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Testimony on Suicide Among Older Americans by Mark Rosenberg, M.D., M.P.P.
National Center for Injury Prevention and Control
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Before the Senate Special Committee on Aging
July 30, 1996

THE PUBLIC HEALTH APPROACH

Ultimately, CDC's goal is to reduce the incidence of suicide by
applying a scientific, goal-oriented approach to identifying and
implementing effective prevention strategies -- what we refer to
as the public health approach. The public health approach to
suicide prevention combines four fundamental activities:
surveillance to identify patterns and epidemics Of suicide and
the differential rates of suicide; research to identify the chain
of causes leading to suicide; the design and evaluation of
interventions to interrupt this chain and prevent suicide; and
the implementation of programs consisting of proven interventions
(figure 2). Part of the strategy in implementing programs is to
transfer knowledge and skills in prevention to public health
practitioners in communities.

Integration among these components is important. Surveillance
often provides information; hypotheses are often generated and
tested during evaluations of interventions; and programs
frequently provide a source of data for surveillance. Though
they are integrated, I will discuss each component separately:

Surveillance

CDC gathers and publishes data on trends in the number and rates
of suicide by age, sex, race, and method of suicide. These data
are based on information from death certificates, and are
obtained by CDC's National Center for Health Statistics through a
cooperative agreement with states. This provides a surveillance
mechanism used to identify and characterize selected problems.
Surveillance is characterized by the collection, analysis, and
interpretation of health related information that is used for
planning, implementation, and evaluation of public health
programs.

For surveillance purposes, suicidal behavior is measured on a
continuum of seriousness from merely thinking about
self-destruction to actually completing the act. Suicide
attempts resulting in no or very minor injury are almost
impossible to monitor. However, most deaths from suicide are
regularly documented and reported.

In an effort to describe the problem, CDC's surveillance
activities include an ongoing series of surveillance summaries.
This year, the National Center for Injury Prevention and Control
published Suicide in the United States, 1980-1992 that examined
trends in suicide mortality among all age groups. In addition,
NCHS regularly publishes monthly data on suicide mortality in the
Monthly Vital Statistics Reports, available through November
1995, and more detailed information in annual publications. One
of the difficulties in conducting surveillance of suicide and
suicide related behavior is the lack of standardized definitions
of key concepts. Although there is a wide spectrum of behaviors
associated with suicide, we only have standardized and
consistently collected data on completed suicide.

Although CDC has basic information about completed suicides, the
scope of our understanding is limited. Moreover, suicides are
just the tip of the pyramid in regards to the problem of suicidal
behavior as a whole. CDC estimates that for every 1 completed
suicide there are 9 suicide attempts with injuries and 22 total
suicide attempts overall. Suicide attempts cost approximately
$56.4 billion annually in health care costs. Although CDC is
monitoring trends in elderly suicide, we would like to do more to
monitor and describe the problem of nonfatal suicide attempts
among the elderly.

Research

To understand the causes of suicide, research on risk factors has
shown that characteristics for suicide among older persons differ
from those among younger persons. The risk factors for suicide
among older persons include alcohol abuse, depression, greater
use of highly lethal methods, and social isolation. In addition,
older persons make fewer attempts per completed suicide, have
often visited a health care provider shortly before their death,
and have more physical illnesses and affective disorders. The
most recent of NCHS' National Mortality Followback Surveys
included special samples of elderly and of deaths due to suicide.
Data from this survey will be available next year, and will be an
important new source for data on these risk factors.

Understanding the etiology of suicide is essential to
implementing the public health approach. Designing and
implementing effective interventions depends upon identifying
modifiable risk factors. To identify such risk factors,
hypotheses about causal relationships must be generated and
tested using appropriate methodology. For suicide, case-control
methodology is useful in studying self-reported suicidal thoughts
and behavior within population-based cross-sectional survey
designs.

Standardized terminology and measurements for assessing the
reliability and validity of research findings is critical to
advancing the understanding of suicide etiology. Development of
standard definitions is difficult, however. Not only do
researchers disagree about the meaning of existing terms used to
describe suicide and suicidal behavior, but our relatively
undeveloped understanding of suicide and suicidal behavior means
that related concepts are correspondingly undeveloped and
ambiguous. As further research helps to refine our understanding
of suicide and suicidal behavior, it will in turn lead to more
concise definitions of important concepts.

Another barrier to suicide research is the fear that asking
questions about suicidal thoughts and behaviors may upset
respondents. Although some respondents may become upset by such
questions, there is no theoretical basis or empirical evidence to
suggest or support the notion that asking questions about suicide
will cause suicidal behavior. Furthermore, numerous research and
intervention efforts have been completed without any reports of
harm. In order to develop interventions, strong scientific
research must progress while maintaining ethical standards of
avoiding harm.

Intervention Development and Evaluation

After causal relationships are established, interventions are
developed and evaluated. Although the public health perspective
recognizes the importance of secondary and tertiary prevention of
suicide-related injuries, the ultimate goal of public health is
primary prevention.

Interventions may affect the sequence of causes leading to
suicide at several points (figure 3). For example, an
intervention that attempts to improve mental health may interrupt
this sequence before a person even begins thinking about suicide.
Thus, it serves as primary prevention of suicidal thoughts,
suicidal behavior, suicidal injury, and suicide. Crisis
intervention and referral is primary prevention for suicide, but
it may be secondary and tertiary prevention for suicidal thoughts
and behavior. Designing an effective intervention involves
specifying how the intervention will interrupt the causal
sequence. Implementation must be consistent with this
specification, yet in practice, it often is not. Reasons for
this deviation may include insufficient resources and
inadequately trained workers.

Evaluation is an essential component before interventions are
broadly implemented. In this era of limited resources,
identification of effective programs will prevent wasteful
spending of time and money. Programs should be evaluated for
effectiveness using appropriately collected baseline, process,
and outcome measures. CDC has a long and successful track record
of implementing and evaluating prevention programs that work.

Once an intervention has been designed and evaluated, it can be
implemented on a larger scale. Interventions that have already
been implemented should continue to be assessed regarding their
ability to achieve primary prevention goals. Even though few
have been evaluated, numerous prevention programs have been
implemented by federal, state, and local agencies and by
community-based organizations.

Program Implementation

We need to do a better job of evaluating strategies that show
potential for preventing suicide among the elderly. Possible
interventions include:

* Community Gatekeeper Training. This type of gatekeeper
program provides training to community members such as care
providers, clergy, police, merchants, and recreation staff, as
well as physicians, nurses, and other clinicians who see older
patients. This training is designed to help these people
identify older persons at risk of suicide and refer them as
appropriate.

* General Suicide Education. Programs need to be developed
and evaluated that provide older Americans with facts about
suicide, alert them to suicide warning signs, and provide
information about how to seek help for themselves or for others.

* Screening Programs. Screening involves the administration
of a survey instrument to identify high-risk individuals in order
to provide more detailed assessment and treatment. Repeated
administration of the screening survey instrument can be used to
measure changes in attitudes or behaviors over time, to test the
effectiveness of an employed prevention strategy, and to obtain
early warning signs of potential suicidal behavior.

* Peer Support Programs. These programs, which can be
conducted in community-based or other settings, could be designed
to foster peer relationships among older persons at high risk of
suicide or suicidal behavior.

* Crisis Centers and Hotlines. While less-likely to be used
by older persons, these programs primarily provide telephone
counseling for suicidal people. Hotlines are usually staffed by
trained volunteers. Such programs may also offer a "drop-in"
crisis center and referral to mental health services.

* Means Restriction. This prevention strategy consists of
activities designed to restrict access to common means of
suicide, such as firearms and drugs.

* Intervention After a Suicide. We need to evaluate
strategies that help individuals to cope with the crisis
sometimes caused by one or more suicides in a community. They
are designed in part to help prevent or contain suicide clusters
and to help older Americans effectively cope with feelings of
loss that come with the sudden death or suicide of a peer.
Preventing further suicides is but one of several goals of
interventions made with friends and relatives of a suicide
victim-so-called "postvention" efforts.

Because current scientific information about the efficacy of
suicide prevention strategies is insufficient, one intervention
strategy cannot be recommended over another. However, CDC offers
several general recommendations. First, suicide prevention
programs should be linked as closely as possible with
professional primary care providers and mental-health resources
in the community. Second, communities should not rely on only
one prevention strategy. Certain strategies tend to predominate
among prevention efforts, despite limited evidence of their
effectiveness. Promising but underused strategies should be
incorporated into current programs where possible. Third, it is
important to incorporate evaluation into new and existing suicide
prevention programs when practical. Evaluation should include
measures of, or closely associated with, the incidence of
suicidal behavior.

Although a knowledge base for making programmatic decisions is
growing, the need to evaluate interventions is critical. There
is simply insufficient scientifically based, quantitative
information for making decisions about where to spend precious
resources. Nonetheless, we must maintain ongoing interventions
and develop new ones. Finding the balance between service
delivery and evaluative research involves difficult choices. It
is important to note, however, that effective service delivery
requires interventions that have been well planned, well
executed, and carefully evaluated.

Nationally, numerous organizations are implementing an array of
promising suicide prevention interventions. However, there is a
need to develop, implement, and evaluate new innovative suicide
interventions. Individual interventions are the foundation of
most suicide prevention programs, yet it is preferable for
prevention programs to move toward multifaceted approaches that
include numerous interventions and multiple segments of the
community. Community organization and networking should be vital
components to any suicide prevention effort. CDC recommends that
communities organize before they find they are in the midst of a
crisis. Such preparation and implementation may reduce the
likelihood of suicide clusters and may reduce endemic suicide
rates among our older population.

The role of the aging network is critical to implement suicide
prevention programs. The aging network, consisting of 57 State
Units on Aging, 670 Area Agencies on Aging, 221 tribal
organizations, as well as caregivers and volunteers serve on the
front lines all across the nation with elderly persons on a daily
basis and often have direct contact with and can assist in
identifying and treating suicidal or depressed seniors.

In addition, programs administered under the Older Americans Act
through the Administration on Aging, which provide critical daily
home and community based services to individuals 60 and over such
as congregate and home delivered nutrition, information and
referral, legal and ombudsman services, and many others provide
good opportunities to improve health of older Americans, prevent
depression and isolation and provide peer support on a regular
basis.

WHAT ELSE IS CDC DOING ABOUT THE PROBLEM OF SUICIDE?

CDC is collaborating with the Indian Health Service to evaluate
three suicide prevention programs in Native American communities
that were implemented by community members. The project involves
evaluation of suicide surveillance, implementation evaluation,
and outcome evaluation of these multi-faceted suicide prevention
programs. This project is nearing completion with early
indications being that one of the interventions has resulted in a
six-year period without any suicides in the target population.
This program may serve as a model that can be implemented in
other Native American communities around the nation.

Communication is fostered by periodic publication of articles
seen by those in public health and the public through the media.
CDC also helps disseminate information through several community
organizations and academic institutions.

CDC is helping to initiate suicide prevention activities through
various means. These include NCIPC's sponsoring meetings of
local, state, and federal public health officials to develop a
strategy that would enable agencies at. all three levels to enact
a working suicide prevention program. CDC has also worked with
the Health and Human Services' Regions VIII and X to develop
plans for comprehensive suicide prevention activities.

Most of CDC's work in the area of suicide prevention, which
represents the ninth leading cause of death in the United States,
has been conducted by a few of our staff who are also assigned to
work in other areas of injury prevention for part of their time.
In the future, CDC hopes to extend its efforts to evaluate
promising interventions and prevention strategies in the area of
suicide among the elderly, and disseminate information to
communities about the magnitude, causes, and prevention of
injuries resulting from suicide and suicidal behavior. CDC may
also expand its surveillance efforts to include injuries
resulting from nonfatal suicide attempts.

Conclusion

The public health approach to suicide prevention is being adopted
by a variety of federal, state, and local agencies and
community-based organizations. While minor progress has been
made, further development of public health oriented suicide
prevention programs with evaluation components is essential.
Surveillance efforts, especially of suicide-related injuries,
must be further developed and refined. Research into causes of
suicidal thoughts and behavior has only begun to uncover
modifiable risk factors. New innovative interventions need to be
developed and evaluated. Adequate resources need to be allocated
for all of these activities and for broad implementation of
proven interventions.

The public health perspective provides a strong framework and
rationale for developing and implementing suicide prevention
programs. While suicide prevention efforts have progressed, the
framework suggested by the public health perspective has not been
fully implemented. Suicide prevention in the United States needs
more planning, coordination, and resources. With these, the
public health perspective can be used to reduce the emotional and
economic costs imposed on society by suicide and suicidal
behavior among the elderly.

Attached are 3 charts: