the patterns and prevention of suicidal behavior

1

The patterns and prevention of suicidal

behavior2019 National Conference of State Legislatures

Convening

Oct 2019Alex E. Crosby

Division of Violence Prevention (DVP),

Centers for Disease Control and Prevention (CDC)

Atlanta, GA

"The findings and conclusions in this presentation have not been formally

disseminated by the Centers for Disease Control and Prevention/the Agency for

Toxic Substances and Disease Registry nor the Substance Abuse and Mental

Health Services Administration and should not be construed to represent any agency

determination or policy."

2

Learning Objectives

❑At the conclusion of the session, participants

should be able to:

▪ Describe why suicide is an important public health

problem

▪ Describe the magnitude of suicidal behaviors

▪ Identify high risk groups for suicidal behaviors

▪ Identify risk and protective factors for suicidal behavior

▪ Cite examples of useful interventions to prevent suicide

3

Why use a public health approach to prevent

suicidal behavior?

❑ Because suicide is a complex and multi-factorial issue, no one sector or

system can address it alone o It encourages emphasis on upstream, midstream and downstream efforts in

promoting successful results

❑ Because it is comprehensive, coordinated and collaborativeo It requires involvement and partnership from many sources

❑ Because if we wait for people at risk for suicide to show up in medical

offices we won’t stop the rise in suicide in the US

❑ Because it works and it is necessary… everyone has a role in preventing

suicideo Examples - motor vehicle safety, vaccines, tobacco cessation, heart disease,

workplace safety, infectious disease control, HIV/AIDS

4

Clinical Interventio

ns

Long-Term Interventions

Policy

Socio-economic factors

Smallest impact

Largest impact

Source: Frieden TR. A framework for public health impact: The health impact pyramid. AJPH 2009

Factors that Affect Health: Health Impact

PyramidExamples:

Eat healthy; be physically

active

Rx for high blood pressure;

high cholesterol; diabetes

Immunizations; colonoscopy

Fluoridation; smoke-free

laws; tobacco tax

Poverty; education; housing;

inequality

Counseling

& Education

5

Different Forms of Violence

CHILDHOOD ADOLESCENCE ADULTHOOD

Peer Violence

Suicidal Behavior

Child Maltreatment:

physical, sexual, emotional, neglect

Dating Violence

Sexual Violence

Intimate Partner Violence

Elder Abuse

Bullying

6

Public Health Approach to

Suicide Prevention

❑The public health approach

seeks to answer the

foundational questions:

• Where does the problem

begin?

• How could we prevent it from

occurring

in the first place?

❑To answer these questions,

public health uses a

systematic, scientific method

for understanding and

preventing suicide.

1. Define and monitor the

problem

2. Identify risk and protective factors

3. Develop and test prevention

strategies

4. Disseminate successful strategies

widely

7

The Public Health Approach

to Prevention

1. Define and monitor the problem


3. Develop and test prevention strategies


widely

8

Leading causes of death – United States,

2017

Rank Cause Number of deaths

1 Heart Disease 647,457

2 Malignant Neoplasms 599,108

3 Unintentional Injuries 169,936

4 Chronic Lower Respiratory Ds 160,201

5 Cerebrovascular Ds 146,383

6 Alzheimer’s Disease 121,404

7 Diabetes mellitus 83,564

8 Influenza and pneumonia 55,672

9 Nephritis 50,633

10 Suicide 47,173

Source: CDC vital statistics

9

0

5

10

15

20

25

30

1933

1938

1943

1948

1953

1958

1963

1968

1973

1978

1983

1988

1993

1998

2003

2008

2013

Year

Ra

te p

er

10

0,0

00

po

pu

lati

on

Male

Female

Total


Suicide among all persons by sex -- United

States, 1933-2017

10

Suicidal rates among males by age group -- United

States, 1999 and 2017

0

5

10

15

20

25

30

35

40

45

^10-14 15-24 25-44 45-64 65-74 75+

Age group

Ra

te p

er

10

0,0

00

1999

2017

Source: CDC National Vital Statistics

74%

35%

27%45% 6%

- 6%

11

Suicidal rates females by age group --

United States, 1999 and 2017

0

2

4

6

8

10

12

^10-14 15-24 25-44 45-64 65-74 75+

Age group

Ra

te p

er

10

0,0

00

1999

2017

Source: CDC National Vital Statistics

240%

93%

42%62%

51%

-11%

12

Suicidal rates among by race/ethnicity -

- United States, 1999 and 2017

0

5

10

15

20

25

30

35

40

Males

1999 2017

0

2

4

6

8

10

12

Females

1999 2017

Source: WISQARS and Curtin SC, Warner M, Hedegaard H. Suicide rates for females and males by race and ethnicity: United States, 1999 and 2014. NCHS Health E-Stat. National Center for Health Statistics. April 2016.

13

Leading causes of death for selected age

groups – United States, 2017

Rank 10-14 years 15-19 years 20-29 years 30-39 years 40-49 years 50-59 years

1 Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Unintentional

Injuries

Malignant

Neoplasms

2 Suicide Suicide Suicide Suicide Malignant

Neoplasms

Heart

Disease

3 Malignant

Neoplasms

Homicide Homicide Malignant

Neoplasms

Heart

Disease

Unintentional

Injuries

4 Congenital

Malformations

Malignant

Neoplasms

Malignant

Neoplasms

Heart

DiseaseSuicide Liver

Disease

5 Homicide Heart

Disease

Heart

Disease

Homicide Liver

Disease

Diabetes

Mellitus

6 Heart

Disease

Congenital

Malformations

Diabetes

Mellitus

Liver Disease Diabetes

Mellitus

Chronic Lower

Respiratory Ds

7 Chronic Lower

Respiratory Ds

Diabetes

Mellitus

Congenital

Malformations

Diabetes

Mellitus

Cerebro-

VascularSuicide

8 Cerebro-

Vascular

Influenza and

Pneumonia

Complicated

pregnancy

Cerebro-

Vascular

Homicide Cerebro-

Vascular


14

0

10

20

30

40

50

00-0

4

05-0

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

485

+

Age Group in years

Rate

per

100,0

00 p

op

ula

tio

n

Males

Females

Suicide rates among all persons by age and

sex--United States, 2017


15

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

0-4

^5-9

^10-

14

^15-

19

^20-

24

^25-

29

^30-

34

^35-

39

^40-

44

^45-

49

^50-

54

^55-

59

^60-

64

^65-

69

^70-

74

^75-

79

^80-

84^8

5+

Age Group

Nu

mb

er

of

death

s

0

3

6

9

12

15

18

21

Ra

te p

er

10

0,0

00

po

pu

lati

on

Rate

Number


Suicides and suicide rates among all

persons -- United States, 2017

16

DC

Age-adjusted suicide rates among all persons by

state -- United States, 2017 (U.S. avg 14.0)

11.0-14.0

6.6-11.0

14.1-18.9

19.0-28.9


Rate per

100,000

17

0

2

4

6

8

10

12

14

16

18

20

22

1999

2002

2005

2008

2011

2014

Year

Ra

te p

er

10

0,0

00

po

pu

lati

on

Non-core (non-metro)

Micropolitan (non-metro)

Small metro

Medium metro

Large fringe metro

Large central metro


Suicide rates by level of county urbanization among

persons aged ≥10 years – U.S., 1999-2015

18

Burden of injury

Hospitalizations

Emergency Dept visits

Events reported on surveys

Unreported events

Deaths

19

Number and ratio of persons affected by suicidal thoughts

and behavior among adults aged ≥18 years — United

States, 2016

*Source: CDC’s National Vital Statistics System,†Source: Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) only 1st diagnosis§ Source: Source: CDC’s National Electronic Injury Surveillance System-All Injury Program ¶ Source: SAMHSA’s National Survey on Drug Use and Health

** Source: SAMHSA’s National Survey on Drug Use and Health

Number in parentheses represent the ratio of deaths to other categories

Deaths*

Hospitalizations †

Emergency Department visits§

Suicide attempts ¶

Seriously considered suicide**

43,427 (1)

114,725 (2.6)

397,975 (9.1)

1,319,000 (30.4)

9,829,000 (226.3)

20

0

50

100

150

200

250

300

350

400

450

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

465

+

Age Group in years

Ra

te p

er

10

0,0

00

po

pu

lati

on

Males

Females

Self-inflicted injury among all persons by

age and sex--United States, 2017

Source: CDC WISQARS NEISS-AIP

21

45K

54%

Nearly 45,000 lives lost to suicide in 2016.

Suicide rates went up more than 30% in half of states since 1999.

More than half of people who died by suicide did not have a known mental health condition.

30%

54%

Results

Source: Stone DM, Simon TR, Fowler KA, Kegler SR, Yuan K, Holland KM, Ivey-Stephenson AZ, Crosby AE. Vital Signs:

Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015.

MMWR Morb Mortal Wkly Rep 2018;67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1

22

DC

Percent change in annual age-adjusted suicide rates,*

state -- United States, from 1999-2001 to 2014-2016

Incr 6-18

Decrease 1

Incr 19-30

Incr 31-37

Percent

change

Incr 38-

58

23

l

Many factors contribute to suicide among those

with and without known mental health conditions.

Relationship

Problem

(42%)

Crisis in the past

or upcoming two

weeks (29%)

Physical health

problem (22%)

Criminal legal

problem (9%)Loss of housing

(4%)

Job/Financial

problem (16%)

Problematic

substance use

(28%)

Note: Persons who died by suicide may have

experienced multiple factors. Data on mental

health conditions and contributing factors are from

coroner/medical examiner and law enforcement

reports. It is possible that mental health conditions

or other contributing factors could have been

present and not diagnosed, known, or reported.

SOURCE: CDC’s National Violent Death Reporting

System, data from 27 states participating in 2015

Source: Stone DM, Simon TR, Fowler KA, Kegler SR, Yuan K, Holland KM, Ivey-Stephenson AZ, Crosby AE. Vital Signs:

Trends in State Suicide Rates — United States, 1999–2016 and Circumstances Contributing to Suicide — 27 States, 2015.

MMWR Morb Mortal Wkly Rep 2018;67:617–624. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a1

Trends in State Suicide Rates — United States, 1999–2016

and Circumstances Contributing to Suicide — 27 States,

2015

24


to Prevention





widely

2525

Socioeconomic Position(of groups)

Social ClassGender

Race/Ethnicity

Sociopolitical and Economic Context

Governance

Macroeconomic Policies

Social Policies

Public Policies

Culture and Societal Values

Structural Determinants of Health Inequities

Education

Income/Wealth

Occupation

Impact on Equity in Health

and Well-Being

Living andWorking Conditions

Behavior and Biological Factors

Psychosocial Factors

Intermediary Determinants of Health

Health Systems

Social Cohesion and Social Capital

Conceptual Framework on the Social

Determinants of Health

World Health Organization (WHO)

Adapted from Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. WHO

26

Population attributable risk (%) estimates for

risk factors for suicidal behavior

Risk factor Males Females

Psychiatric disorder

Affective disorder 26.3 31.6

Substance abuse 19.0 25.4

Anxiety disorder 4.6 11.7

Personality disorder 15.2 5.5

Socioeconomic factors

Income 10.2 4.0

Education 40.9 20.3

Occupation 33.1 6.8

Unemployment 4.0 2.2

Source: Li Z, 2011

27


to Prevention





widely

28

http://www.cdc.gov/violenceprevention/pub/technical-packages.html

Helping States and Communities Take Advantage of the Best Available Evidence

Source: Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., & Wilkins, N. (2017). Preventing Suicide: A Technical

Package of Policy, Programs, and Practices. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease

Control and Prevention.

29


to Prevention





widely

30

National Strategy for Suicide

Prevention (NSSP)

❑4 strategic directions; 13 goals; 60 objectives

❑Strategic Directions

1.Healthy and Empowered Individuals, Families, and Communities

2.Clinical and Community Preventive Services

3.Treatment and Support Services

4.Surveillance, Research, and Evaluation

Source: U.S. Department of Health and Human Services (HHS) Office of the

Surgeon General and National Action Alliance for Suicide Prevention. 2012

National Strategy for Suicide Prevention: Goals and Objectives for Action.

Washington, DC: HHS, September 2012

31

Taking Action

Guidance for State and Local Health Agencies and Other Stakeholders

VetoViolence.cdc.gov

32

7 phases in comprehensive

violence prevention

Evaluation

Partnership

Implementation

Planning Policy Efforts

AdaptationStrategies and Approaches

35

Conclusion

• Suicide is a significant public health problem

• Results from an interaction of factors• never a single item that causes a suicide

• multiple opportunities for action

• Research has shown much of suicidal behavior can be prevented

• Broad responsibility for addressing the issue

• communities must work together

• no one person or group can do it alone

36

Thank You

For more information please contact

Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

37

Questions and Comments

38

Extra slides

39

Technical Package Development

Review of

literature

Identification of

strategies & approaches

Written draft

Review by

partners

Editing and formatting

of final product

Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., & Wilkins, N. (2017). Preventing

Suicide: A Technical Package of Policy, Programs, and Practices. Atlanta, GA: National Center for Injury

Prevention and Control, Centers for Disease Control and Prevention.

40

0

2

4

6

8

10

12

14

16

18

1999

2002

2005

2008

2011

2014

2017

Year

Ra

te p

er

10

0,0

00

po

pu

lati

on


Suicide rates among persons aged

10-24 years by age group – U.S., 1999-2017

10-14

15-19

20-24

41

Leading causes of death by ethnicity –

United States, 2017

Source: CDC Vital Statistics

Rank White Black American

Indian/AN

Asian Latino

1Heart Disease Heart Disease Heart Disease Malignant

NeoplasmsMalignant Neoplasms

2Malignant Neoplasms

Malignant Neoplasms

Malignant Neoplasms

Heart Disease Heart Disease

3Chronic Low Respiratory

Unintentional Injuries Unintentional Injuries

Cerebrovascular Unintentional Injuries

4Unintentional

InjuriesCerebrovascular Diabetes Mellitus Unintentional Injuries Cerebrovascular

5 Cerebrovascular Diabetes Mellitus Liver Disease Diabetes Mellitus Diabetes Mellitus

6Alzheimer’s Disease Chronic Low

RespiratoryChronic Low Respiratory

Alzheimer’s Disease Alzheimer’s Disease

7Diabetes Mellitus Homicide Cerebrovascular Influenza and

pneumoniaLiver Disease

8Influenza and pneumonia

Kidney Disease Suicide Chronic Low Respiratory

Chronic Low Respiratory

9Suicide Alzheimer’s Disease Influenza and

pneumoniaKidney Disease Suicide

42

0

5

10

15

20

25

30

35

40

00-0

4

05-0

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

465

+

Age Group in years

Rate

per

100,0

00 p

op

ula

tio

n

Eur-Amer NonLatino

Afr-Amer NonLatino

Native American Non-Latino

Asian-PI Non-Latino

Latino

Suicide rates by ethnicity and age

group -- United States, 2013-2017

Source: CDC Vital Statistics

43

0

3

6

9

12

15

18

21

1999

2002

2005

2008

2011

2014

2017

Year

Rate

per

100,0

00 p

op

ula

tio

n

Age-Adjusted

overall

15-24

25-34

35-44

45-54

55-64

65+


Suicide Among All Persons by Selected Age

Groups in Years United States, 1999-2017

45

Suicide Variables*

➢ Current depressed mood

➢ Current mental health problem

➢Other mental health diagnosis

➢ Current treatment for mental

illness

➢ Ever treated for mental illness

➢ Alcohol problem

➢Other substance problem

➢Other addiction

➢ Job problem

➢ School problem

➢ Financial problem

➢ Anniversary of a traumatic event

➢ Person left a suicide note

➢ Disclosed intent to commit suicide

➢ History of suicide attempts

➢ Crisis in past 2 wks

➢ Physical health problem

➢ Intimate partner problem

➢ Other relationship problem

➢ Suicide of friend or family in past 5

years

➢ Other death of friend or family in

past 5 years

➢ Recent criminal legal problem

➢ Eviction/loss of home

*Source: Nat’l Violent Death Reporting System

46

Military and Veteran Suicide

Surveillance

▪ Findings and Impacts

▪ Intimate partner problems are just as important as mental health problems

Impact: Submitted DoD proposal to evaluate “Strength at Home” program re suicide-related outcomes

▪ Military /Veteran suicides mostly involve firearms and are highly concentrated in small % of counties

Impact: Informed 2017 DoD Safe Firearm Storage Policy

Intimate Partner Problems (54%)

Mental Health Problems (53%)

Both Problems (29%)

Break up/divorce = 35%Recent argument = 31%Abandonment = 28%Infidelity = 18%IPV = 14%

DepressionPTSD

Source: Logan JE, Fowler KA, Patel NP, Holland KM. Suiicide Among Military Personnel and Veterans Aged

18–35 Years by County—16 States. American Journal of Preventive Medicine. 2016; 51 (Supp 3):S197-S208.

ISSN 0749-3797. https://doi.org/10.1016/j.amepre.2016.06.001.

47

Suicide by method – United States, 2017

Firearms

50.6%

Suffocation

27.7%

Cut/pierce

1.8%

Poisoning

13.9%

Fall

2.4%

Other

3.6%

sa


48

Overlap of spheres of influence for

suicidal behavior

Individual Peer/Family

• Spirituality

• Incarceration

• Social isolation vs

supportCommunitySociety

• Age

• Sex

• Mental illness

• Substance misuse

• Stressful life events

• Inappropriate access

to lethal means

• Geography

• Economy

• Cultural values

• Family history of

interpersonal or self-

directed violence

• Exposure to violence

the patterns and prevention of suicidal behavior

Documents