Working Together to De-stigmatize Mental Health and Enhance Suicide Prevention

Remarks as prepared; not a transcript.

RADM Steven K. Galson, M.D., MPH
Acting Surgeon General
U.S. Department of Health and Human Services

Address to the University of Missouri-Kansas City

September 4, 2008
Kansas City, MO

I am pleased to be with you today.

H-H-S Secretary Michael Leavitt and the Dr. Joxel Garcia, the Assistant Secretary for Health, and I, extend greetings and best wishes to you.

I applaud the Kansas City Suicide Awareness and Prevention Program (KCSAPP) and your partners for all that you are doing to bring attention to the issue of suicide prevention in this community and throughout Missouri and Kansas. 

Your leadership is commendable; I am honored to be part of and applaud your efforts during Suicide Prevention Month (September), Suicide Prevention Week (Sept. 7-13), and World Suicide Prevention Day (Sept. 10).  

We need to keep pushing to get the word out during these days, weeks, months and all year round – that suicide is preventable – that with help there is hope!

Before I turn to my main subject - enhancing suicide prevention and raising awareness about behavioral and mental health care and services - I want to share with you the H-H-S vision for American health care.

Value-Driven Health Care

H-H-S Secretary Leavitt and I, indeed the entire leadership of the H-H-S  have been talking about the critical need for change in American health care and how important it is that we have a system which is value driven.

As the Secretary says, “...consumers know more about the quality of their television than about the quality of their health care.”

At H-H-S, we are committed to bring about a future in which consumers:

... can compare doctors, not just on what they charge, but also in the quality of the care they give, and

... approach health care the way they would any other major purchase.

We foresee a future in which:

... Personalized health care - service delivery carefully tailored to meet an individual’s needs - is the norm.

... Every American is insured – every citizen, without exception, has access to basic health insurance at an affordable price.

This leads me to discuss the priorities that we have in the Office of the Surgeon General.

My Priorities

As Acting Surgeon General, I serve as our nation’s chief “health educator”- responsible for giving Americans the best scientific information available on how to improve their health and reduce the risk of illness and injury.  

My first priority is Disease Prevention. Right now, we spend the vast proportion of our health care dollars in this country treating preventable diseases.

There is a need to move from a treatment-oriented society to a prevention-centered society in which healthy lifestyles are promoted and sustained.

Seven out of 10 Americans die each year of preventable chronic illnesses such as heart disease, diabetes and cancer.

The medical care costs of people with chronic diseases account for as much as $1.4 trillion of the nation’s medical care costs.

A modest increase in the time, emphasis and resources we invest to prevent chronic diseases will save lives and potentially reduce healthcare costs.

This increased emphasis on prevention includes, of course, continual advances in suicide prevention, a topic I’ll turn to a bit later.

My next priority is Public Health Preparedness - we must be prepared to meet and overcome challenges to our health and safety, whether natural or man-made.

Emergency preparedness has increasingly become a major part of the H-H-S mission to protect, promote, and advance the health and safety of the nation.

In fact, my office oversees the 6,000-member Commissioned Corps of the United States Public Health Service.

These officers are available to respond rapidly to urgent public health challenges and emergencies.

And preparedness is multi-dimensional. It must also involve planning by every level of society, individuals, families, and communities.

Another priority is the Elimination of Health Disparities.

A couple of illustrations:

• African Americans are 1.5 times as likely as non-Hispanic whites to have high blood pressure.
• Cancer is the second leading cause of death for most racial and ethnic minorities in the United States.
• For Asians and Pacific Islanders, cancer is the number one killer.
• Hispanics are 50 percent more likely than non-Hispanic whites to die from diabetes.

Unfortunately, these statistics go on and on.

It is imperative that things change, and we need to work collaboratively to improve health care access.

Another one of my priorities that coincides directly with health disparities is a term we call Health Literacy.

In 2003, an estimated 77 million American adults, about 36 percent of the population, were reported to be at or below basic health literacy levels (Source: National Center for Education Statistics, Institute for Education Sciences).

We cannot make improvements in health care and prevention if our messages aren’t being understood because of language and education barriers.

Moreover, improving the public’s understanding of mental health and mental illness, and improved suicide prevention are both “about” reduced health disparities and improved health literacy.  

There is much at stake. The burden is enormous.

In the past year (2007), there were an estimated 24.3 million, almost 11 percent, of adults aged 18 or older in the United States met the criteria for Serious Psychological Distress (SPD) - meaning survey respondents endorsed having symptoms at a level known to be indicative of having a mental disorder.   (Source: SAMHSA/NSDUH 2007)

Mental disorders are the leading cause of disability in the United States and Canada, accounting for 29.6 percent of all years of life lost to disability and premature mortality.

Moreover, as you know suicide is the 11th leading cause of death in the United States, accounting for the deaths of 32,000 Americans each year – an average of 1 person every 16 minutes. 

That is almost twice as many people who die from homicide.   We need to create a sense of urgency.  inform the public and build the will for change.

Suicide is a preventable tragedy.  In 1999, the Office of the Surgeon General’s Call to Action declared suicide as one of the Nation’s most serious public health problems. 

Guided by the National Strategy for Suicide Prevention published by HHS in 2001, a multitude of program and informational efforts from the public and private sectors have worked to educate the public, media, healthcare and public service communities about the risk of suicide and what can be done to help prevent it.

As a Nation we have supported the development of services for helping individuals at risk and for addressing the needs of survivors and their families.  All these efforts are designed to not only save lives but build a more hopeful future for everyone affected by this problem.

However, the annual numbers of deaths from suicide remain stubbornly persistent and in some groups may be growing.  

Clearly much more MUST be done. 

Financing; misunderstanding the seriousness of mental illness; not knowing where to go for services; and worries about negative opinions are all barriers to recovery – and roadblocks for prevention.

So the important question becomes, how do we eliminate these barriers?  I believe we must erase stigma by erasing the word from our conversations and must replace it with hope.

The task before us is to find new, innovative approaches and messages to get the word out to Americans that mental illness is an illness much like any other. 

Our efforts and work together across the country must be focused on providing information, building a sense of the familiar and guiding people in the right direction. 

People with mental illnesses need information to seek and obtain services that best fit their needs.  Families and communities need information to promote full inclusion and recovery of people with mental illnesses. 

Every American needs to understand mental illnesses are very real.  Treatment works.  Recovery is the expectation.  Help for mental health problems should be sought with the same urgency as any other health condition.   And just like any other health condition, compassion and understanding should be the reaction.

Blaming stigma as the problem has and will continue to fall short.   We must offer hope.   The hope for recovery is the driving force that has most recently taken conversations about cancer and AIDS from hushed whispers to national expectations for new research, the highest quality care, and compassion.  

In line with providing the message of hope, the process of cultural change begins at home - I’m pleased to tell you that the SAMHSA-funded Resource Center to Address Discrimination and Stigma Associated with Mental Illness decided to change its name to the “Resource Center to Promote Acceptance, Dignity and Social Inclusion Associated with Mental Health.”

The process of attitudinal change also must start early.

SAMHSA’s Campaign for Mental Health Recovery was established to encourage and educate, people between the ages of 18 and 25 to support their friends who are experiencing mental health problems.

The prevalence of serious mental health conditions in this age group is almost double that of the general population, yet young people have the lowest rate of help-seeking behaviors.

When we launched the Campaign at the National Press Club, the Office of the Surgeon General and our partners highlighted the campaign theme—What a Difference a Friend Makes—which promotes social acceptance.

The opportunity for recovery is more likely in a society of acceptance, and this initiative is meant to promote cultural change toward acceptance and decreasing the negative attitudes that surround mental illnesses.

While we are working to get the message out – we are also building capacity to deliver on the promise of suicide prevention. 

The National Suicide Prevention Lifeline, funded by SAMHSA (1-800-273-TALK), immediately routes callers to the nearest of 135 networked crisis centers.

(Calls from Kansas are automatically routed to “Headquarters Counseling Center” in Lawrence. If the line is busy, the caller is immediately routed to a backup center. The same holds for calls from Missouri, which are initially routed to either “Behavioral Health Response” or “Life Crisis Services” in St. Louis).

In the past year, nearly half a million calls were answered by Lifeline counselors across the Nation.   To reach out specifically to our returning veterans, SAMHSA partnered with the Department of Veterans Affairs last year to use Lifeline as a conduit for a new VA Suicide Prevention Hotline.

Veterans and  family members calling the Lifeline who “press 1” are automatically routed to a specialized veterans crisis center where they have immediate access to more than 150 Suicide Prevention Coordinators in their local VA medical centers.

The Garrett Lee Smith Campus Suicide Prevention program is assisting colleges and universities in creating a comprehensive approach to prevent suicide attempts and completions and to enhance services for students with mental and behavioral health problems, such as depression and substance abuse, which put them at risk.

The 34 current grantees include Northwest Missouri State University (in Maryvale), Linn State Technical College (in Linn, Missouri) and Kansas State University (in Manhattan).

And, if you do not know already, SAMHSA is currently accepting applications for new Campus Suicide Prevention Grants.

The Suicide Prevention Resource Center, also funded by SAMHSA provides prevention support, training, and resources to help states and organizations to develop suicide prevention programs, interventions, and policies. There is a wealth of information on its website: www.sprc.org.

We are also building on existing suicide prevention programs and community infrastructure through our State/Tribal Youth Suicide Prevention Program grantees.  

By developing a tribal or statewide network of youth-serving facilities and organizations, such as schools, juvenile justice systems, substance abuse programs, and foster care systems, our grantees are enhancing the provision of suicide prevention services in their communities. Since this program began in 2005 SAMHSA has awarded 36 grants to State and Tribal organizations.

It is clear that suicide risk encompasses the lifespan. 

Older Americans have among the Nation’s highest suicides rates, particularly those aged 75 and older. 

And, the magnitude of the suicide problem is amplified when attempts and ideation are considered.  It is estimated that there may be between 8 and 25 attempted suicides for every death.  Once again, these numbers vary by age. 

For young adults aged 15-24, it is estimated that there is one suicide for every 100-200 attempts, while among adults 65 and over, there is one suicide for every 4 attempts.   

I discussed earlier the emphasis we place upon prevention with my office and within H-H-S.  Suicidal behavior is complex. Some risk factors vary with age, gender, or ethnic group and may occur in combination or change over time.

Clear language...health literacy... families and friends knowing what to do in a crisis, is crucial:

If you think someone is suicidal, do not leave him or her alone. Try to get the person to seek immediate help from his or her doctor or the nearest hospital emergency room, or call 911. Eliminate access to firearms or other potential tools for suicide, including unsupervised access to medications.

Professional referral services are as vital as they are commonplace; and the suicide prevention lifeline and its network of community-based crisis centers is literally life saving.

The benefits of research sponsored by the National Institutes of Health and its NIMH, while less immediate in effect than acute intervention, offers the prospect of steady and continual improvement in suicide prevention: I am talking about a decline in the rates of suicide attempts for years into the future.

These scientific studies help determine which factors can be modified to help prevent suicide and which interventions are appropriate for specific groups of people.

Before being put into practice, prevention programs should be tested through research to determine their safety and effectiveness. 

For example, because research has shown that mental and substance-abuse disorders are major risk factors for suicide, many programs also focus on treating these disorders.

Studies showed that a type of psychotherapy called cognitive therapy reduced the rate of repeated suicide attempts by 50 percent during a year of follow-up.

A previous suicide attempt is among the strongest predictors of subsequent suicide, and cognitive therapy helps suicide attempters consider alternative actions when thoughts of self-harm arise.

Specific kinds of psychotherapy may be helpful for specific groups of people.

For example, scientists report that a treatment called dialectical behavior therapy reduced suicide attempts by half, compared with other kinds of therapy, in people with borderline personality disorder (a serious disorder of emotion regulation).

The medication clozapine is approved by the Food and Drug Administration for suicide prevention in people with schizophrenia. Other promising medications and psychosocial treatments for suicidal people are being tested.

Since research shows that older adults and women who die by suicide are likely to have seen a primary care provider in the year before death, improving primary-care providers' ability to recognize and treat risk factors may help prevent suicide among these groups.

In that connection, I want to speak for a moment about what might be considered an under-appreciated part of public health and medical care: I’m referring to federal Community Health Centers.

For more than 40 years, Health Resources and Services Administration (HRSA)-supported Health Centers have provided comprehensive, services to medically underserved communities and vulnerable populations.

Health centers are community-based and patient-driven organizations that serve populations with limited access to health care. These include low income populations, the uninsured, those with limited English proficiency, migrant and seasonal farm workers, individuals and families experiencing homelessness, and those living in public housing.

Our community health centers have access to a large segment of the population.   For example in 2006, Health Resources and Services Administration (HRSA) funded more than 4,000 health center sites that served more than 16 million low-income patients around the country. 

Consistent with the message ‘change begins at home,’ we need to take behavioral health service to the people where they are and not wait until they are in crisis. 

By encouraging health care professionals to identify at-risk populations and intervene early, we can significantly reduce the burden of substance abuse and mental illness among Americans and our social institutions. 

Since 2001, health center sites have seen a 170% increase in the number of patients receiving mental health care, from 176,000 to an estimated 470,000.  During this time period, health center sites have also reported a 20 percent increase in the number of patients receiving substance abuse services, from 76,000 to an estimated 92,000. 

In fact, right here in Kansas City, the Swope Parkway health center offers the following Behavioral Health Care Programs: adult community support, children community support, adult and child outpatient counseling, comprehensive substance abuse treatment and school-based prevention, intervention and mental health.

Federally funded health centers offer care even if you have no insurance. You pay based on what you can afford.

For the reasons I just described, Community Health Centers are an especially important resource and valuable partner.

Closing and Charge

The breadth of change required is apparent, and perhaps daunting to some. 

We must actively and continually reach across the American population, geographic boundaries and socio-economic status -  to parents; from to primary care providers to behavior health specialists and advocates like you; to medical professionals in every discipline; from community leaders to schools, teachers mentors of young people; to seniors, their families, allies and caregivers.

In reaching out to all of them, we must provide hope, deliver care, and eliminate discrimination.

Our approach to changing public attitudes, to improving suicide prevention and mental health services in a broader sense means practitioners and advocates must not merely contribute, but continue to lead.

The process of creating lasting change will remain more deliberate than any of us would like, because changes in long held notions take place slowly even in the best of circumstances.

Bringing about the significant change necessary is foremost, OUR task...it is YOUR task.  The work is not glamorous nor financially rewarding and it is incredibly difficult.

However, WE - as clinicians, academicians, experts and advocates - have the ability to make things happen.

We would all do well to remember:

• sharing accurate information is the key to our eventually success; and at those times when the progress we achieve we seems only incremental, that progress is no less essential.

And: while the challenge of changing attitudes and improving suicide prevention are certainly formidable, the rewards of success of even greater.

That said, at the beginning of my remarks today I recognized KCSAPP for its leadership.

I urge everyone here to help make KCSAPP’s work ever-more successful.

You can do so becoming and remaining involved.

Be a visible and integral part of the community and the   voluntary efforts of KCSAPP and other groups.

Remain dedicated to educating the public, educators, professionals and community leaders on how we can all work together to improving quality of mental health care.

Insist that your colleagues and neighbors do the same. 

In that spirit, I offer a final reminder: working with a singleness of purpose, WE can make a difference today, tomorrow and for as long as it takes.  

TOGETHER, let’s make it happen.

Thank you.