Hello, my name is Alex Crosby.

I work as a medical epidemiologist in

the division of Violence Prevention at
the Centers for Disease Control and
Preventions Injuries Center.
Today, what I'm going to talk about
is the public health approach to
preventing suicidal behavior.
I wanted to thank the people at
Emery University for the invitation.
And what I will do,
is I will try to layout for
you, the public health approach
to preventing suicidal behavior.
It's an important topic,
as many of you may be aware.
It's one of the leading causes of death in
the United States and around the world.
And not just a leading cause of death but
also has a significant burden
of morbidity and mortality.
Those who are made ill.
Those who made suicide attempts.
The families, the friends, the communities
that are effected by suicidal behavior.
As I mentioned, why is suicidal
behavior a public health issue?
Many people approach suicidal behavior as
strictly a mental illness related problem.
That does limit the ability to
look at the different strategies,
the different solutions,
the recommendations, the research.
And so by looking at suicidal
behavior as a public health issue,
it broadens our ability to
bring in more instruments.
Bring in more disciplines.
Bring in more different, diverse
populations that can be involved in
the solution of trying to
address suicidal behavior.
Why should it be addressed
as public health issue?
Well, one thing is the morbidity and
mortality.
In the United States,
it is the 10th leading cause of death.
In 2011, that's our most recent
mortality data, accounted for
over 39,000 deaths in the United States.
It's estimated that almost half a million,
over 480,000 emergency department visits
for self-inflicted injury in 2012.
There are many health consequences
as a result of suicidal behavior.
Physical, mental, behavioral,
reproductive, and
sexually transmitted diseases can all
be associated with suicidal behavior.

There's an impact that

public health can make.
If it wasn't able to do anything
then maybe it shouldn't be part of
a public health approach.
But public health can help in
the aspect of approaching and
addressing suicidal behavior
because of its focus on prevention.
Because of the science base that's
associated with public health, and
also because it stresses
a multi-disciplinary approach.
Thirdly, the mission of public health
includes the issue of suicidal behavior.
Part of the mission of public health
is to reduce the amount of disease, or
adverse health conditions, premature death
and disease producing discomfort and
disability in the population.
This is what the public
health approach looks like.
And oftentimes, it's depicted
in these four different stages.
One is assessing the problem.
What's the who, what, when,
where of a particular issue?
Next is identifying the causes.
What are the risk factors,
the protective factors, the ideology?
Why did it happen?
Then moving on to developing and
evaluating programs and policies.
Trying to figure out what works and
what doesn't, so
that you can apply it to the problem.
And then, lastly,
implementation and dissemination.
How do you do it?
How do you take what you've learned and
spread the news?
That's the dissemination part.
How do you get information out to
the communities that are trying to
address the problem?
And then implementation,
taking those programs and
actually applying them in a diverse
range of different locations.
First, I'll talk a little bit
about assessing the problem.
Here's what suicidal behavior looked
like in the United States in 2011.
These are deaths due to suicide.
One thing that's remarkable
about this is that males die of
suicide about four times higher,
four times higher rate than females.
And you can especially see that
kind of the two peaks in regards to

male suicide rates are among those over

age of 70 and those in the middle age.
But that's particularly pronounced in
terms of looking at females that have
died of suicide in which their
highest rates are among those in
their forties and fifties.
Another aspect of looking at assessing
the problem is what are the methods that
occur and I've been demonstrated as the
predominant methods in regards to suicide.
As you can see in the United States,
over 50% of the suicides,
a firearm was in the mechanism of that.
Around the world you could see that
there is quite a range in terms of
how suicide rates affect
different populations.
From areas in Asia that have
very high suicide rates.
To those in some places in South America
that have very low suicide rates.
And so these are some of the things that
can affect what happens in regards to
suicide and how people try to address it.
Deaths are just really one
piece of the puzzle in
regards to looking at suicidal behavior.
In the United States, using 2011 as
an example, over 39,000 deaths with a rate
of 12.3, over 147,000 hospitalizations,
the rate of 47.2 per 100,000.
So, you can see just in regards to those
two aspects that the rate of deaths to
hospitalizations, hospitalizations
are about four times higher.
And then we look at emergency department
visits, over 400,000 emergency department
visits due to self inflicted injury,
a rate of 157.4.
And so the magnitude of the burden
increases as you move from deaths,
to hospitalizations,
to emergency department visits.
And then when we've done surveys,
in which we've asked people in the past 12
months have you made a suicide attempt?
Those numbers tend to be even bigger.
Among adolescents, about 8% of
all adolescents reported in 2013
that in the past 12 months they've made
a suicide attempt, about 1% of all adults.
This is the data in regards to
emergency department visits for
self-inflicted injury.
One of the contrasts here between this
data and the data regarding deaths due to
suicide is that you can see the highest
rates are among adolescents and
young adults.

Whereas with deaths due to suicide,

highest rates were among middle age and
older adults.
The other thing here is,
I mentioned that males die of suicide
about four times higher than females.
But you can see in almost every age group
here among emergency department visits,
females have more predominance
in terms of victimization.
So it's important to look at the contrast
between fatal and non-fatal behavior.
Identifying the causes, why did it happen?
There's much research
that has tried to look at
the issues regarding various
aspects of suicidal behavior.
One of the ways is looking at
the social ecological model.
What that does is it tries to
look at individual level factors,
factors that effect the family and
the peer level.
The other factors that look
at the community level.
And then others that look
at the societal level.
The individual level might be things
like age, like sex, like mental illness.
At the family and
peer level it may be exposure to
violence or previous victimization.
Or history of violence in the family.
Whether that's interpersonal violence,
assault related or self-inflicted violence
that others in the family have
been victims of suicidal behavior.
At the community level, it may be
things like looking at spirituality,
which is actually a protective factor.
Or aspects like social isolation and
social social network and social support.
Social isolation being the risk factor.
Social support being
the protective factor.
And then at the societal level, it may
be inappropriate access to lethal means.
Things like the economy have been
demonstrated to play a role in
suicidal behavior along with
aspects like geography and culture.
The next aspect of the public
health approach is developing and
evaluating programs and policies.
What works and what doesn't,
and the various schemes for
trying to take a look at applying
prevention practice to suicidal behavior.
As you see across the, the top row,
universal programs that try to do

a program within the entire population.

Those might be things that are done across
a whole community, across a whole school.
One aspect might be restricting
access to lethal means.
And then second is selective interventions
that look at at-risk populations.
Things like gatekeeper programs in
which you try to train people to be on
the lookout for those that might
be at-risk for suicidal behavior.
And then an example in the indicated type
of strategy are those that are high-risk
individuals in which you are treating
those that have exhibited a risk factor.
So, for instance, maybe those that have a
previous suicide attempt, that you try to
prevent them from repeating that attempt
or dying as a result of suicide.
There are also integrated programs in
which they try to incorporate all of
those different kinds of strategies.
Universal, selective, and
indicated strategies.
The United Nations and World Health
Organization, for example, back in
the early 90s released recommendations for
how nations can develop national
strategies for suicide prevention that
incorporate a broad range of strategies.
And then the U.S. Air Force back in
the 90s also developed a program that
incorporated a number of
different kinds of strategies.
From universal strategies, in which
they targeted the whole Air Force,
all the way to those that were more
indicated in which they tried to
identify those that were
at-risk individuals.
Lastly, implementation and dissemination
and one example of that is the U.S.
National Strategy for Suicide Prevention.
That strategy was just revised and
released in 2012,
it has four strategic directions,
13 goals, 59 objectives.
The strategic directions try
to incorporate a wide range of
different kinds of approaches.
Healthy and empowered individuals,
families, and
communities are one of
those strategic directions.
Another is developing clinical and
community preventive services, so not just
services directed at medical care, but
also those kind of preventive services
that might be addressed to a broad
range within the community residents.

There's also treatment and

support services.
And then lastly, surveillance,
research and evaluation.
How do we better identify the extent of
the problem, the burden, the magnitude?
What kind of research needs to go
into trying to identify factors in
which we can make modifiable changes?
And then evaluation.
How well are we able to tell, whether our
programs are working, they're not working,
what kind of difference are they making?
In conclusion, suicide is
a significant public health problem.
It affects a broad range
within our society.
The tenth leading cause of death,
affects many families, communities,
relatives and friends.
It results from an interaction
of various factors.
From factors that occur within
an individual, within a family,
within a community, within a society.
There's never a single
item that causes suicide.
And so we really have to
address it from a broad range.
There are multiple opportunities for
action which allow many different ways in
which prevention practitioners
can make an effect.
Research has shown much of suicidal
behavior can be prevented.
Oftentimes suicidal behavior
had been looked at as
something that was unavoidable.
And unpreventable, but nothing,
anybody could do about it.
But actually, research has shown that
there are things that we can look at and
know that these are risk
factors that can be addressed.
There's a broad responsibility for
addressing the issue of suicidal behavior.
Communities must work together.
Because it is a societal problem,
there's no one agency or
one organization that
can do it by themselves.
It's not just public health.
It's not just the medical community.
It's not just the schools and education.
It's not just social services.
Not just law enforcement, but all of
them working together across a broad,
a broad range of different kinds
of strategies, disciplines,
organizations, that can really make

the difference in suicidal behavior.

And it has been demonstrated that those
kind of approaches can make a difference.
Thank you very much.