Just had a chance to read a report put out by well meaning people on the topic of suicide prevention in youth. In that report the author kept repeating about the many community and school-based programs that have been proven to prevent youth suicide. While I wish that this was true, it is simply not the case. So I am going to write a few blogs about how we know if a program actually prevents youth suicide or not. The first issue is what does the program measure as an outcome?

If a program intends to prevent suicide it must measure suicide. No other measure can be substituted. To my knowledge, there is no data available on this key outcome variable in reports about these community and school-based programs. Instead, we read that some programs increase knowledge about suicide or even decrease the incidence of self-harm behaviors over a short period of time. These are what we call proxy measures and these do not predict changes in suicide rates. We have many examples of interventions that change proxy measures and yet have no impact on the key outcome measure. You can not determine the depth of a well by measuring the length of the pump handle!

Unfortunately, too many people use these proxy measures as “proof” of suicide prevention and go about putting these programs into place. This is a big problem. Not only do we not know if these programs decrease suicide or not, but we do not know if they do any harm! Some early research showed that well intended school interventions actually increased suicide rates! And, guess what, the decrease in suicide rates begin well before suicide prevention programs were put into place and occurred in locations where these programs never existed!

“Fools rush in where angels fear to tread”. “It is not enough to do something. It is imperative that we do the right thing”. “The road to hell is paved with good intentions. Remember all these cautions?” Could be that they apply to so called suicide prevention programs also?

–Stan

Last week, there appears an article in the San Francisco Chronicle about suicide deaths due to jumping from the Golden Gate Bridge http://www.sfgate.com/cgi-bin/blogs/inmarin/detail?&entry_id=55733.  According the Chronicle, last year there were 31 deaths, the year before that there were 34.  Over 1,300 people have died by suicide from jumping from the bridge since it was built.

And what is the essence of the story?  Apparently the Marin County Coroners Office wants to recommend suicide prevention barriers and this is controversial.  And guess what – more studies are apparently recommended.

Now, readers of this blog know how committed I am to research.  You also know that I am committed to action.  Will putting up an appropriate barrier decrease the rate of successful suicides by jumping from the bridge?  Highly likely.  Is this a good thing.  For sure.  So why is it not being done.  Who knows?

I remember the hard work that went into getting barriers erected on the Bloor St. Viaduct in Toronto.  There the effort was lead by a young man with lived experience of mental illness.  I know of the hard work that went into getting a barrier erected on the MacDonald Bridge in Halifax.  There the effort was lead by a mother who had lost her son to suicide from the bridge.

It the courageous activity of people like those Toronto and Halifax citizens that seems to be necessary before authorities can act.  I am so proud to know and support those leaders and I thank them for everything that they have done and continue to do in this regard.  What I don’t get is this.  Why is it so hard to do the right thing when it comes to mental health action?

Recently, my research team published a scientific commentary in the Canadian Medical Association Journal dealing with an important mental health concern.  We conducted an assessment of the information dealing with psychological debriefing in schools and found that there was no substantive evidence to support the use of that kind of intervention following traumatic events.  We also found that the best available evidence in studies of adults showed that these type of interventions were not helpful, and indeed in some studies turned out to be harmful (see: Psychological debriefing in schools, www.cmaj.ca Online publication, January 4, 2010)…

Yet, these interventions have been very popular and used so frequently that they have become commonplace.  Who has not heard the news on the radio that grief counselors have been dispatched to a school after a traumatic event?

This raises a very important issue.  That is, before we start wide-scale mental health interventions we need to be pretty sure that they work and we need to be really sure that they do not cause harm.  If we put programs into place that do not work we are creating a false sense of security and using scare resources; money and people, to no good end.  Furthermore, because of our investment in such programs we may be less interested in considering other options – options that may actually work.  In other words, what seems like a good idea may not be a good idea and if that gets codified or ingrained in an organization or institution it may have more negative than positive consequences.

So, what is to be done?  First, when we do get solid substantive evidence that what we are doing does not really work, is not cost effective, could be done better in a different way or may cause harm – we should stop doing whatever that is that we are doing.  Sounds simple but it is not so easy.  Usually because there has been a big investment in the initial program and there may even be a big industry and local champions pushing for its continuation.  Second, before putting in a program we should demand solid substantive evidence that the program really works and that it causes no harm. Third, if we decide to put programs in without the kind of evidence we need to have, we better make sure that we also provide the kind of independent and unbiased research that is needed to help us determine if the program works or not, if it is cost effective and it does not lead to harm!

We have to do the right thing, not just do something.

–Stan

Today I saw an article about the movie Avatar.  This article tells all who read it that this movie is causing people to become depressed and suicidal.  What a bunch of journalistic hokum. (http://www.news.com.au/entertainment/feature/avatar-perfection-causing-depression/story-e6frfnv0-1225819063598). 

What this likely illustrates is what a topic of a previous blog has been: the inappropriate use of the word “depression”.  People do not become clinically depressed after watching a movie; they may however experience a variety of negative feelings (or sometimes positive feelings).  We do not call the feeling state that a movie such as Chariots of Fire engenders “mania”.  No, on the contrary.  We call it; uplifting, joyous, awesome, elevating, etc.  Why do we call negative feelings “depression”?

There are so many other words to use.  Our language is so rich in words that describe affect.  So let’s use some of them: dispirited; demoralized; dysphoric; distressed; disgruntled; disaffected; pathic; etc. And while we are at it, lets give reporters who may not know how or can not be bothered to write clearly. (or  who are using emotive words to sell copy),  a clear message that these headlines are of no value in furthering our understanding of the human spirit.  Can a movie stir our emotions? Totally!  Does it cause mental disorder?  No!

–Stan

Some of us think we have a problem in our suicide research and in our suicide prevention approaches.  Actually there may be many problems with those (stay tuned for future blogs) but one of the concerns is the meaning of the statistics when it comes to the definition of “suicide attempt”.

A suicide attempt can be defined as a purposeful self-injury with the intent to die.  A self-harm attempt on the other hand can be defined as a purposeful self-injury without the intent to die.  Self-harm can be the result of many different factors, including but not limited to: difficulties with problem solving, difficulties with impulse control, copycat phenomenon,  social or situational control, etc.  Increasingly, research is showing that young people who self-injure may be substantially different from those who attempt suicide.  So what does this mean?

Hospitals that use the ICD system (and that is all of them) tend to code self-injury as a suicide attempt.  Even DSM at the time of this writing, does not allow for differentiation of self-injury from suicide attempt.  Could it be that many of our statistics about suicide attempts are incorrect?  Could it be that “truths” that we think we know – such as more females attempt suicide than males – may not be accurate but may be an artifact of not separating out self-harm attempts from suicide attempts?

And what about suicide prevention programs?  Does a decrease in reported incidents of self-harm equal a decrease in real suicidal behaviour – that is suicide attempts?  That does not mean that we should not try to bring down self-harm attempts, but it may mean that the methods useful for one outcome may not be useful at all for another outcome.

Actually, I think its time that we started to think more critically about what we mean when we use the words “suicide attempt”.  Is it really a suicide attempt or is it a self-harm event?  It is an important distinction.  Both are important targets for interventions – public health type and clinical type.  We need to separate them out in our statistics and we need to separate them out in our programs.  Then we can get a better handle on what is actually happening and what we can do about it.

-Stan

Today’s Los Angeles Times carried a front page local story regarding youth suicide in Palo Alto: “Palo Alto campus searches for healing after suicides”.   Although details are sketchy and of course incomplete, the story points out that there has been a cluster of suicides involving students from the same school campus over a short period of time, occurring in the same place and under similar circumstances.  As expected, such tragic events have caused substantive community consternation.

Youth suicide is a very emotional issue.  It cuts to the very core of our families and our communities.  It leaves scars in parents, siblings, grandparents, other family members, friends and many others.  It elicits strong responses from individuals or from communities.  Some of those responses are of grief – private and shared with only a few.  Some of those responses are very public – it is not clear what motivates them or how these differ from the private responses.  Some of these responses may be helpful – such as support and counseling from family and friends.  Some of these responses may be harmful – such as bringing in grief counselors and creating community emotional contagion in the wake of a suicide.  Some of these responses may be neither helpful nor harmful – but may be costly.  So, what can be done?

Here the evidence is not fully in yet and each situation begs careful assessment and considered planning before anything is started.  What is not helpful is putting into place those things we know do not work.  What is likely not helpful is grief contagion.  This can be created by mass grief counseling and enthusiastic and well meaning initiatives to “do something”.  What may be useful is identifying young people who know the victims and addressing their mental health needs and emotional concerns.  What may be useful is for the newspapers and television and radio stations to stop running front page stories and prime time news about youth suicide.  This does not mean that we do not talk about it.  This does not mean that we avoid the topic.  Not at all!  This means that we address this tragic and emotionally issue rationally and responsibly.

-Stan

Another  World Suicide Prevention Day (September 10, 2009) has passed and in many locations a variety of activities were underway across Canada, for example, community suicide awareness walks such as the one that has been initiated in New Minas/Kentville Nova Scotia and one that will be occurring in Halifax on the weekend following. The Canadian Broadcasting Corporation has presented a number of stories on the topic and the London Free Press newspaper has announced that it will publish obituaries in which suicide can be identified as a cause of death. The president of the Canadian Association for the Prevention of Suicide is quoted as saying that a national suicide prevention strategy is needed. All in all, there is increasing awareness of the importance of this issue nationwide.

Unfortunately, in all the media reports I have seen or heard on this issue there has been not one mention of what I consider to be the most important item that needs to be addressed. That is, based on solid scientific evidence we already know what to do to decrease suicide rates, so why are we not doing those things? Marches are good for raising awareness but do we need to march to put effective programs into place?

So what do we know helps bring down suicide rates? First of all is the identification and effective treatment of people who are living with a mental illness – especially depression, bipolar disorder and schizophrenia. Second is the reduction of access to lethal means – be that through control of handguns or barriers on bridges. Third is the creation of “gatekeeper” programs in organizations such as schools or similar institutions. In this way those individuals at highest risk can be identified and interventions provided to them. None of these are difficult to do. None of these are costly to develop and implement. So why are they not universally in place?

Health care systems are notoriously inert – change comes very slowly and often inefficiently. Stigma against the mentally ill pervades the health care system and providers are not immune from its insidious effects. Could this be a reason why those relatively simple and proven effective approaches are not already in place everywhere? Where are our legislators - provincial/territorial and federal? Why are they not demanding that these approaches are in place and properly supported? Perhaps it is because they feel no pressure to do so. Perhaps the scientific evidence and moral imperatives are not enough. Perhaps they need a push from the people.

So, what do I have to say about this? Walk on. Speak out. Demand change. Demand that what we already know works be implemented. Demand that we learn more. Crush the stigma and let the science lead us to do what works best!

Dr. Stan Kutcher

Sun Life Chair in Adolescent Mental Health

IWK and Dalhousie University

FOR IMMEDIATE RELEASE July 30, 2009

As millions of college students graduate college this year, mtvU, MTV’s 24-hour college network and The Associated Press today revealed the results of a new poll examining the emotional health of college students as they face a global recession and a receding job market, finding that more than half of college seniors are worried they won’t be able to secure a job after graduation.

The study finds that although financial pressures are a major source of daily stress, they do not surpass worries about academic performance. The economy has definitely taken a toll with concerns about finding a job ranking high among stressors, and intensified struggles reported by the almost one in five students whose parents have experienced job loss. Additionally, an alarming number of college students are struggling with mental health issues, but many are not actively seeking out the help that they need. Despite all of this, young people are generally happier than they were last year, are adapting to their environment by switching their majors, going to graduate school or making other proactive changes in their lives, and maintain positive attitudes about the value of their college experience.

The mtvU and Associated Press study follows a month of on-air and online mtvU programming exploring how college students are impacted by increasing financial pressures as part of mtvU and The Jed Foundation’s ongoing “Half of Us” campaign. A similar study examining the impact of stress, mental health struggles, the economy, and other issues facing college students was conducted in 2008 by mtvU / AP in conjunction with “Half of Us.”

Detailed findings from the 2009 study include:

STRESS ON CAMPUS

With 85 percent of students reporting that they experience stress on a daily basis, up from 80 percent last year, it’s clear that stress is a prevalent factor on college campuses today. However, even in light of larger national issues, academic concerns like school work and grades, with 77 percent and 74 percent respectively, maintain their positions as the top drivers of student stress. Financial woes followed close behind, with 67 percent stating that money matters accounted for a lot or some of their daily stress.

In the face of stress and uncertainty, 82 percent maintain positive attitudes surrounding their college education, feeling that it has been worth the time and financial investment.

At the same time, the study shows that stress is taking a serious toll on the everyday lives of college students, affecting them academically and socially:

• Six out of 10 students report having felt so stressed they couldn’t get their work done on one or more occasions.
• 53 percent of students report feeling so stressed they didn’t want to hang out with friends on one or more occasions.

DEPRESSION, SUICIDAL THOUGHTS AND GENERAL MENTAL HEALTH

The mtvU/AP polls from 2008 and 2009 confirm that mental health struggles are common among the college audience and continued efforts are needed to educate students on avenues for seeking support. When stress becomes excessive and impacts a student’s ability to function, it can have severe consequences, especially for students with a mental health condition. Low energy levels, sleep troubles and appetite issues are among the most common indicators of emotional health problems experienced by students, and nearly one out of every 10 students are reporting signs of moderate to severe depression, and an alarming number of students have reached crisis mode:

• 17 percent of students overall report that their friends have talked about wanting to end their lives.
• 10 percent report having a friend who has made a suicide attempt.
• Seven percent report that they have seriously thought about ending their own lives in the past year.

84 percent of students know where they would go for help if they were coping with emotional distress, with 77 percent turning to friends and 67 percent reaching out to their parents for help. Only half of students report that they are familiar with counseling resources available on their campus, and even fewer students actively seek them out. Among students reporting symptoms of moderate to severe depression, 47 percent of state that they are not familiar with the counseling resources available on their campuses, and only 32 percent received any support or treatment from a counselor or mental health professional since beginning college.

Additional findings from this poll can be found at http://www.halfofus.com/press.aspx.

Official press release

A new report will better position government and its partners to help Nova Scotians at risk of attempting suicide.

The report, Suicide and Attempted Suicide in Nova Scotia, was released today, July 15. Its purpose is to help those who work in the areas of suicide prevention, intervention and support.

“Suicide is a very complex and sensitive public health issue,” said Dr. Robert Strang, Nova Scotia’s chief public health officer. “We need to talk about it more and better understand it to ensure the right programs and supports are in place to help Nova Scotians.”

The report describes the conditions surrounding suicide and attempted suicide in Nova Scotia. The data is based on hospital and vital statistics records of suicides and suicide attempts from 1995 to 2004. It examines demographic factors, how people attempt suicide and complete suicide, and the types of health-care services used by Nova Scotians at risk.

“This report is a baseline we can use to evaluate future efforts on this important issue, and we’ve made good progress since 2004,” said Dr. Strang. “We’ve developed a suicide prevention framework to reduce suicides and attempted suicides, we’re doing additional research with the medical examiner’s office, and we fund our community partners who work with Nova Scotians.”

Dr. Stan Kutcher, Sun Life Financial Chair in Adolescent Mental Health, a partnership with the IWK Health Centre and Dalhousie University, said that even though suicide and suicide attempt rates are decreasing, and Nova Scotia is experiencing lower suicide rates than most Canadian provinces, there is more to be done.

“Improving care for people with mental disorders, enhancing the capability of health care and education professionals to identify people at risk, promoting overall good health and resiliency, and improving access to good mental health care, can all help further reduce Nova Scotia’s suicide rates.”

Highlights of the report include:

• The rate of hospitalizations for suicide attempts declined by 30 per cent over the 10-year period
• 55 per cent of those hospitalized were female
• Lower income was associated with higher rates of both hospitalizations for suicide attempts and suicide deaths
• The rate of suicide death declined from 11 to nine individuals per 100,000
• Nova Scotia’s suicide rate was lower than the national average, nine out of 100,000 individuals compared to 11 out of 100,000
• 84 per cent of suicide deaths were male
• 55 per cent of suicide deaths were previously diagnosed with a mental disorder

The report is available online at www.gov.ns.ca/hpp.

Thanks to Mr. Steve Snider the CEO of the Halifax-Dartmouth Bridge Commission for finally moving to install a barrier that will substantially increase the difficulty of completing suicide from the MacDonald Bridge.

Many large cities have a “favoured” location to which individuals contemplating suicide congregate. In Halifax-Dartmouth, the MacDonald Bridge is one of those places. The fact that it is conveniently close to a major mental health facility only serves to accentuate its importance in this problem.

Since the impetus to complete suicide often waxes and wanes, actions that can substantially delay the final act leading to suicide may deter the suicidal individual from acting and may increase the probability of choosing life instead. Indeed, many people who have decided not to complete suicide or who have survived a suicide attempt go on to live positive and productive lives and when reflecting on their suicide considerations are very pleased that they did not go through with their plans.

Restriction of lethal means is one of the few public health measures that have been associated with decreasing suicide rates. Although method substitution is technically possible, research studies have not been able to demonstrate a clear pattern of this occurring when a bridge barrier is erected. So is it likely that putting up a barrier on the MacDonald Bridge will save lives? Probably. Will it send a clear message of concern for this important health issue? Totally! Is it about time this happened? Absolutely!

Actually, important as the role that Mr. Snider had in moving this agenda forward, the true heroes of the story are Carol Cashen and a concerned group of citizens and mental health advocates. As many residents of Halifax-Darthmouth Ms. Cashen is a public health nurse and the mother of a young man who took his life by jumping from the MacDonald Bridge. Together with other members of the community , with the input of the Canadian Mental Health Association and with responsible print and electronic media reporting Carol and the citizens of Halifax-Dartmouth were able to accomplish what the professionals and government were not able to do. They have made the difference. They are the people we all have to be thankful to.

Further Reading:
AJA Award winner: Adam’s Fall, by Matthieu Aikins
Mother calls for screen to stop bridge jumpers

~ Dr. Stan Kutcher

(photo credit)