On March 11, 1987, four teenagers from a suburban New Jersey community committed suicide by locking themselves inside a 13-car garage and sitting in a car with a running engine. Two of the young people were males aged 18 and 19, and two were females aged 16 and 17. The young women were sisters; the young men were not related. The two men died of a synergism of carbon monoxide poisoning, cocaine, and alcohol; the two young women, of a synergism of carbon monoxide and cocaine. The 19-year-old male had a history of alcohol abuse. Both males had evidence of recent, nonfatal cuts on their wrists. All four teenagers had had trouble in school: three had dropped out of high school, and one had recently been suspended. Both males had been friends of an 18-year-old youth who had died after falling from a cliff 6 months earlier (Table 1). One had witnessed this fall.

Within days after these suicides, the community responded with a number of efforts, coordinated mainly by the municipal government, to prevent other suicides. School officials identified students they thought might be at high risk, such as close friends of the victims or students with a history of suicide attempts, and provided counselors for these students and any others who wanted help. A local suicide hotline was started, and a walk-in center was opened and staffed 24 hours a day. Local police also assisted in locating anyone reported to have threatened suicide or who was thought to be at imminent risk of suicide. The garage where the suicides occurred was locked and put under periodic police surveillance.

Despite these measures, a 20-year-old female and a 17-year-old male attempted suicide together in the same garage by the same means 6 days after the simultaneous suicides. A policeman found them unconscious in a car after noticing that the lock on the garage had been broken. Both were successfully resuscitated. The garage door was removed.

During the following months, the municipal government developed a mental health emergency response plan in cooperation with school officials, clergy, and family guidance and mental health professionals. This plan called for creating a community response team to coordinate the crisis response through four sectors of the community: the municipal government, the school system, mental health agencies, and the clergy. The plan was divided into precrisis planning, crisis operations, and postcrisis programs. For each phase, specific protocols were developed to address such issues as 1) the responsibilities of various community agencies during a mental health crisis, 2) implementation of programs, 3) identification of persons at high risk of suicide or otherwise in need of acute mental health services, and 4) provision of timely information to the public and the media.

An epidemiologic investigation of the suicides and suicide attempts was also carried out. Investigators assessed the comparative magnitude of background suicide mortality for the period 1980-1984* in the community by calculating 5-year suicide rates for residents of the community, the county in which the community lies, New Jersey, and the United States. Local health department and state medical examiner records for January 1, 1986, through March 11, 1987, were also reviewed for all deaths from nonnatural causes among residents of the community.

For this community, the 5-year crude suicide rate was 7.0/100,000 per year (Table 2). The county rate was 6.5 overall and 5.2 for persons 15-24 years of age. These community and county suicide rates are lower than those for both New Jersey and the United States as a whole.

From 1980 through 1986, one or two suicide deaths occurred annually among the residents of this community, for a total of 12 suicides over the 7-year period. Two of these 12 persons who committed suicide were between the ages of 15 and 24. For all of 1987, six persons committed suicide; five of these were between 15 and 24 years old. However, the number of suicides in 1987 would not have been unusually high had it not been for the cluster of four suicides on March 11.

In the 9 months preceding the multiple-suicide incident of March 11, 1987, nine community residents died of nonnatural causes; five were 15-24 years of age (Table 1). One of these five decedents committed suicide, and two died from unintentional injuries. Both of these latter deaths were rumored to have been suicides, but in neither case was the evidence sufficient to justify such a determination. The manner of death was undetermined in one case and is pending in another. Reported by: JW Farrell, MSW, ME Petrone, MD, WE Parkin, DVM, State Epidemiologist, New Jersey Dept of Health. Intentional Injuries Section, Epidemiology Br, Div of Injury Epidemiology and Control, Center for Environmental Health and Injury Control, CDC. Editorial Note: This cluster of suicides in New Jersey is the first investigated by CDC in which all of the decedents committed suicide together in an apparent "suicide pact." Nevertheless, there are more similarities than differences between this cluster in New Jersey and others: 1) as in most other reported suicide clusters (1), the New Jersey decedents were all teenagers or young adults; 2) the imitative suicide attempts on March 17 suggest that suicide may have a "contagious" (2,3) effect; 3) other young people had died from nonnatural causes** before the identified cluster, and these deaths may have influenced the young people involved in the cluster of suicides; 4) the suicide cluster caused anger, confusion, and fear in the community as well as an urgent sense that something needed to be done to prevent other suicides; 5) community leaders felt that the intense demands of the media for information disrupted efforts to address the crisis; and 6) although some opportunities for prevention may have been missed initially, a coordinated community response was developed.

Reports of suicides committed simultaneously by two or more individuals in an apparent suicide pact (multiple simultaneous suicides) are relatively rare. Suicide clusters in general--whether multiple simultaneous suicides or a series of suicides occurring close together in time and space--may account for no more than 1%-5% of all youth suicides (4). Nevertheless, when a suicide cluster does occur, an extraordinary amount of community effort and resources is temporarily devoted to suicide prevention. This is true even when, as in the New Jersey community, background mortality rates do not suggest that the community has any ongoing problem with suicide.

Such a response by a community faced with a suicide cluster is appropriate. Anecdotal evidence suggests that suicides early in a cluster may influence the persons who commit suicide later in the cluster. There is also research evidence that exposure to a suicide that was not part of a cluster may lead certain persons to take their own lives (5,6). Thus, it is prudent for a community faced with a suicide cluster to make every effort to anticipate and prevent additional suicides among susceptible individuals.

In some circumstances, a community may want to consider implementing a suicide response plan before a cluster has begun. Many of the suicide clusters of which CDC is aware have been preceded by one or more deaths due to injuries (either intentional or unintentional) among teenagers or young adults in the community. For example, in the New Jersey cluster, the multiple simultaneous suicides occurred after four traumatic deaths among persons 15-24 years of age in a 9-month period. In other clusters, the first suicide of the cluster had been recognized at the time by school officials or others as being particularly stressful for many students and young adults. Both of these situations suggest the possibility of anticipating and thus preventing such clusters.

In November 1987, the New Jersey Department of Health and CDC cosponsored a workshop on community responses to suicide clusters. Participants included individuals who had played key roles in community responses to nine suicide clusters, including the New Jersey cluster. These persons represented different sectors, including local government, school systems, and crisis centers; the medical community; mental health organizations; university research programs; and state and federal public health agencies. Also participating at that workshop were representatives from the National Institutes of Mental Health, the Indian Health Service, the American Association of Suicidology, and the Association of State and Territorial Health Officials. Based on ideas from this workshop, recommendations are being developed for a plan that community leaders could implement to prevent or contain suicide clusters. These recommendations will be published in an MMWR supplement later in the year. References

1. Coleman L. Suicide clusters. Boston: Faber and Faber, 1987.

2. Robbins D, Conroy RC. A cluster of adolescent suicide attempts: is suicide contagious? J Adolesc Health Care 1983;3:253-5.

3. Davidson L, Gould MS. Contagion as a risk factor for youth suicide. In: US Department of Health and Human Services. Report of the Secretary's Task Force on Youth Suicide. Vol. 2: Risk factors for youth suicide. Washington, DC: US Government Printing Office (in press).

4. Gould MS, Wallenstein S, Kleinman M. A study of time-space clustering of suicide: final report. Atlanta, Georgia: Centers for Disease Control, September 11, 1987; contract no. RFP 200-85-0834 (P).

5. Phillips DP, Carstensen LL. Clustering of teenage suicides after television news stories about suicide. N Engl J Med 1986;315:685-9.

6. Gould MS, Shaffer D. The impact of suicide in television movies: evidence of imitation. N Engl J Med 1986;315:690-4. *Population estimates for later years were not available. **The earlier deaths were from suicide and unintentional injuries.

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