[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
1. Moscicki EK. Epidemiology of suicide. In: Jacobs DG, ed. Guide
to Suicide Assessment and Intervention. San Francisco: San Francisco;
1999:40-51.
2. Murphy SL. Deaths: final data for 1998. In: National Vital
Statistics Report 48(11). Hyattsville, MD: National Center for Health
Statistics; 2000.
3. Joffe RT, Offord DR, Boyle MH. Ontario child health study:
suicidal behavior in youth age 12-16 years. American Journal of
Psychiatry. 1998;145(11):1420-1-423.
4. Kann L, Kinchen SA, Williams BI, Ross JG, Lowry R, Grunbaum JA,
Kolbe, LJ. Center for Disease Control and Prevention. Youth risk
behavioral surveillance--United States. In: CDC Surveillance Summaries.
June 9, 2000;49:No. 22-5.
5. Ploeg J, Ciliska D, Dobbins M, Hayward S, Thomas H, Underwood J.
A systematic overview of adolescent suicide prevention programs.
Canadian Journal of Public Health. 1996; 87(5):319-324.
6. Garland A, Whittle B, Shaffer D. A survey of youth suicide
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7. Kalafat J, Elias MJ. Suicide prevention in an educational
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9. Randell BP, Eggert LL, Pike KC. The immediate post-intervention
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10. Shaffer D, Garland A, Vieland V, Underwood M, Busner C. The
impact of curriculum-based suicide prevention programs for teenagers.
Journal of the American Academy of Child and Adolescent Psychiatry.
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11. Vieland V, Whittle B, Garland A, Hicks R, Shaffer D. The impact
of curriculumbased suicide prevention programs for teenagers: an 18-
month follow-up. Journal of the American Academic of Child and
Adolescent Psychiatry. 1991;30:811-815.
12. Shaffer D, Craft L. Methods of adolescent suicide prevention.
Journal of Clinical Psychiatry. 1999; 60(supp. 2):70-4.
13. Jacobs DG, Brewer M, Klein-Benheim M. Suicide assessment: an
overview and recommended protocol. In: Jacobs DG, ed. Guide to Suicide
Assessment and Intervention. San Francisco: San Francisco; 1999:3-39.
14. Brent DA, Kolko DJ. The assessment and treatment of children
and adolescents at risk for suicide. In: Blumenthal SJ, Kupfer DJ, eds.
Suicide Over the Life Cycle: Risk Factors, Assessment, and Treatment of
Suicidal Patients. Washington, DC: American Psychiatric Press;
1990:253-302.
15. Lewinson PM, Rohde P, Seeley JR. Psychosocial risk factors for
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Psychology. 1994; 62:297-305.
16. Andrews JA, Lewinsohn PM. Suicidal attempts among older
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19. Davis JM, Sandoval J. Involving peers in suicide prevention.
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20. Kellam SG, Koretz D, Moscicki EK. Core elements of
developmental epidemiologically based prevention research. American
Journal of Community Psychology. 1999; 27:463-482.
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23. Aseltine RH Jr. An evaluation of a school-based suicide
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25. Raudenbush S, Bryk A, Cheong YF, Congdon, R. HLM 5:
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26. Rossi PH, Freeman HE. Evaluation: A Systematic Approach 5.
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27. Sankoh AJ, Huque, MF, Dubey, SD. Some comments on frequently
used multiple endpoint adjustment methods in clinical trials.
Statistics in Medicine. 2000; 16, 2529-2542.
28. Aicken M, Gensler, H. Adjusting for multiple testing when
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Journal of Public Health. 1996; 86:726-728.
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awareness programs in the schools: effects of gender and personal
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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.]