among observations 
within classrooms for each outcome variable; at the most only 7-9% of 
the variance in these outcomes occurs at the classroom level.

     EXPLAINING THE EFFECTS OF THE SOS PROGRAM ON SUICIDE ATTEMPTS

    As mentioned in the Introduction, the impact of the SOS program on 
suicidal behavior may be due in part to its role in fostering greater 
knowledge and more constructive attitudes about depression and suicide. 
To examine the role of knowledge and attitudes in explaining the 
effects of the SOS program on suicidality, these 2 measures were 
included as predictor variables in the level 1 model for self-reported 
suicide attempts. Results of this analysis are presented in Table 4. 
More adaptive attitudes toward depression and suicide and greater 
knowledge of depression and suicide were both significantly associated 
with a lower probability of self-reported suicide attempts. Controlling 
for these variables substantially reduced the effect of the SOS program 
on self-reported attempts, as the coefficient capturing the effect of 
the program on this outcome was reduced by approximately 40 percent 
(i.e., [(^.467)-(^.264)]/^.467) when these variables were controlled 
and was no longer statistically significant. Although there is some 
casual ambiguity regarding the associations between these concurrent 
measures of attitudes and behavior, this analysis suggests that a 
substantial portion of the effect of the SOS program on self-reported 
suicide attempts may be explained by improving subjects' understanding 
and attitudes about depression and suicide. 



                               DISCUSSION

    It is clear from these data that the SOS suicide prevention program 
had a substantively important short-term impact on the attitudes and 
behavior of high school-aged youth in high-risk settings. By 
significantly reducing rates of self-reported suicide 2001 school year 
found evidence that the number of youths seeking assistance from school 
personnel, either because of their own emotional problems or those of 
friends, is generally lower in urban communities. Second, there are 
several barriers to help-seeking that are specific to schools involved 
in this study, particularly in Hartford. Administrators in the Hartford 
schools reported a serious shortage of staff available to assist 
students with mental health concerns. Moreover, a series of informal 
discussions conducted in 12 classes from three Hartford schools several 
months following exposure to the program revealed that students are 
unlikely to seek out school personnel to discuss emotional problems due 
primarily to confidentiality concerns. Instead, students reported that 
friends were the first people they would turn to when feeling 
depressed, a finding which is corroborated in previous research.\7\
    Some may question the rates of self-reported suicide attempts in 
this sample (4.5% over a 3 month period), which appear to be somewhat 
higher on an annualized basis than recent 1 year national prevalence 
estimates from the CDC's Youth Risk Behavior Surveys (8.5-10.5%).\4\ 
Although there is ample reason to expect higher rates of suicidal 
behavior in this sample due to the predominance of seriously 
disadvantaged youth at high-risk for depression, substance abuse, and 
suicidal behavior, research has shown that one cannot ``annualize'' 
data collected using shorter recall periods by simple multiplication 
(i.e., multiplying the 3 month prevalence by 4). For example, 
epidemiologic data from the National Comorbidity Survey on the course 
of major depression among adolescents indicate that the 1 month 
prevalence rate for major depression is approximately one half that 
observed for the past year due to chronicity and the lengthy duration 
of depressive episodes.\30\ Applying this logic to the 3 month 
prevalence rates obtained in this study yields annual prevalence rates 
that are not inconsistent with the national data published by the CDC. 
No suicides were reported in any of the participating schools during 
the study period.
    Finally, this study has a number of limitations that must be 
acknowledged. First, the present evaluation should be replicated in 
more socially and geographically diverse locations. The significant 
positive impact of this program on high-risk youth in urban settings is 
certainly an important finding, but replication in rural and suburban 
settings containing fewer disadvantaged youth is necessary to determine 
whether these findings are generalizable to a broader population. 
Second, the effects of this program were observed over a very short 
post-intervention period. A longer term follow up of youths exposed to 
the SOS program is necessary to determine whether the observed effects 
are enduring. Third, pretest measures of the outcomes assessed in this 
study would add confidence that the assignment of classes to 
experimental conditions resulted in equivalent groups. Fourth, this 
study has revealed some of the challenges facing school-based programs 
designed to foster help-seeking among students. Concerns regarding 
confidentiality may be acting to suppress interaction between students 
and school personnel regarding serious mental health concerns, which 
may lead to acute problems among youths in high-risk settings who 
possess limited parental and financial resources. Relatedly, future 
research should seek to assess the degree to which help-seeking among 
emotionally troubled adolescents is directed toward friends and 
siblings, and assess as well the impact of support received in these 
relationships on suicidal behavior. Finally, readers may question 
whether our results are tainted by the desire of those exposed to the 
program to provide what they perceive to be the ``right answers'' 
attempts in the 3 months following exposure to the program, SOS appears 
to have had a substantial impact on the ultimate target of suicide 
prevention programs. Efficacy in deepening students' knowledge of and 
promoting more adaptive attitudes toward depression and suicide was 
also demonstrated, and further analysis highlighted the importance of 
these variables in potentially accounting for the beneficial effects of 
the SOS program on self-reported suicide attempts. Although further 
research is necessary to determine whether the effects of the SOS 
program are enduring, the short-term impact of this program on 
students' attitudes and behavior was noteworthy. This is the first 
school-based suicide prevention program for which a reduction in self-
reported suicide attempts has been documented with a randomized 
experimental design.
    In contrast, significant effects of the program on suicidal 
ideation and help-seeking were not observed. The fact that self-
reported suicide attempts were reduced by a much greater extent than 
were thoughts of suicide is most likely a result of the SOS program's 
relatively greater emphasis on action and behavior. Reductions in 
levels of suicidal ideation are expected to be an ancillary benefit of 
SOS, particularly if the program's efforts to encourage active 
engagement and communication with peers around these issues foster a 
general mobilization of peer support.\22\ However, suicide prevention 
programs that place greater emphasis on personal growth and positive 
youth development will likely have a greater relative impact on 
outcomes such as depressed mood and suicidal ideation. While 
significant effects of the intervention on help-seeking behaviors were 
expected, further investigation revealed several likely explanations 
for the absence of program effects on help-seeking for this particular 
sample. First, a process evaluation involving site coordinators at 
schools implementing the SOS program during the 2000--when responding 
to survey questions about their attitudes and behavior. As discussed in 
the introduction, however, suicide prevention programs have 
historically demonstrated very little in the way of efficacy. 
Adolescents have not felt compelled to pick what they feel are the 
``right answers'' in prior research, and there does not appear to be 
anything unique about this sample that would lead students to do so 
here. Second, if students are endorsing the right answers as opposed to 
their true feelings and experiences, then it is reasonable to expect 
that treatment effects would be observed across the board. The 
selective impact of this program on the various outcomes assessed in 
this study provides fairly strong evidence to the contrary.

                                Endnotes

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behavioral surveillance--United States. In: CDC Surveillance Summaries. 
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    11. Vieland V, Whittle B, Garland A, Hicks R, Shaffer D. The impact 
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    12. Shaffer D, Craft L. Methods of adolescent suicide prevention. 
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overview and recommended protocol. In: Jacobs DG, ed. Guide to Suicide 
Assessment and Intervention. San Francisco: San Francisco; 1999:3-39.
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and adolescents at risk for suicide. In: Blumenthal SJ, Kupfer DJ, eds. 
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Psychology. 1994; 62:297-305.
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                  Prepared Statement of Fran M. Gatlin

    Good morning. Thank you, Chairman DeWine, Ranking Member Kennedy, 
and all the members of the subcommittee for hosting this hearing and 
giving me the opportunity to testify on this important issue. My name 
is Fran Gatlin. I have been a practicing school psychologist for more 
than 28 years. I am currently working at Robinson High School, in 
Fairfax County, Virginia, which serves more than 3,000 students. 
Professionally, I am a Nationally Certified School Psychologist and a 
member of the National Association of School Psychologists and the 
American Association of Suicidology.
    It is encouraging that I have been asked to share with you my role 
as a school-based mental health professional in the effort to help 
prevent suicide among our children and adolescents. I am fairly 
confident that my experience reflects that of many of my colleagues 
across the country. The role of schools in the identification of 
student mental health needs, including the prevention of suicide, 
cannot be underestimated. Indeed, schools have been identified by 
almost every stakeholder as a critical component in an effective system 
of mental health care that also includes families, community services, 
and the medical profession.
    Why? Because virtually every community has a school, and most 
children and youth spend on average of 6 hours a day there under the 
care of familiar, trained professionals. We have the opportunity to 
observe students at risk, connect with them and their families, and get 
them the help they need. Equally important, we can create an 
environment in which students feel safe and able to seek help. We can 
use the learning environment to educate students and their parents 
about the signs and treatment of suicide risk and other mental health 
problems. And, as we are learning is so important, we can help students 
understand the vital role they play in preventing the suicide of a 
friend or classmate by telling an adult when they believe a peer is at 
risk.
    But we need the resources to do this important work.
    Professionally, I became deeply concerned about suicide prevention 
over 10 years ago. I noticed that students who made suicide attempts or 
had a psychiatric hospitalization had no diagnosis or treatment before 
that crisis. So I organized, advertised and offered panel discussions 
for parents on adolescent depression and suicide. No matter how I 
advertised these events there were never as many parents in attendance 
as panel members there to speak to them. I interpreted that outcome as 
reflecting parental denial that these were issues that could affect 
their families.
    This lack of awareness is a serious problem given the scope of the 
epidemic. Suicide is the third leading cause of death of students aged 
10-18. It ranks second among college students. In my state of Virginia, 
the rate of suicide among high school age youth is approximately one 
per week. In the United States 30,000 people die of suicide each year. 
In the world, the suicide rate is approaching a million. As former 
Surgeon General, Dr. David Satcher said, suicide is the most 
preventable form of death, but it requires an investment to save lives. 
The public needs to be educated about suicide. People need to 
understand that most suicide results from untreated depression and that 
depression is a treatable illness. Surveys tell us that as many as one 
in five teenagers seriously considers suicide. 520,000 teenagers 
require medical services as a result of suicide attempts each year. The 
psychological pain implied in these numbers is sobering.
    The reasons for this pain are numerous and ultimately individual to 
each person. But current thinking is that among teenagers 85% to 90% 
have a mental health disorder at the time of the suicide while 10 to 
15% die of an impulsive reaction to a painful event. The break-up of a 
relationship, a sense of deep humiliation or retribution when the teen 
feels wronged by another all can lead to an impulsive suicide death. 
Talking with teens about the ambivalence of suicidal individuals may 
save lives. When they understand there are alternatives to ending 
psychological pain without ending their life, an unnecessary death may 
be prevented.
    Talking to students is a central part of any suicide prevention 
effort. I learned early on that, of adolescents who kill themselves, 
80% tell someone before they die. But they are most likely to tell 
another adolescent, usually a friend, not their parents, and not 
someone who is likely to take action on their behalf.
    I began going into tenth grade health classes and teaching part of 
the unit that covers mental health, specifically adolescent depression 
and suicide. In addition to recognizing the signs of depression, my 
message to these teens is that they may be the only one who knows their 
friend is depressed and potentially suicidal. They may be the only 
person who can seek help for their despairing friend and potentially 
save a life. I only later learned that this strategy is known as ``peer 
gatekeeper training.''
    I also began offering a mental health support group within my 
school. This group is specifically for students who have had a 
psychiatric hospitalization or a suicide attempt. We know that the 
people at highest risk for a suicide attempt are those who have already 
made an attempt. Additionally, those with a psychiatric diagnosis, 
particularly a mood disorder, are at high risk. Such school-based 
support groups function both to provide services to students in need, 
but also to keep a watchful eye on the well-being of this vulnerable 
population. Three years ago I had so many students with this need that 
I formed two weekly sessions of the group to meet the demand. It is a 
group that is on-going and not time-limited. This means that I have 
students who enter as freshman and remain in the group until graduation 
if the need continues. I should also interject that this group has 
included a valedictorian, a recruit to a Big-Ten football program, and 
many bright, talented and ultimately successful individuals. You see, 
depression and suicidal feelings can affect anyone, and often 
disproportionately impact highly intelligent and creative people.
    The single largest cause of suicide is untreated or under-treated 
depression. I had been a volunteer screener in the community on 
national depression screening day for several years. When the Signs of 
Suicide (SOS) program became available at the high school level, I 
sought permission to begin depression screening at my school. We offer 
the screening on a voluntary basis, but require parental permission. We 
enlist students to make posters advertising the screening and a 
videotaped ``commercial'' that is played on the televised morning 
announcements in advance of the screening day. In this manner the 
message is from student to student, encouraging their peers to take 
advantage of the opportunity. In the 4 years we have been offering 
depression screening, well over a hundred students have been screened. 
One was immediately hospitalized and many have entered therapy.
    A particularly poignant situation was when a mother phoned after 
her daughter brought home the literature and permission form. She was 
skeptical and indicated she and her daughter had an exceptionally close 
relationship and good communication. She indicated she would know if 
her daughter were depressed. The mother agreed when I asked what she 
had to lose by signing the permission. The result was an indication of 
some very serious issues and her mother followed through immediately by 
seeking treatment. Six months later she emailed me with a lovely thank 
you message. She reported that the family had entered treatment 
together and in that time had resolved issues they had not previously 
recognized. She praised the depression screening as the event that 
brought her family the opportunity to grow closer and become stronger. 
As in this case, many times there is not a serious depression, but 
instead there are stresses and life events which are creating pain for 
the student. In these cases the depression screening is providing an 
outlet for expression of that pain so that help can be gotten.
    While the use of screenings and assessments are critical to this 
effort, they are only a first step. There must be an established system 
to address the needs of the students who screen positively for mental 
health service needs. Further, there must be prevention programs in 
place to catch many of the students who do not get screened. The 
support and infrastructure must be part of the school environment to 
ensure access to services and necessary follow-up.
    We also need to understand and eliminate the contributing factors 
to suicide.
    A significant factor in suicide attempts and deaths is the use of 
drugs and alcohol. Fifty percent of teens who die by suicide have 
significantly high blood alcohol levels or blood chemistry levels at 
the time of their deaths. Simply stated, 50% of teens are drunk or high 
at the time of their deaths. The dis-inhibiting effects of the alcohol 
or drugs may be the dynamic which tips the scale toward death rather 
than life. Many times when I'm interviewing students at my school 
because of concerns about depression or suicide I ask if they have been 
thinking about suicide. The most common response I hear under those 
circumstances is: ``Sure. Everybody does. But I wouldn't really do 
it.'' I believe those people are wrong on two counts: Not everyone 
considers suicide. Some people who are very depressed never consider 
suicide. Brain research will, no doubt, provide an answer some day why 
some people tend toward suicide and others never do, even under grim 
circumstances. But I believe that access to alcohol or drugs when an 
individual is feeling hopelessness and despair can lead to a fatal 
outcome. While they might not take action to commit suicide while 
sober, the substance abuse can mobilize them to take unfortunate 
action.
    The other factor that greatly impacts the outcome in these pivotal 
times is access to a lethal means. Specifically access to a firearm all 
too often results in the permanent solution to a temporary problem. 
Nearly two-thirds of adolescent suicide deaths happen by firearm, just 
as in the adult population. Study after study in the United States and 
elsewhere indicate that restriction of access to lethal means saves 
lives. When blocked from following through on a plan, frequently the 
chain of events is interrupted. The person lives. On a side-note, I 
would like to thank you, Chairman DeWine, Senator Kennedy, Senator Reed 
and other members of the Subcommittee for supporting S.1807 to close 
the gun show loophole and, hopefully, prevent juveniles from buying 
firearms at gun shows.
    Suicide also leaves a legacy of suicide. The immediate family and 
closest friends of a suicide victim are at eight times greater risk for 
suicide themselves. Schools can help minimize this risk.
    Five years ago, the year began at my school with the suicide deaths 
of two students in a three-week period. These events prompted my school 
to ask the executive director of the American Association of 
Suicidology to educate us further to ensure we were doing everything 
possible to prevent another student death. My commitment to suicide 
prevention was increased further in hearing Dr. Lanny Berman speak. I 
offered a support group to the students who were friends of deceased. 
This was a powerful and productive experience-several of these students 
had found phone messages or email messages from their friend that left 
them devastated that they had not received them in time to reach out 
and help. For all of them the loss was excruciating and powerful. But 
helping these teens deal with the death and understand it as an 
unfortunate choice will hopefully keep them from ever making that 
choice. It was reassuring and rewarding to see them reach a point of 
being able to return to fond memories from the life of their friend 
instead of remaining stuck in the horror of an unnecessary death.
    Teens looking forward to graduation and meeting the next phase in 
their lives have reflected, ``I can't believe that 2 years ago my brain 
was telling me to kill myself.'' In the middle of a serious depression 
the individual is overwhelmed with a sense of hopelessness and the 
belief that it won't ever get better. But rational thinking helps us to 
see that usually things do get better. The depression lifts, a new 
friend comes along, a new opportunity emerges and hope and happiness 
are restored. During a serious depression, the thinking is not 
rational. People whose thinking is flawed by the overwhelming gloom of 
depression are often reliant on family and friends to get them the help 
they need to survive to see a better day.
    Schools can play a critical role, as well.
    Teens do not generally have independent access to mental health 
services. Increasing access to school-based mental health services is 
vital to our efforts to improve suicide prevention. Students need to 
have someone who is visible and in a familiar setting to feel 
comfortable in seeking help. Still, even if there are mental health 
professionals working in their school, many teens are unaware. One of 
the benefits of my peer gatekeeper training is that all of the students 
learn I am available to them. I see a great number of students who ask 
for my support and have also had good success in getting them into 
treatment. However, as the National Institute of Mental Health (NIMH) 
indicates, of some 7.5 million children under the age of 18 requiring 
mental health services, only one in five children receive needed 
services.
    This statistic not only has alarming implications for suicide rates 
but also for other dangerous risk behaviors. We are seeing an 
increasing number of students engaging in intentional self-injury and 
substance abuse. The use of alcohol and other drugs to self-medicate 
mood disorders is common. I believe there is a general lack of 
awareness that substance abuse may not be the result of simply 
partying, but instead reflect self-medication of depression. It would 
be far simpler to treat a mood disorder than to break the cycle of 
substance abuse and relapse when an individual is struggling with an 
underlying depression. I believe that any efforts to ensure that our 
schools are safe and drug-free, must also include school-based mental 
health services to address the great need of these students. Although 
the No Child Left Behind Act includes mental health services as an 
allowable use of funds under the Safe and Drug Free Schools Program, 
there is tough competition for these limited funds and such services 
are frequently not offered. Support for mental health programs needs to 
come from the top levels of federal, state and local education policy 
leaders.
    I am hopeful that my school can help me collect data on the 
effectiveness of these efforts with our students. Since it is not 
possible to measure suicides that don't happen, my hope is that 
research would show that the peer gatekeeper training and exposure to 
advertising for depression screening affect the student's attitudes 
toward help-seeking. My hope is that research would indicate what I 
observe anecdotally: students who have been exposed to these programs 
are more likely to tell an adult if they are depressed or suicidal or 
if they are concerned about a friend. I have seen an increase in 
students who tell the adults at school. For example, a boy went to his 
guidance counselor and said he should go to John Doe's web page and see 
what was posted. The result is that John Doe is now in a partial 
hospitalization program. His parents are very grateful to know that he 
was planning a suicide before it occurred. In the most dramatic 
episode, a student called 911 and revealed a suicide plan in progress 
by his friend. The police department utilized heat-sensing technology 
in a helicopter to locate a warm spot in the woods. Police officers 
went in and found the boy unconscious on a winter night after he had 
consumed alcohol and injected himself with morphine. Our teens are 
finding more serious and frightening ways to act out their 
psychological pain.
    As professionals, we are better positioned and trained to help as 
well. Six years ago I transported a senior in high school to an 
emergency mental health service after her legal guardian refused. She 
had let me know she was having suicidal thoughts. The psychiatrist 
diagnosed depression and prescribed an antidepressant medication. The 
community mental health clinic provided therapy based on her individual 
capacity to pay. This past December she graduated with a master's 
degree in clinical psychology-also with no financial support from her 
family.
    The President's New Freedom Commission on Mental Health report, 
Achieving the Promise: Transforming Mental Health Care in America, 
indicates the need for schools to play a crucial role in identifying 
students in need of mental health treatment as well as linking them to 
services. The Commission specifically recommends that: Schools work 
with parents and local agencies to support screening, assessment, and 
early intervention; Mental health services become part of all school 
health centers; School-based mental health services be federally 
funded; Empirically supported approaches be used for prevention and 
early intervention; and State-level structures for school-based mental 
health services be created to provide consistent leadership and 
collaboration between education, general health, and mental health 
systems.
    I am in whole-hearted agreement. Our linkages between school and 
community-based services need to be enhanced. The health and well-being 
of our next generations depend on our capacity provide effective 
suicide prevention education and services.
    Thank you for the opportunity to address this panel. I look forward 
to hearing more from the Subcommittee on the issue of suicide 
prevention and hope you can include support for more school-based 
mental health and prevention programs in future legislation.

     Appendix--Extracted From the General Literature by Fran Gatlin

Principles for Talking With Teens About Suicide

     Talk about suicide should focus on the data that the vast 
majority of suicide deaths are completed by individuals with a 
diagnosable mental illness.
     The majority of individuals who die by suicide are 
depressed or have bipolar illness (formerly known as manic depression).
     Depression is a treatable illness.
     A suicide attempt frequently is accompanied by significant 
feelings of ambivalence. The person doesn't necessarily want to die; 
but doesn't see an alternative for ending the psychological pain he is 
feeling.
     A teen may be the only person who knows a friend is 
depressed or potentially suicidal. The majority of teens who tell 
someone they are contemplating suicide, tell a peer.
     Telling an adult is not ``ratting'' on a friend, it is 
help-seeking.
     Use of alcohol or illegal drugs is a dangerous dynamic, 
particularly when a teen is depressed. It could be the factor that 
mobilizes a teen to commit suicide.
     Access to lethal means, such as firearms, increases the 
chance of a fatal outcome. Restriction of means saves lives.
     Suicide, which is the third-leading cause of death among 
teens, is a preventable form of death.
     Suicide leaves a legacy of suicide. It puts the family and 
closest friends at eight times greater risk for suicide themselves.
     Pair any discussion about suicide with information about 
who to see to seek help.

Things to Avoid in Talking With Teens About Suicide

     Talking about specific means of suicide should be avoided 
when possible. It sometimes plants an idea.
     Avoid romanticizing the topic in any way possible. Framing 
it as resulting from mental illness or making an unfortunate choice is 
safer.
     Avoid videos, particularly those which use attractive 
teens who talk about surviving a previous attempt. This may plant the 
idea they too will survive and be a ``hero'' or a ``legend'' with their 
peers.

       Response to Questions of Senator Bingaman From Fran Gatlin

    Question 1. Access to treatment for mental illness is a serious 
problem in this country. Yet there is a reluctance to cover mental 
illnesses at the same level as physical illnesses. How important is 
health insurance parity between mental and physical illnesses in 
reducing the risk for suicidal behavior?
    Answer 1. We need to change the thinking in this country that there 
is a difference between the physical nature of illnesses which occur 
``below the neck and above the neck.'' Depression is no less physical 
an illness than diabetes. Such thinking not only limits funding for 
treatment but contributes to the shame and continued stigma which stop 
many people from seeking treatment. For a pragmatic individual, one 
needs only look at the costs in lost work productivity to see that it 
is cost-effective to not only provide early treatment but also to do 
prevention work. Prevention and early treatment can reduce the level of 
impact in which people become hopeless, despairing and suicidal.

    Question 2. The New Freedom Commission on Mental Health and the 
Surgeon General's 1999 Report on Mental Health both identified a 
national shortage of mental health professionals trained to treat 
mental illness in children and adolescents. How can we reduce this 
shortage?
    Answer 2. It seems that a relatively small amount of money in 
scholarship, stipend and internship programs could help encourage 
people to consider these fields. When parents lose a child to suicide 
they often look for ways of preventing other children from dying. This 
would be an excellent way for such parents to have an impact on future 
generations. Endowment of scholarships could help to reduce the 
shortfall of mental health professionals available to meet the 
increasing mental health needs of our children and adolescents. 
Additionally, publicity about the need in these (sometimes well-paying) 
fields may encourage young adults to consider them. Because these 
fields require a high level of education before the person is employed, 
financial aid may help more people to complete these courses of study. 
(School psychologists have the highest entry-level certification 
requirement of any school-based professional.)

    Question 3. Adolescents with mood disorders, such as major 
depression and bipolar disorder, are at high risk for suicide. How 
effective are current treatments for early-onset mood disorders? How 
can we make evidence-based treatments available to more vulnerable 
young people?
    Answer 3. There has been a great deal of information in the press 
lately about untested treatments used with children and adolescents. 
The result has been an increased fearfulness of parents to fill 
prescriptions ordered by the medical doctor or psychiatrist. Clearly we 
need more study of the efficacy and safety of these medications. We 
need funding for a state-of-the-art psychiatric diagnostic facility 
specifically for children and adolescents. This would stimulate 
understanding at the local level of best-practices treatment of a 
population which too frequently receive treatment as ``not fully-
developed adults.''
    The same dynamic is true of school-based suicide prevention. The 
literature is full of reports of the problems and dangers of such 
prevention programs. I am hopeful that my county will undertake 
research into the effectiveness of my school-based prevention efforts. 
In the meanwhile, I believe, that it is dangerous to do nothing. For 
that reason I supplied an appendix in my written testimony which 
extracts from the available literature the do's and don'ts of talking 
with groups of adolescents about suicide.

    Question 4. Substance abuse is also a high-risk factor for suicide. 
What programs are most effective in reducing adolescent substance 
abuse?
    Answer 4. I'm pleased to see public service announcements like 
``Parents: the anti-drug'' on television. Teens need greater 
supervision than they typically receive today. They need more 
information about the extent to which substance abuse is related to 
``selfmedicating'' depression and other mood disorders. Teens need 
support and services when they live with substance abusing parents. 
This is an enormous societal problem. I believe the figure is that one 
in four teens lives in a home where someone in the family is a 
substance abuser. The most direct answer to your question is that I am 
not aware of any program with researched effectiveness in reducing 
adolescent substance abuse.

    Question 5. Teenage suicides are always tragic, but there is a 
consistently high Native American adolescent suicide rate and a recent 
dramatic increase in the African American suicide rate. Do you 
recommend intense federally supported interventions to address the risk 
factors that result in these statistics?
    Answer 5. You are certainly right about the incidence of suicide in 
the Native American populations. Those groups have all the highest risk 
factors: high rates of substance abuse, living in rural areas, isolated 
from mental health support services, the presence of firearms in the 
home, and the reduction or loss of traditional cultural practices, 
values and support systems. I find it important to draw a distinction 
in considering African-American youth suicide rates. African-American 
females have extremely low rates--the lowest among our demographic 
groups. When I've engaged African-American women about the reason for 
this impressive fact they tend to cite the ``sisterhood'' they feel--
the support they receive from their peers in coping with life's trials. 
African-American male youth suicide rates, however, have risen 
dramatically. I believe this is a population which feels very isolated 
from supports and are unlikely to access supports which are available. 
The dynamics which have resulted in more African-American males being 
in prison than in colleges are, I believe, having a profound effect on 
that population. There is a very revealing book on this issue: Lay My 
Burden Down: Unraveling Suicide and the Mental Health Crisis among 
African-Americans by Alvin Poissaint and Amy Alexander. I believe that 
research, education, prevention, and additional services are all 
important to reduce the psychological pain and suicide in these 
populations. However I don't believe we have enough information to put 
into place ``intense federally supported interventions'' at this time.

    Question 6. Schools serve as gatekeepers for the early 
identification and referral of young people with mental illness. How 
can we prepare schools to serve more effectively in this role?
    Answer 6. School systems rarely have school-based school 
psychologists and social workers (even on a part-time basis). More 
frequently this staff is allocated to be at the school to do individual 
evaluations or specific meetings. In other districts these services are 
provided on a contractual basis with community mental health or private 
practitioners. Until there are well-trained mental health staff 
available on a regular basis in schools, school-based intervention can 
not be effective. Students need to be aware of well-trained and 
professional staff who are available to them on a predictable basis. 
Staff need to be trained to refer students with significant warning 
signs. Most importantly, though, students need to be trained to seek 
help for their peers who are at risk. Students are frequently the only 
people who know of other students with mental health issues or suicidal 
thoughts.

    Question 7. Over 1,400 school-based health centers deliver primary 
preventive and early intervention services to more than a million 
children in 45 States. Mental health counseling is the leading reason 
for visits by students and the fastest growing component of school-
based care. How can we expand the availability of such services?
    Answer 7. My belief is that the numbers in your question are a 
grand overstatement of school-based mental health services currently in 
existence. That is a goal we should work toward. The lack of funding 
and the number of adequately trained staff to do such important work 
limit the true practice of effective prevention work.

         Response to Questions of Senator Dodd From Fran Gatlin

    In addition to screening and assessment for depression and other 
mental illnesses I believe there should be effective linkages to the 
appropriate community-based services and private mental health 
professionals. We have limited opportunities to link students and their 
families to services. If we refer them to the community mental health 
center and they are placed on a 4 month waiting list, there is little 
chance the student will ever receive services. Our practice must be to 
carefully refer to available services and those which are within the 
economic means of the family. In today's managed care that often means 
we need to have the parents bring their insurance provider list and 
help them select practitioners who are trained in the area of the 
student's need. I believe it is important to provide as many school-
based services as staffing-level permits. Support groups within schools 
can help to meet the needs of students with depression and other mood 
disorders, students with histories of suicide attempts, psychiatric 
hospitalizations, substance abuse problems and other risk factors for 
suicide. Schools can also provide education for staff, parents and 
students to reduce stigma, encourage help-seeking and encourage 
wellness as preventive of risk factors.
    I am not aware of a model program currently. I have asked for 
support in researching the effectiveness of my work at my high school. 
We, of course, need research evidence of effectiveness before we seek 
to replicate programs.
    Question 1. What are some of the principle mental health needs of 
students you evaluate in your school?
    Answer 1. With 3,000 students at my school the needs are very 
diverse. I'm very sad to report that one of the students to whom I 
referred in my testimony on Tuesday died on Thursday. There are endless 
reminders of the extreme seriousness of the mental health needs of our 
youth today. I deal with many depressed high school students. Their 
issues are not usually so simple as to be covered with one diagnostic 
label. My response to your question was just interrupted to interview a 
student who is diagnosed with depression and who cuts herself (self-
mutilation). She is in private treatment and takes an antidepressant. 
Because these are issues of longstanding I invited her to join the 
mental health support group I offer which meets weekly at school. 
Substance abuse, obsessive-compulsive disorder (and other anxiety 
disorders) and eating disorders frequently co-occur with depression. 
The mother of a student in my mental health group phoned this morning 
to say her daughter had been hospitalized yesterday evening for the 
second time because of her eating disorder. The services we offer at 
school generally do not replace but support the private, community-
based treatments the students are receiving. In addition to providing a 
variety of support groups, and the sessions I do on adolescent 
depression and suicide in their health classes, students can walk in at 
any time to talk about their own concerns or about their friends or 
family. Parents call or stop in to ask for help, suggestions or 
referrals to treatment.

    Question 2. How can we best talk with groups of students about 
suicide and make certain we don't unintentionally romanticize the 
subject?
    Answer 2. I added an appendix to my written testimony in order to 
distill the existing literature for the best ways to talk with teens 
about this issue. There have been so many concerns about talking about 
suicide in the wrong way that many people are afraid to try. It is 
crucial to frame any talk about suicide within the context of mental 
illness. At least 85 percent of suicide occurs as the result of 
untreated depression or other mental illness. Teens get the message 
that there is nothing glamorous about mental illness, even if the 
person affected is a rock star. Teens also respond to the notion that 
the quality of thinking is distorted with a severe depression. The 
result of the distortion is the person's inability to see another 
solution to ending the psychological pain they are experiencing other 
than ending their life. Teens readily see that there are other 
solutions and that suicide is a bad decision when their thinking is 
healthy. Finally we must always present the idea that alcohol and drugs 
not only complicate effective treatment for depression and other mental 
health problems, but also may be the factor that pushes the individual 
``over the edge'' to complete a suicide.

                                 ______
                                 
     Alliance for Human Research Protection (AHRP),
                                        New York, NY 10023,
                                                     March 2, 2004.
Committee on Health, Education, Labor, and Pensions,
U.S. Senate,
Washington, D.C. 20510.

Re: Evidence linking antidepressant drugs to increased suicidal risk 
        for children

    Public concern about the safety of antidepressant drugs is 
intensifying as reports continue to emerge about increased suicide \1\ 
and suicidal acts by children for whom these drugs are routinely 
prescribed. To obtain unbiased information and insight about this 
growing crisis affecting American children, one must turn to Britain. A 
British Member of Parliament recently stated in Parliament that 10 
million children in the United States have been prescribed 
antidepressants \2\--despite a lack of evidence that these drugs are of 
any benefit for children. UK drug regulators took action to protect 
British children \3\ from drugs that pose an increased risk of suicide 
and suicidal behavior. In sharp contrast, the FDA has taken no action 
to protect American children.
    American parents don't know what to believe, lacking clear guidance 
from the professionals from whom they seek help, their fears and 
anxiety are further increased by the persistent contradictory advice 
they are given by promoters of antidepressant drugs--almost all of who 
have financial ties to the manufacturers of these drugs. The 
psychiatric and general medical establishment and the FDA are waffling 
about acknowledging the role of antidepressants in reports of self-
destructive threats and suicidal behavior. But this was made abundantly 
clear during the course of a hearing convened by the FDA, on February 
2, 2004. An FDA advisory committee meeting addressed the growing 
controversy about the safety of antidepressants for children and the 
public health crisis. About 60 family members from all parts of the 
United States testified about the harrowing drug-induced suicidal 
behavior of their children, soon after they were prescribed an 
antidepressant such as Prozac, Zoloft, Paxil, Effexor. Those 
testimonies corroborate previously concealed evidence from company 
controlled clinical trials, leading the committee to urge the FDA to 
add warning labels without delay about the potential suicide risk that 
antidepressant drugs pose for a minority of children.
    The Alliance for Human Research Protection (AHRP), an independent 
national network of concerned professional and lay people dedicated to 
openness and full disclosure, is taking the initiative in bringing to 
this committee's attention a body of evidence that may have been 
deliberately kept hidden from the committee. This committee will be ill 
advised, indeed, should it issue any recommendations without first 
carefully examining the disturbing but credible body of evidence about 
the hazards of antidepressant drugs of the selective serotonin reuptake 
inhibitors class.
    As early as 1991, it was found that in a Prozac study, 6 of 42 
children who tested Prozac became suicidal.\4\ Independent, non-
industry controlled analyses of the data from clinical trials and 
clinical experience, coupled with recently uncovered confidential 
company documents \5\ \6\ reveal a consistent pattern of increased 
suicidal behavior in children prescribed an SSRI compared to those 
given a placebo. There is a body of evidence to prove that the medical 
community and the public have been largely misled (if not deceived) by 
pharmaceutical company statements, advertisements and reports.\7\ \8\ 
\9\ \10\ The very integrity of the scientific literature that guides 
doctors' practice has been tainted by reports that rely on partial 
(positive) findings \11\ \12\ written by ghostwriters \13\ and 
psychiatrists with substantial conflicts of interest.\14\ \15\
    Despite the evidence, the FDA has refused to take precautionary 
action on behalf of children. The FDA has allowed false claims about 
the efficacy and safety of the SSRIs to go unchecked in shaping the 
behavior of prescribing physicians and the public. Only after the 
British announced a ban on Paxil (June 2003), did the FDA announce an 
intention to conduct a review of all pediatric SSRI trial data. Why did 
the FDA fail--all these years--to conduct a scientifically valid review 
of the complete data set?
    Not only has the FDA failed to carry out its mission of 
``protecting the public health'' by requiring manufacturers to 
demonstrate the safety and efficacy of drugs according to rigorous 
scientific standards, but the FDA has also actually abetted drug 
companies to circumvent Federal regulations that require prominent 
warning labels to be used when there is ``reasonable evidence'' of an 
associated serious risk.\16\
    More galling still are actions taken by the FDA to intervene in 
court cases to help drug manufacturers evade State laws that mandate 
truth in advertising. In August 2002, the FDA intervened with a Federal 
judge's order requiring GlaxoSmithKline (GSK) to stop advertising 
``Paxil is non-habit forming,'' because the commercials were 
``misleading and created inaccurate expectations about the ease of 
withdrawal.'' The FDA argued that it alone was authorized to determine 
what should be disclosed in drug advertisements.\17\ \18\
    Two months later, on October 13, 2002, the BBC-Panorama \19\ 
documentary provided compelling evidence of patients' extreme 
difficulty in withdrawing from Paxil. BBC received 67,000 phone calls 
and 1,500 e-mails providing additional evidence of Paxil-induced severe 
withdrawal symptoms. On June 18, 2003, GSK issued a letter \20\ to UK 
healthcare professionals alerting them of changes in the Seroxat/Paxil 
label: changes include deletion of the claim ``Seroxat/Paxil is non-
addictive,'' acknowledgment of adverse side-effects, and advising UK 
doctors not to prescribe Paxil for children.
    The U.S. Code of Federal Regulations, 21 C.F.R.  201.57(e), 
requires prominent warnings whenever there is ``reasonable evidence of 
a possible association of the drug with a serious health hazard.'' 
Although the Code does not say evidence of causation, but ``reasonable 
evidence,'' Daniel Troy, FDA's Chief Counsel misrepresented the 
language of that Federal regulation in Amicus Curiae brief that was 
submitted on FDA's behalf, in 2003, in support of Pfizer 
Pharmaceuticals (his former client) in U.S. Court of Appeals, 9th 
District. (See attached) The brief claimed: that a State may not 
require any such warnings''--no matter the warning's language . . . any 
warning that suggested a causal relationship between Zoloft and suicide 
would have been false or misleading, and thus would have misbranded the 
drug.'' (p. 15, 17) The brief further asserts, ``had Pfizer given a 
warning as to a causal relation between Zoloft and suicide, FDA would 
have disapproved that warning . . . because it would be contrary to 
Federal law.'' (p. 15) Furthermore, the Chief Counsel said, ``FDA's 
regulation of prescription drugs is designed to ensure each drug's 
optimal use . . . under-utilization of a drug . . . could well 
frustrate the purposes of Federal regulation.'' (p. 23)
    Was this the intent of Congress when it authorized the FDA to 
protect the public health, or is this an abuse of FDA authority?
    Even without scientifically valid supporting evidence, senior FDA 
officials pronounced these drugs safe and effective in briefs submitted 
to judicial bodies. They made these pronouncements on the basis of 
cursory reviews of partial evidence and incomplete reports submitted by 
the manufacturers.\8\ There is also evidence that senior FDA officials 
suppressed the agency's own medical officer's report \21\ because his 
review corroborated the suicidal findings of the British Medicines 
Authority.\22\ The arguments put forth by senior FDA officials are 
contradicted by the suicidal warnings issued to physicians in the UK by 
two of SSRI drug manufacturers--GlaxoSmithKline \23\ and Wyeth \24\ 
Pharmaceuticals.
    Attached are seven documents to help the committee in its 
investigation of the issues:
    (1) AHRP comments submitted to the FDA advisory committee review of 
the safety evidence;
    (2) Correspondence between AHRP and FDA regarding implementation of 
FDA rule to prevent conflict of interests to taint the advisory 
committee process;
    (3) AHRP letter to Dr. Janet Woodcock, requesting FDA's SSRI data 
for independent analysis;
    (4) An open letter to the FDA by the foremost international expert 
on antidepressants, Dr. David Healy, detailing more than ``reasonable 
evidence'' of an association between SSRIs and suicidal and aggressive 
behavior in children and in healthy volunteers--based on a combination 
of raw clinical trial data files of the drug manufacturers--some not 
seen by FDA reviewers--and FDA medical reviews;
    (5) Copy of FDA brief in Paxil litigation with declaration by 
Robert Temple, M.D., claiming an ``in-depth'' review concluded ``the 
drug is, in fact, not habit forming;''
    (6) Copy of an Amicus Curiae brief in support of Pfizer, Inc. 
submitted by FDA's Chief Counsel, claiming ``any warning by Pfizer that 
suggested causation would have subjected the company to Federal 
regulatory enforcement action.'' (p. 13)
    We believe that the FDA's failure to issue label warnings when 
there is ``reasonable evidence'' to inform physicians and parents about 
these drugs' potential hazards, as well as their failure to demonstrate 
a benefit for children, is exacerbating the problem and contributing to 
increasing numbers of preventable deaths.
            Sincerely,
                                       Vera Hassner Sharav,
                 President, Alliance for Human Research Protection.

                               REFERENCES

    \1\ Wall, J.K. and Tuohy, J. Suicide brings changes to Lilly drug 
trials Indianapolis Star, February 11, 2004, Front page. http://
www.indystar.com/articles/5/119765-2375-102.html
    \2\ Paul Flynn, Esq. MP (Lab) Statement. February 23, 2004. Online 
at:http://www.publications.parliament.uk/pa/cm200304/cmhansrd/cm040223/
debtext/4022331.htm#40223-31 head0
    \3\ U.K. MHRA. Committee on Safety in Medicines. New Warnings Re: 
Use of antidepressant drugs for children Sept. 2003 http://
www.ahrp.org/risks/MHRAssri09O3.html ; MHRA Update February 12, 2004. 
Advice on SSRIs in children. http://medicines.mhra.gov.uk/ourwork/
monitorsafequalmed/safetymessages/ssriqa_10120 3.pdf
    \4\ King RA, Riddle MA, Chappell PB, Hardin MT, Anderson GM, 
Lombroso P, Scahill L. Emergence of self-destructive phenomena in 
children and adolescents during fluoxetine treatment. Journal of 
American Academy of Child & Adolescent Psychiatry. 1991.30: 179-86.
    \5\ Vandatam S. 2004, January 28, ``Antidepressant Makers Withhold 
Data on Children,'' The Washington Post, Online at: http://
www.washingtonpost.com/ac2/wo-dyn/A58130-2004Jan28?lanquage=printer
    \6\ See, SmithBeecham confidential internal memo. Seroxat/Paxil 
Adolescent Depression Position Piece on the Phase III trials. October 
1998. http://www.ahrp.org/risks/SSR10204/GSKpaxil/pg1.html
    \7\ Zuckoff, Z. June 11, 2000, Prozac-New directions: Science, 
money drive a makeover The Boston Globe, Front page.
    \8\ SmithKIineBeecham. 1998. Confidential Memo. Seroxat/Paxil 
adolescent antidepression: Position on Phase III trials, October. 
Online at: http://www.ahrp.org/risks/SSR10204/GSKpaxil/pg1.html
    \9\ NPR. Frontline Dangerous prescription. November 13, 2003 http:/
/www.pbs.org/wgbh/pages/frontline/shows/prescription/
    \10\ Curiously, there has been little mention of the fact that In 
December 2003, Eli Lilly informed UK doctors (but not U.S. doctors) 
that Prozac is ``not recommended'' for children, while in the US Prozac 
is recommended for children. See: http://www.ahrp.org/risks/
ProzacKids1203.html
    \11\ Graham Emslie, M.D., the principal investigator of Prozac and 
Paxil acknowledged in The New York Times that he knew of negative 
studies involving children that have been withheld by drug companies. 
See: Harris, G. August 7, 2003. Debate Resumes on the Safety of 
Depression's Wonder Drugs. The New York Times, Front page. Online at: 
http://www.nytimes.com/2003/08/07/health/
07DEPR.html?hp=&pagewanted=all&position=
    \12\ For example, Thomas P. Laughren, MD. Team Leader, Psychiatric 
Drug Products Division of Neuropharmacological Drug Products, 
acknowledges for the first time that published reports by Keller et al. 
and Wagner et al., claiming positive trial results were false. See: 
U.S. Food and Drug Administration (FDA) CDER. Memorandum from Thomas P. 
Laughren, M.D., to Members of PDAC and Peds AC January 5, 2004. See 
also: Keller MB, Ryan ND, Strober M, Klein RG, Kutcher SP, Birmaher B, 
Hagino OR, Koplewicz H, Carlson GA, Clarke GN, Emslie GJ, Feinberg D, 
Geller B, Kusumakar V, Papatheodorou G, Sack WH, Sweeney M, Wagner KD, 
Weller EB, Winters NC, Oakes R, McCafferty JP. Efficacy of paroxetine 
in the treatment of adolescent major depression: A randomized, 
controlled trial. Journal of the American Academy of Child & Adolescent 
Psychiatry, 2001, 40:762-772; see also, Wagner KD, MD, Ambrosini P, 
Rynn M, Wohlberg C, Yang R, Greenbaum MS, Childress A, Donnelly C, Deas 
D, for the Sertraline Pediatric Depression Study Group. Efficacy of 
Sertraline in the Treatment of Children and Adolescents With Major 
Depressive Disorder. JAMA. 2003. 290:1033-1041
    \13\ Healy D. 2003. Let Them Eat Prozac, published by the Canadian 
Association of University Teachers.
    \14\ American College of Neuropsychopharmacology. January 21, 2003. 
Task Force on SSRI Antidepressants and Suicidal Behavior in Youth with 
Depression issued an ``Executive Summary'' of an unreleased, 
unpublished report claiming there was no risk. Of note, see disclosure 
of conflicts of interest of this Task Force at the end of the Executive 
Summary.
    \15\ Cato J. January, 23rd, 2004 Report casts doubt on drug, 
suicide link The Herald, at: http://www.heraldonline.com/local/story/
3264586p-2918424c.html
    \16\ U.S. Code of Federal Regulations, 21 C.F.R.   201.57(e), 
governing warnings, requires prominent warnings whenever there is 
``reasonable evidence'' of a possible association of the drug with a 
serious health hazard. The Code does not say evidence of causation; but 
reasonable evidence.
    \17\ Judge Bars Paxil Maker from Claiming Drug Is Not Habit-
Forming. 2002, August 28. Pharmaceutical Litigation Reporter, Volume 
18, Issue 5, Andrews Number 30.4.5.1
    \18\ Wilborn W. 2002, August 23 Judge reconsiders, says anti-
depressant can be labeled nonaddictive. Associated Press. http://
www.nj.com/newsflash/national/index.ssf?/cgi-free/getstory 
ssf.cgi?a0960 BC PaxilAds&&news&newsflash-national
    \19\ British Broadcasting Corporation-Panorama. October 13, 2002. 
The Secrets of Seroxat. Transcript available at: http://news.bbc.co.uk/
1/hi/programmes/panorama/2310197.stm
    \20\ GIaxoSmithKline. June 18, 2003. Letter to UK healthcare 
professionals at: http://www.ahrp.org/risks/PaxilRisks06O3.html
    \21\ Waters R. February 1, 2004 Drug report barred by FDA Scientist 
links antidepressants to suicide in kids. The San Francisco Chronicle, 
Front page. URL: sfgate.com/article.cgi?file=/chronicle/archive/2004/
02/01/MNGB64MJSP1.DTL
    \22\ British MHRA. Committee on Safety of Medicines. December 12, 
2003. Selective Serotonin Reuptake Inhibitors (SSRIs): Overview of 
regulatory status and CSM advice relating to major depressive disorder 
(MDD) in children and adolescents including a summary of available 
safety and efficacy data. Online at: http://medicines.mhra.gov.uk/
ourwork/monitorsafegualmed/safetymessages/ssrioverview 101203.htm
    \23\ GIaxoSmithKline. June 18, 2003. Letter to healthcare 
professional in the UK. See: http://ahrp.org//risks/PaxilRisks06O3.html
    \24\ Weyth Pharmaceuticals. August 23, 2003. Letter to healthcare 
professionals. http://ahrp.org//risks/effexorLtr082203.html.

                                 ______
                                 
   Joint Statement from the American Academy of Child and Adolescent 
          Psychiatry and the American Psychiatric Association

                              INTRODUCTION

    The American Academy of Child and Adolescent Psychiatry (AACAP) is 
a medical membership association established by child and adolescent 
psychiatrists in 1953. Now over 7,000 members strong, the AACAP is the 
leading national medical association dedicated to treating and 
improving the quality of life for the estimated 7-12 million American 
youth under 18 years of age who are affected by emotional, behavioral, 
developmental and mental disorders. AACAP supports research, continuing 
medical education and access to quality care. Child and adolescent 
psychiatrists are the only medical specialists fully trained in the 
treatment of mental illness in children and adolescents.
    The American Psychiatric Association (APA) is a national medical 
specialty society, founded in 1844, whose 38,000 members specialize in 
the diagnosis, treatment and prevention of mental illnesses including 
substance abuse disorders.
    The AACAP and APA would like to thank Senator Mike DeWine (R-OH), 
chairman of the Substance Abuse and Mental Health Services Subcommittee 
for holding this hearing and for his continued commitment to improving 
access to treatment for mental illnesses for children and adolescents.
    Suicidal behavior is a matter of grave concern for child and 
adolescent psychiatrists who treat children and adolescents. Suicide, 
very rare before puberty, becomes increasingly frequent through 
adolescence. The incidence of suicide attempts reaches a peak during 
the mid-adolescent years, and mortality from suicide, which increases 
steadily through the teen years, is the third leading cause of death 
for teenagers. According to the Surgeon General's Call to Action to 
Prevent Suicide, 1999, from 1980-1996, the rate of suicide among 
persons aged 15-19 years increased by 14 percent and among persons aged 
10-14 years by 100 percent.
    The factors that predispose to completed suicide are many and 
include pre-existing psychiatric disorders and both biological and 
social-psychological facilitating factors. The overwhelming majority of 
adolescents who commit suicide (more than 90 percent) suffered from an 
associated psychiatric disorder at the time of their death. The top 
risk factors for attempted suicide in adolescents are depression, 
alcohol or other drug use disorder, and aggressive or disruptive 
behavior.
    Even the most experienced physician can find it difficult to 
differentiate between benign and ominous suicidal behavior; although, 
depressive disorder can predict an immediate risk. Many adolescents who 
have made a medically serious attempt will never do so again, while 
others who have made what seemed like only a mild ``gesture'' may 
eventually commit suicide. The impact of such a ``gesture,'' called so 
by some clinicians to denote a nonlethal action that is deemed a cry 
for help, is therefore misleading because it minimizes the potential 
risk for suicidal behavior. Unfortunately, one cannot gauge future 
suicidal behavior. Despite this fact, research has provided some broad 
indicators about risk factors that should be considered by all 
physicians dealing with patients exhibiting suicidal behaviors. In 
general, males are at a much higher risk for suicide than females. The 
high risk factors for suicide among males include:
     Previous suicide attempt
     Aged 16 years or older
     Associated mood disorder
     Associated substance abuse
    The high risk factors among females include:
     Mood disorders
     Previous suicide attempts
    Some of the psychiatric illnesses in adolescents which include 
suicidal thoughts or behaviors include depression, ADHD, and bipolar 
disorder. Of these, depression has been identified as the top risk 
factor. About 5 percent of children and adolescents in the general 
population are depressed at any given point in time. Children under 
stress, who experience loss, or who have attentional, learning, conduct 
or anxiety disorders are at a higher risk for depression. The behavior 
of depressed teenagers may differ from the behavior of depressed 
adults. For example, depressed teenage boys often exhibit aggressive or 
risk-taking behavior.
    Teenagers with bipolar disorder may have an ongoing combination of 
extremely high (manic) and low (depressed) moods. Although less common, 
it does occur in teenagers. Family history of drug or alcohol abuse 
also may be associated with bipolar disorder in teens. Bipolar disorder 
may begin either with manic or depressive symptoms. Its manic symptoms 
include severe changes in mood, including irritability, a significant 
increase in energy and the ability to go with little sleep, 
distractability, and repeated risk-taking behavior, such as abusing 
alcohol or drugs, or reckless driving. Depressive symptoms include 
persistent sadness, thoughts of death or suicide and a low energy 
level.

Minority and Gay Adolescents

    According to the Surgeon General, from 1980 to 1996, the suicide 
rate for African American males aged 15-19 has increased 105 percent. 
Some research has pointed to increased access to firearms in African 
American communities. The only consistent research findings, however, 
point to very similar risk factors for young African Americans as those 
for white youth, including long-term depression and substance abuse. 
More research is needed to determine what, if any other risk factors 
are attributable to the rise in African American youth suicide.
    There is strong evidence that gay, lesbian and bisexual youth of 
both sexes are significantly more likely to experience suicidal 
thoughts and attempted suicide. A number of studies have shown that the 
increased risk ranges from 2-fold to 7-fold. Gay, lesbian and bisexual 
youths were shown in these studies to carry a number of risk factors 
for suicidal behavior, including high rates of drug and alcohol use. 
Gay adolescents are at significant risk for suicide due to chronic 
bullying and victimization at school.

Prevention

    Public health approaches to suicide prevention have targeted 
suicidal children or adolescents, the adults who interact with them, 
their friends, pediatricians and the media. One initiative is telephone 
hotlines. Although widely used, preliminary research has shown that 
hotlines do not reduce the incidence of suicide. More study is needed 
to determine their overall effectiveness. Some studies have shown that 
restricting young people's access to firearms may result in a short-
term reduction in the rates of suicide, but there is not yet evidence 
that this has a permanent effect.
    Traditional suicide prevention programs used frequently minimize 
the role of mental illness, and, although designed to encourage self-
disclosure by students or third party disclosure by friends, these 
initiatives have not been shown to be effective against suicidal 
behavior. A safer approach might be to focus on the clinical signs of 
depression or other mental illnesses that predispose to suicidality. 
Screening or suicide prevention programs should include procedures to 
evaluate and refer teenagers at serious risk for suicide. It is 
advisable for teachers and counselors to use questionnaires to screen 
for depression and suicidal behavior. Those identified as being at risk 
should be referred to a child and adolescent psychiatrist for further 
evaluation and treatment.

Treatment

    Successful treatment depends on a number of factors, with safety 
considerations being of the utmost importance. The good news is that 
treatment options for mental illnesses, including the disorders that 
lead to suicidal behaviors, are increasing.
    Because of the need to respond to a suicide crisis, treatment 
should ideally be provided within a ``wrap around'' service delivery 
system that includes resources for inpatient, short and long-term 
outpatient, and emergency intervention. Adolescents who have attempted 
suicide should be hospitalized if their condition makes behavior 
unpredictable. Outpatient treatment should be used when the adolescent 
is not likely to act on suicidal impulses, when there is adequate 
support at home, and when there is someone who can take action if the 
adolescent's behavior or mood deteriorates. The prescribing of 
antidepressants to depressed individuals, combined with therapy, has 
been found to be effective in reducing suicides, particularly among 
children and adolescents.

Policy Recommendations

    The AACAP supports the following policies that relate to teen 
suicide prevention and treatment:
     The creation and funding of suicide prevention programs 
which destigmatize mental illness and include screening instruments to 
identify adolescents at risk for suicide.
     Increased access to mental health care will prevent 
adolescent suicide. Barriers to accessing appropriate mental health 
care, including cost and availability of specialists, such as child and 
adolescents psychiatrists, must be removed. Enactment of State and 
Federal mental health parity laws will remove the cost barrier for 
children, adolescents and their families.
     The implementation of community-based early intervention 
strategies which identify children and adolescents with emotional and 
behavioral. Adolescents who display signs and symptoms of these 
problems should be referred for evaluation and treatment by a mental 
health professional who has specific training, experience and expertise 
in working with children and adolescents.
     School-based mental health programs are the first line of 
defense for identifying children and adolescents with emotional or 
behavioral problems. Receiving services in a school-based health center 
is easier than going to a private office or a community clinic for many 
adolescents, especially those from lower-income backgrounds.
     Expanded geographic and financial access to drug and 
alcohol treatment will help prevent adolescent suicide, since drug and 
alcohol abuse presents a high risk factor for suicide.
     Increasing research into the causes of suicide and 
effective treatments.
     Increasing training support for mental health specialists 
like child and adolescent psychiatrists.
     Reform of the juvenile justice system with the inclusion 
of comprehensive mental health services for youth offenders including 
screening, evaluation and wrap-around treatment.
     Reform of the foster care system so that children receive 
comprehensive mental health services including screening, evaluation 
and wrap-around treatment.
     The creation of comprehensive community-based systems of 
care including access to psychiatric hospitalization.
     Increased State and Federal support for child abuse 
prevention. Abused children are at high risk for developing long-term 
depression and other mental illness as a result of abuse.
     Increased State, local and Federal support for adolescent 
pregnancy prevention.
     Increased local, State and Federal support for bullying 
prevention programs in schools and communities. Recent studies have 
revealed that children and adolescents who are bullied are at high risk 
for suicide.
    The AACAP and APA appreciate this opportunity to submit a statement 
for the record for this important hearing. Please contact Nuala S. 
Moore, AACAP Assistant Director of Government Affairs, for more 
information about teen suicide at 202.966.7300, ext. 126.

                               REFERENCES

    (1) U.S. Public Health Service, The Surgeon General's Call to 
Action to Prevent Suicide. Washington, DC: 1999.
    (2) Journal of the American Academy of Child and Adolescent 
Psychiatry, 40:7 Supplement. Practice Parameter for the Assessment and 
Treatment of Children and Adolescents With Suicidal Behavior. July, 
2001.
    (3) American Journal of Psychiatry, 160:11, Supplement. Practice 
Guidelines for the Assessment and Treatment of Patients With Suicidal 
Behaviors. November, 2003.
  Prepared Statement of the American Occupational Therapy Association
    The American Occupational Therapy Association (AOTA) submits this 
statement for the record of the March 2, 2004 hearing. We appreciate 
the opportunity to provide this information regarding the relationship 
of occupational therapy services to meeting the needs of children and 
youth with mental health needs and who are at risk for suicide. It is 
critical for Congress to be aware of issues regarding America's public 
health needs so that it can develop appropriate national policies to 
meet society's needs. The topic of this hearing is critical to the 
development of a better, clearer picture of how to address the growing 
problem of youth suicide.
    Issues related to mental health needs in this country have been 
clearly articulated in numerous sources, including the 1999 Surgeon 
General's report on mental health and the 2003 report of the 
President's New Freedom Commission on Mental Health. These include 
problems in the service delivery system, shortages of service 
providers, negative public attitudes about mental illness, and barriers 
to early identification, screening, and access to services and 
appropriate treatment. Data from the Centers for Disease Control and 
Prevention (2000) indicates that suicide is the third leading cause of 
death among youth, 10-24 years of age. Furthermore, the Substance Abuse 
and Mental Health Services Administration (SAMSHA) reports that 36 
percent of youth who are at risk for suicide (out of nearly 3 million) 
receive any mental health treatment. Many of these mental services are 
provided in schools. This fact speaks to the need for schools to 
effectively utilize and train all school personnel to appropriately 
recognize and address children's mental health needs. Occupational 
therapy services can play an important role in this effort.

How Occupational Therapy Helps Address Children's Mental Health Needs

    Occupational therapy is concerned about an individual's ability to 
perform everyday activities, or occupations, so that they can 
participate in school, at home, at work, and in the community. 
Occupational therapists and occupational therapy assistants provide 
critical services to and for children and youth in a variety of 
educational and community settings, who have a variety of educational, 
learning and behavioral needs, including children that may be at risk 
for suicide. Occupational therapy practitioners use purposeful 
activities to help children and youth bridge the gap between their 
capacity to learn and full, successful participation in education, 
work, play, and leisure activities.
    Occupational therapists look at the individual's strengths and 
needs with respect to daily life performance in school, home and 
community life, focusing on the relationship between the client and 
their performance abilities, the demands of the activity, and the 
physical and social contexts within which the activity is performed. In 
addition, each individual's occupational performance is viewed through 
a psychological-social-emotional lens. This perspective helps the 
occupational therapist to understand what is important and meaningful 
to the child as well as how their past roles, experiences, strengths 
and patterns of coping work together to shed light on current issues 
and problems.
    Occupational therapy intervention for children and youth emphasizes 
functional and readiness skills and behaviors, and includes 
consultation with parents and families, teachers and other 
professionals. Services are directed toward achieving desired outcomes 
that were developed in collaboration with the family and other 
professionals.
    In education-settings, occupational therapists identify the 
underlying performance skills, including motor, process, communication 
and interaction skills that impede the student's ability to participate 
in learning and other school-related activities. Intervention 
strategies and service models are designed to support desired 
educational outcomes, and may be provided individually or in small 
groups. The therapist also works with classroom teachers and the 
student's family to determine how to modify the home or classroom 
settings, routines and schedules to provide structured learning 
opportunities and experiences to support the student's emerging skills.

Why Occupational Therapy?

    Children and youth are being challenged by many societal factors 
and increasingly higher standards of educational performance and 
achievement. They may feel pressure from parents, peers, and others to 
behave in certain ways or to conform to certain expectations that may 
be in conflict with one another. Occupational therapy intervention for 
these students can emphasize new skills, behaviors and more effective 
ways to cope with these challenges. With its roots in mental health, 
occupational therapy practitioners can recognize a child's social and 
emotional skills and assess how well they match the demands of the 
environment.
    Occupational therapy for children/youth at risk for suicide 
utilizes activity-based interventions that serve as the vehicle for 
enhanced self-understanding, provide a reality-based structure, and 
supports skill acquisition or enhancement. Services focus on mobilizing 
both internal and external resources that support the individual's 
self-understanding within the context of a safe, caring relationship. 
Intervention strategies address interpersonal communication and other 
social behaviors. Strategies include helping the child learn to manage 
and organize their behavior and classroom work space and environment, 
and to complete assigned tasks. Intervention may also address 
underlying sensory-motor concerns that affect the student's active 
participation in school activities.
    AOTA believes that occupational therapy is an underutilized service 
that can meet and address the mental health needs of children and youth 
in schools and the community. Services for school-aged children are 
intended to help them succeed in school. Intervention strategies may 
focus on improving the child's information-processing ability, academic 
skill development, and ability to function in the school environment. 
For adolescents, occupational therapy focuses on preparation for work 
life choices, improvement of social and work skills, and learning how 
to create or adapt the environment to maximize productivity.
    AOTA believes that many children and youth who could benefit from 
occupational therapy do not receive services, particularly those with 
mental health needs. This limited access affects both students 
receiving special education under the Individuals with Disabilities 
Education Act (IDEA) as well as students in general education. Often 
this limitation is due to a lack of understanding about how 
occupational therapy can help or because of perceptions that therapists 
only address ``motor'' issues. Occupational therapy training is 
comprehensive and covers physical, psychological, social and 
pedagogical aspects of human occupation. Occupational therapy's 
understanding of human performance, or ``do-ing,'' can be invaluable in 
helping parents and school staff to understand the relationship between 
the physical and psychosocial and how these factors support or impede 
children's progress.

What is Occupational Therapy?

    Occupational therapy is a vital health care service, designed to 
help individuals participate in important every day activities, or 
occupations. Occupational therapy services address underlying 
performance skills, including motor, process, communication and 
interaction skills to assist in the correction and prevention of 
conditions that limit an individual from fully participating in life. 
For children with disabling conditions and other educational needs, 
occupational therapy can help them to develop needed skills within the 
context of important learning experiences and to perform necessary 
daily activities such as feeding or dressing themselves and help them 
get along with their peers at school. Occupational therapy services can 
help identify strategies for teachers and families to use to facilitate 
appropriate reading and writing development.
    Occupational therapy practitioners have the unique training to 
assist individuals to engage in daily life activities throughout the 
lifespan and across home, school, work and play environments. Services 
may be provided during only one period of the child's life or at 
several different points when the child is having difficulties engaging 
in his or her daily school occupations, such as when they are faced 
with more complex demands in the classroom resulting from increased 
emphasis and reliance on written output. Occupational therapy services 
may be provided in the family's home; at school; and in the community, 
such as daycare and preschool programs, private clinics, and vocational 
programs.
    Occupational therapy evaluation determines whether an individual 
would benefit from intervention. The evaluation looks at the 
individual's strengths and needs with respect to daily life function in 
school, home and community life, focusing on the relationship between 
the client and their performance abilities, the demands of the 
activity, and the physical and social contexts within which the 
activity is performed. The findings of the occupational therapy 
evaluation inform the team of the need for intervention. Occupational 
therapy practitioners use purposeful activities to help individuals 
bridge the gap between capacity to learn and full and successful 
engagement in work, play, and leisure activities.
    For example, occupational therapy for infants and young children 
may include remediation of problem areas, development of compensatory 
strategies, enhancement of strengths, and creation of environments that 
provide opportunities for developmentally appropriate play and learning 
experiences. Services for the school-aged child are intended to help 
them be successful in school. Intervention strategies may focus on 
improving the child's information-processing ability, academic skill 
development such as handwriting, and ability to function in the school 
environment. For adolescents, the occupational therapy intervention 
focus is on preparation for occupational choice, improving social and 
work skills, and learning how to create or alter the environment to 
maximize their productivity.
    Occupational therapy is a health and rehabilitation service covered 
by private health insurance, Medicare, Medicaid, workers' compensation, 
vocational programs, behavioral health programs, early intervention 
programs, and education programs. AOTA represents 30,000 occupational 
therapists, occupational therapy assistants, and students. We thank 
you, once again, for the opportunity to submit our comments for the 
record.
                                 ______
                                 
      National Association of School Psychologists,
                                        Bethesda, MD 20814,
                                                 February 23, 2004.
Hon. Mike DeWine, 
Chairman,
Subcommittee on Substance Abuse and Mental Health Services,
Washington, DC 20510.
Hon. Edward M. Kennedy,
Ranking Member,
Subcommittee on Substance Abuse and Mental Health Services,
Washington, DC 20510.

    Dear Senators DeWine and Kennedy: I am writing to you as the 
Executive Director of the National Association of School Psychologists 
to express my support for the SOS High School Suicide Prevention 
Program.
    Schools are an ideal place to reach and teach all students about 
depression and suicide. We have access to students for an extended time 
period. We can guide and reinforce their understanding. We can respond 
to their questions and we can observe and respond to their needs. My 
members appreciate that the SOS Program is flexible--schools can design 
a program as large, or small, as their needs and resources dictate. 
Many schools are incorporating it into their health curriculum.
    The SOS Program teaches teens the signs of suicide--such as the 
words, behaviors, and signals--so that they will recognize them in 
their friends or within themselves. The program outlines action steps 
for dealing with those signs as a Mental Health Emergency, which is the 
unique difference in this program. Teaching teens to recognize and 
appropriately respond to the signs of potential suicidality as a mental 
health emergency bridges crucial awareness with action. This is a 
critical point.
    The program helps teens to understand the important connection 
between suicide and undiagnosed, untreated mental illness--which 
typically involves depression. It teaches that suicide is not a healthy 
or effective way to react to stress or emotional upset. It strives to 
increase help-seeking behaviors in teens by teaching them to ACT. We 
chose the acronym, ACT, to reinforce the programs message of 
empowerment. The A in ACT teaches students to acknowledge that their 
friend has a serious problem; the C encourages students to let their 
friend know that they care about them, and, most importantly, the T 
reminds them to tell a trusted adult.
    Recent history has shown us that, all too often, a student who is 
depressed and thinking of taking his own life--or someone else's life--
will tell a peer beforehand, and many times more than one person. The 
SOS Program teaches students the difference between loyalty to their 
friends and keeping a secret that can kill.
    The SOS Programs advisory board developed a kit of materials. It 
includes information for students and their parents, a Procedure Manual 
for professionals implementing the program, and a video. Titled, 
Friends For Life: Preventing Teen Suicide, this video is the main 
teaching tool of the program and dramatizes the right and wrong ways 
for students to help their friends.
    The program was first introduced in the year 2000; by the second 
year it was in more than 1,000 schools nationwide. The SOS Program has 
an excellent safety profile. Participating schools report a nearly 150 
percent increase in help-seeking among students who took part in the 
program, and approximately 90 percent of site coordinators--usually a 
school psychologist, nurse or counselor--agreed that the program 
brought students in need to their attention. The new study being 
published in the American Journal of Public Health that shows that the 
SOS program reduced suicidal attempts by 40 percent is further evidence 
of the importance of this program.
    The National Association of School Psychologists' 22,000 members 
need and want programs that are easily replicable in a variety of 
school settings using existing staff. I believe that the SOS High 
School Suicide Prevention Program is one such example and that it 
should be fully funded and available to any high school in America who 
wants it. Thank you for your consideration and for all you do to 
support children and youth across the USA.
        Sincerely,
                                          Susan Gorin, CAE,
                                                Executive Director.
                                 ______
                                 
           Prepared Statement of Suzanne Vogel-Scibilia, M.D.
    Chairman DeWine, Senator Kennedy and Members of the Subcommittee, 
NAMI would first like to thank you for your leadership in holding this 
critically important hearing on Suicide Prevention and Youth: Saving 
Lives.
    I am Suzanne Vogel-Scibilia, M.D. of Beaver, Pennsylvania, a member 
of the National Alliance for the Mentally Ill (NAMI) Board of Directors 
and a psychiatrist serving both youth and adults in my practice. In 
addition to serving on the NAMI Board, I am also the mother of five 
children. Two of my children are diagnosed with mental illnesses and 
one of my sons has attempted suicide--so I know first hand about this 
troubling issue, as do many other NAMI families.
    I am pleased today to submit the following testimony on behalf of 
NAMI on the critically important issue of youth suicide and steps that 
must be taken to ensure early intervention and suicide prevention to 
reduce the tragically high number of youth suicides in our Nation.
    NAMI is a nonprofit, grassroots support and advocacy organization 
of consumers, families (including parents and caregivers of children 
and adolescents with mental illnesses) and friends of people with 
serious mental illnesses. Founded in 1979, NAMI today works to achieve 
equitable services and treatment for more than 15 million Americans 
living with mental illnesses and their families.

The Crisis in Youth Suicide and Untreated Mental Illnesses

    Youth suicide is a public health crisis linked to underlying mental 
health concerns. According to the Surgeon General's 1999 seminal report 
on mental health, 1 in 10 youth in the United States suffers from a 
mental illness severe enough to cause impairment. Yet, fewer than 1 in 
5 of these young people receives needed mental health treatment.
    Too many youth in our Nation with mental health needs are not 
receiving any services. The circumstances are worse for African-
American, Native-American, Latino and other youth from ethnically and 
culturally diverse communities--who often bear a greater burden from 
unmet mental health needs (Surgeon General 2001 Report on Mental 
Health: Culture, Race, and Ethnicity).
    We know the staggering long-term consequences for the roughly 80 
percent of youth with mental illnesses who fail to receive services. 
Suicide is the third leading cause of death in youth aged 10 to 24. 
(Centers for Disease Control, 1999) Over 4,000 young lives are lost 
each year to suicide. Studies show that 90 percent of youth who commit 
suicide were suffering from a diagnosable and treatable mental illness 
at the time of their death (Shaffer, 1996).
    It is difficult to imagine the pain associated with losing a child 
to suicide. NAMI wishes to acknowledge the incredible courage that 
Senator Gordon Smith (R-OR) and his wife exhibited at the hearing by 
sharing their recent and unthinkable personal loss of their young son 
to suicide. Their willingness to speak about this tragedy--undoubtedly 
one of life's most painful experiences--and his struggle with mental 
illness helps to raise a much broader awareness about these issues.
    NAMI also appreciates the tremendous work of the Suicide Prevention 
Action Network (SPAN) in raising awareness and educating the public and 
policymakers about suicide and the impact that it has on families and 
communities.
    Suicide is not the only disastrous consequence of untreated mental 
illnesses in youth. They also tragically end up in the criminal justice 
system. According to a recent study--the largest ever undertaken--an 
alarming 65 percent of boys and 75 percent of girls in juvenile 
detention have at least one psychiatric diagnosis. (Teplin, Archives of 
General Psychiatry, Vol. 59, December 2002). The prevalence rates of 
children and adolescents with mental illnesses in the juvenile justice 
system is a moral outrage and speaks to our Nation's failure to build 
an effective mental health treatment system.
    Youth with mental illnesses also have the poorest academic 
achievement and the highest failure and dropout rates of any disability 
group. We must respond to these crises with the necessary political 
will to change the broken mental health system in this country.
    What is the impact of untreated and poorly treated mental illnesses 
in children on families? Simply put--devastating. Stigma and shame 
drive many families away from the treatment system. Suicide severely 
impacts the families left behind--who often wrongly live with extreme 
shame and guilt over not having prevented the death of their loved one.
    More children and young adults die from suicide each year than from 
cancer, AIDS, heart disease, chronic lung disease, stroke, and birth 
defects combined. Our Nation is experiencing a public health crisis 
related to mental illnesses in youth and suicide. The sad reality is 
that we know how to treat most mental illnesses in youth and many of 
these tragedies could be avoided.

What Can Be Done?

    Our Nation simply must make early identification of mental health 
needs in youth and appropriate intervention--a national priority. The 
need to do so is now well documented in report after report.
    Schools and primary care settings are a natural place to conduct 
early mental health screenings and to ensure appropriate interventions 
for children and adolescents and their families. These settings are 
familiar, comfortable and low-stigma places to reach children with 
mental health needs and their families.
    NAMI applauds the work of Laurie Flynn, the national director of 
the Columbia University TeenScreen program and the long-time former 
Executive Director of NAMI. Her testimony outlined the vital need for 
mental health screening for youth and the need to refer young people, 
when indicated, for a more thorough mental health evaluation and 
services. The Columbia University TeenScreen program, recognized in 
President Bush's New Freedom Commission on Mental Health Report, 
represents an effective program to detect mental health concerns in 
youth and to link them to appropriate services.
    We also need to educate and train our Nation's school professionals 
about the early warning signs of mental illnesses. Families express 
grave concern that school professionals often do not understand even 
the basic facts about early onset mental illnesses. Consequently, they 
are not in a position to recognize the early warning signs of these 
disorders and to refer a student for an appropriate evaluation. Also, 
NAMI families report that school officials continue to blame parents 
for a child's mental illness--which often drives youth and families 
away from the treatment system.
    It is also critically important that we identify youth with mental 
health needs and intervene with appropriate services in other child-
serving systems, including--juvenile justice, substance abuse programs, 
the child welfare system and others. Unfortunately, most families 
express grave concern that these systems fail to communicate and fail 
to coordinate services. The children's mental health system and other 
child-serving systems are fragmented and overly bureaucratic. Most 
States and communities fail to offer home- and community-based mental 
health services. Families in crisis are left on their own to navigate 
multiple, complex systems that do not work well. This often results in 
youth falling through the cracks. It is vital that States and child-
serving systems develop effective interagency collaboration to help 
identify youth at risk for suicide and in need of mental health 
services and offer home- and community-based mental health services.
    NAMI is frequently contacted by families from across the country 
that have struggled to get treatment for their child's mental illness. 
Often these families have long since exhausted their private insurance 
benefits for mental health coverage (90 percent of private health 
insurance plans place restrictive and discriminatory caps on mental 
health benefits) and paying for intensive services is simply not 
financially feasible. Most of these families do not qualify for 
Medicaid benefits. State agencies and others tell many families that 
the only way to access critically needed treatment is by relinquishing 
custody of their child to the State. This causes unthinkable stress for 
children and families, hit at their most vulnerable moment.
    One of the key barriers to treatment is the severe shortage of 
available specialists trained in the identification, diagnosis and 
treatment of childhood mental illnesses. Primary care providers report 
seeing a large number of children and youth with mental health 
problems, but have difficulty finding available clinicians to take 
referrals. The Surgeon General's 1999 report found that ``there is a 
dearth of child psychiatrists, appropriately trained clinical child 
psychologists, or social workers.'' Our Nation currently has 
approximately 6,300 child and adolescent psychiatrists with a need of 
32,000 to treat young people with mental disorders. Families are put on 
long waiting lists for mental health services. We must address this 
critical shortage of qualified children's mental health providers.
    Stigma drives youth and families away from the mental health 
treatment system. Families are suffering a great and unnecessary burden 
because of the lack of effective treatment for youth with mental 
illnesses. The broken mental health system all too often leads to 
tragic consequences--including youth suicide.

Immediate Federal Action is Needed to Help Reduce Youth Suicide

    NAMI applauds Senator DeWine and Senator Dodd for introducing 
Federal legislation--The Youth Suicide Early Intervention and 
Prevention Expansion Act of 2004--to help address the youth suicide 
crisis in our Nation.
    This legislation provides States, local governments and other 
eligible entities with funding to develop and implement effective 
statewide youth suicide early intervention and prevention strategies. 
This legislation holds real promise in helping to reduce youth suicide.
    Clearly, though, other steps must be taken to address the youth 
suicide crisis and the unacceptably high percentage of youth with 
untreated mental illnesses. In addition to support for the Youth 
Suicide Early Intervention and Prevention Expansion Act of 2004--NAMI 
asks for Congressional support of the following Federal legislation 
pending in Congress that can make a difference in reducing youth 
suicides in our Nation--
     The Paul Wellstone Mental Health Equitable Treatment Act 
of 2003 (S. 486 and H.R. 953)--parity legislation to end insurance 
discrimination in health insurance against children and adults with 
mental illnesses so that families can access appropriate mental health 
services for their loved ones (NAMI applauds Senators DeWine, Kennedy, 
Bingaman and Reed for cosponsoring this legislation);
     The Keeping Families Together Act (S. 1704/H.R. 3243)--
provides grants to States to develop home- and community-based mental 
health services to serve youth with mental illnesses and their families 
in the least restrictive and most appropriate setting and requiring 
child-serving agencies to collaborate in developing an appropriate 
service system (NAMI applauds Senator Bingaman for cosponsoring this 
legislation);
     The Family Opportunity Act of 2003 (S. 622)--allows States 
the option of expanding Medicaid coverage to low and middle-income 
families on a sliding cost-sharing basis for those families that have 
children with the most intensive mental health service needs (NAMI 
applauds Senators Enzi, Ensign, Kennedy, Bingaman and Reed for 
cosponsoring this legislation);
     The Child Healthcare Crisis Relief Act (S. 1223 and H.R. 
1359)--to address the national shortage of children's mental health 
specialists which acts as a barrier to families accessing timely and 
appropriate services for their child (NAMI applauds Senator Bingaman as 
the sponsor of this legislation and Senator Kennedy for cosponsoring 
the bill).

Conclusion

    Chairman DeWine and Senator Kennedy, thank you for the opportunity 
to share NAMI's views on this important issue. We look forward to 
working with you and all members of the HELP Committee to ensure that 
the Senate acts on the Youth Suicide Early Intervention and Prevention 
Expansion Act of 2004 to reduce youth suicide in this country.
                                 ______
                                 
           University of Connecticut Health Center,
                             Farmington, Connecticut 06030,
                                                 February 23, 2004.
Hon. Mike DeWine,
Chairman,
Subcommittee on Substance Abuse and Mental Health Services,
Washington, DC 20510.
Hon. Edward M. Kennedy,
Ranking Member,
Subcommittee on Substance Abuse and Mental Health Services,
Washington, DC 20510.

    Dear Mr. Chairman and Ranking Member: It is my pleasure to share 
with you the result of an Outcome Evaluation of the SOS Suicide 
Prevention Program.
    The objective of this study was to examine the effectiveness of the 
SOS prevention program in reducing suicidal behavior.
    We conducted the study with 2100 students in five high schools in 
Columbus, Georgia and Hartford, CT. The students were randomly assigned 
to intervention and control groups.
    The results were as follows:
     Significantly lower rates of suicide attempts among those 
exposed to the program--a 40 percent reduction
     Greater knowledge and more adaptive attitudes about 
depression and suicide
    We concluded that the SOS program is the first school-based suicide 
prevention program to demonstrate a significant reduction in self-
reported suicide attempts in a study utilizing a randomized 
experimental design.
    I hope this helps in your efforts to examine the important subject 
of teen suicide. I am available to discuss this study in more detail at 
anytime. I can be reached at (860) 679-3262.
        Sincerely,
                            Robert H. Aseltine, Jr., Ph.D.,
                                               Associate Professor,
            Department of Behavioral Sciences and Community Health,
                           University of Connecticut Health Center.

    [Whereupon, at 11:48 a.m., the subcommittee was adjourned.]

                                    
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