01. Introduction

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suicide 1.jpg

" Suicide, a tragic potentially preventable public health problem is the leading cause of violent related deaths worldwide, outnumbering homicide or war related deaths" (World Health Organization). It is the act of deliberately killing one's self. Suicidal behavior begins with the thought, followed by the plan and then the attempt which may or may not be successful.(1)

02. Impact

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According to the Centers for Disease Control and Prevention (CDC), suicide is the third leading cause of death among youth between the ages of 10 and 24. CDC estimates that 4400 youth lives are lost each year and 149,000 youth receive medical care for suicidal self-inflicted injuries at emergency departments across the U.S.

03. Trends

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By method, 46% of youth suicides occur via firearms, 37% via suffocation and 8% via poisoning.(2)
By gender, boys are more likely to successfully commit suicide while girls are more likely to attempt suicide.(2)
Firearm is the most common method in of suicide in males while hanging/suffocation is most common in females.(2)
Ethnic and cultural variations show that native American/Alaskan native and Hispanic youth have the highest rates of suicide.(2)

Graph 1 : Trends in Suicide Rates* Among Females, by Age Group, United States, 1991-2006
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Graph 2: Trends in Suicide Rates* Among Females 10-24 Years, by Mechanism, United States, 1991-2006
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Graph 3: Suicide Rates* Among Persons Ages 10-24 Years, by Race/Ethnicity and Sex, United States, 2002-2006
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Images: "CDC - At A Glance - Statistics - Suicide - Violence Prevention - Injury." Centers for Disease Control and Prevention. N.p., n.d. Web. 30 Apr. 2012. .

04. Risk Factors

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History of previous suicide attempt (2)
History of mental disorders especially depression (2)
Exposure to the suicidal behavior of others (2) (3)
Family history of child maltreatment (3)
Family history of suicide (2)
Impulsive and aggressive tendencies (4) (3)
Alcohol or drug abuse (2)
Stressful life event e.g. loss of job or economic difficulty (2) (4)
Easy access to lethal weapons or means (2)
Incarceration (2)
Barriers to accessing mental health services:
-loss of cultural and religious identity/beliefs (5)(6)
-stigma attached to mental health /substance abuse disorders (5)(6)

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05. Cost Estimate

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According to the Center for Suicide Prevention, in 2005, the estimated costs of deaths due to suicide in the entire USA population was 16 billion dollars, while that of non-fatal suicide attempts was 4.7 billion dollars. Yang and Bijou (2007), estimated the economic cost of each youth that completed suicide to be $1,022,950 from lost lifetime savings (using a life expectancy of 65) while the estimated medical costs for a failed suicide attempt was estimated to be $12,570 in 2005.

The costs-benefits of suicide are two-fold: (1) The direct and indirect costs-benefits of suicide and failed suicide attempts (2) The costs-benefits of creating and sustaining suicide prevention intervention programs. The cost-benefits can be described as monetary, non-monetary, perceived and actual.

Direct Costs:
• Emergency department visits and ambulance costs to the hospital.
• Outpatient clinic visits to primary care physician or psychiatrist.
• Inpatient hospital mental health care cost.
• Psychologist, counselor, social worker or nurse or counselor visits.
• Medico-legal and law-enforcement costs.
• Lost revenue of railway corporation on days there are suicide attempts on railways.
• Administrative costs for processing compensation/disability claims.

Indirect costs:

• Lost lifetime productivity years from premature death.
• Disability adjusted life years (DALY). (7)

• Costs for purchasing suicide screening tools and materials, training staff and implementing suicide education curriculum in the schools.
• Costs of establishing and maintaining mental health facilities, crisis centers and payments of phone bills for hotlines.
• Cost of establishing and maintaining recreation centers and activities to engage youth in the society.
• Costs of suicide research.
• Cost of social marketing to promote suicide prevention.

Suicide has a ripple effect and many people may be affected by a suicide - the deceased parent/s, siblings/s, school friend/s, and neighbor/s.Mental health services are provided not only to the youth that attempted suicide but also to their family and friends that may have been impacted by a suicide or suicide attempt. (5)(6).

The personal experiences of people who had attempted suicide, who cared for someone who had attempted suicide or who had been bereaved by suicide cannot be quantified monetarily. Not uncommonly, these people blame themselves for the decision of the suicidal individual to take his/her life. The combination of grief and guilt can lead to prolonged bereavement which may persist for many years.

If there is a lack of community awareness, the bereaved may face community misconceptions that the suicide resulted from a failure on their part. They may subsequently have difficulty keeping up at work and lose their jobs, they may move away from their usual locale due to stigma or shame, seek counseling, require medications such as antidepressants, become drug or alcohol dependent, develop strained relationships with partners, family and friends and even contemplate suicide.(1)(8)

09. Factors limiting progress

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Inaccurate reporting due to
• Cultural and religious beliefs.
• Stigma attached to mental health /substance abuse disorders.
• Inadequate or lack of health insurance coverage.
• Lack of community engagement in planning and implementing suicide prevention intervention(5)(6)

10. Reporting procedures

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Suicides are reported in the National Violent death Reporting system by CDC.Reporting can be limited by the following:

• Sometimes some attempts are acts to gain attention and not actual intent to commit suicide. Sometimes however, an error can occur and the youth dies.(9)
• Many suicide attempts mislabeled as accidents.

11. Suicide Intervention Programs

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According to the CDC, successful suicide intervention programs incorporate the following 8 strategies:
1. School gatekeeper training designed to help school staff identify and refer students at risk of suicide. Interval reassessments monitor behavior improvements or worsening. Training also includes response to suicide situations and the prevention of suicide clusters by providing support to youth trying to cope with the loss of a loved one or peer to suicide.

2. Community gate-keeper training designed to train community members (teachers, coaches, clergy and healthcare providers who see youths to identify and refer at risk individuals for further care.

3. General suicide education for students to learn about suicide, it's warning signs and how to seek help for themselves and others. An example is the 'Linking Education and Awareness of Depression and Suicide '(LEADS) curriculum implemented in Minnesota high-schools by 'Suicide Awareness Voices of Education' (SAVE), a non-profit organization in Bloomington, Minnesota dedicated to preventing suicide by educating people.

4. Screening programs that use screening instruments and questionnaires to identify high-risk individuals.

5. Peer support programs in schools and non-school settings to foster friendships and develop social competency in youth. Adult mentoring sessions can focus on techniques to increase dialogue with their children and the youth. Parents should be educated on communication, problem-solving and knowledge of child development in an effort to prevent rather than react to problems. Family members should show concern and provide social and emotional support for one another. By adopting a modus of daily reciprocal communication and shared activities, youth have an abode of peace and happiness; promoting health, bonding and resilience to stress. Advice and correction should be given without criticism or condemnation and cultural values and traditions shared. If individual families adopt this lifestyle, children are brought up having a sense of belonging and being valued. Like herd immunity, the influence of negative peer pressure (substance abuse, use of weapons) is minimal to non-existent and depression due to situational stresses is reduced.

6. Crisis centers and hotlines: Services including face to face and telephone counseling, referral for mental health care are provided by staff trained for suicidal persons.

7. Restriction of access to lethal means: Activities should be designed to restrict access of handguns, drugs, and other lethal means to population at risk and the government has a role to play by promoting such legislation. Bridges can be fenced to prevent people jumping off; health providers should ensure well regulated doses and amounts of medication prescribed especially in high risk individuals. Family members should ensure medications are safely stored to reduce access and chances of overdose and poisoning and weapons should be unloaded and locked away.

8. Interventions after suicide i.e "postvention" that employ strategies for communities to deal with suicide situations.

12. Haddon's Matrix

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The Haddon Matrix is commonly used in injury prevention.
It was developed by William Haddon in 1970, the matrix looks at factors related to personal attributes, vector or agent attributes, and environmental attributes before, during and after an injury or death.It helps to develop and design interventions to prevent injury or death.

Haddon's Matrix.pdf

13. Haddon's Ten Strategies

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1. Prevent initial creation of hazard.
• Motivational signs at bridges to divert people who may decide to jump from bridges.
• Guns should not be available for non-military or non-law-enforcement use. If made available, proper screening is required before license is provided.
• Manufacture of highly toxic household bug sprays, etc. has to be reduced.
• Ensure social support systems- family, peer groups, school mentoring programs.
• Increasing avenues available for engaging youth in constructive activities and recreation.

2. Reduce amount of hazard created.
• Increase connectedness within family and community members
• Suicide education in schools. An example is the 'Linking Education and Awareness of Depression and Suicide '(LEADS) curriculum implemented in Minnesota high-schools by 'Suicide Awareness Voices of Education' (SAVE), a non-profit organization in Bloomington, Minnesota dedicated to preventing suicide by educating people.
• Peer support groups.
• Reduced sales of firearms.
• Reduced sales of poisonous pills and toxic sprays.

3. Prevent release of already existing hazard.
• Gatekeeper training to identify at-risk individuals. Community members who have regular contact with youth; teachers, counselors, nurses, coaches, community recreation center staff, clergy, police, merchants and healthcare providers, are trained to identify those at risk for suicide.
• Questionnaires or screening instruments are used to identify high-risk youth and to provide further assessment and treatment.
• Increase access to and awareness of mental health services.
• Creation of crisis hotlines.
• Reduce access to amount of alcohol, frequency of alcohol especially in youth.
• Set stricter laws and regulations for purchase of firearms.
• Set Prescription restriction to buy toxic sprays and poisonous pills.

4. Modify rate of release or spatial distribution of hazard from its source.

• Prevent large consumptions of pills by packaging medicines as individual pills.
• Physicians can also prescribe shorter courses of medications so that people do not have access to large quantities at once.
• Reduce time required for pills to produce its effect on the body. i.e. medication formulations can be made into extended release versions so that effects can be delayed and reversed on time.

5. Separate in time and space, hazard from person.
• Ensure rules and regulations for firearms purchase totally excludes purchase to people with mental illness.
• Homes or facilities that have firearms should have them locked away and the bullets should not be kept in the same place as the firearms.
• Knives and substances such as cleaning agents which could be poisonous should be safely stored away so that young kids do not have easy access.

6. Interpose a barrier between hazard and person.
• Barriers placed in bridges and high buildings to prevent people from jumping.
• Set up computerized system which allows only owner to use the gun.
• Cars have codes for starting the engine so that teenagers are prevented from driving off in a parent's car to commit suicide.
• Safety caps to bottles containing pills to reduce the time taken to consume the pills. This may change the person's mind.
• Reduce purchase of gasoline into containers so that the risk of setting fires is prevented.

7. Modify contact surfaces to reduce injury.

• Difficult access to aloof bridges and tall buildings.
• Ensure that most rooms inside homes don't have locks or latches, so that a person who is trying to commit suicide can be accessed easily from outside.

8. Strengthen resistance of person who will be injured.
• Intervention programs.
• Suicide prevention curricula in schools.
• Inspire youth to achieve something in life.
• Create mentoring and support groups that include families that have been impacted by suicide so they can help support other community members and youth.
• Increase access to and awareness of Mental Health Centers, crisis centers etc.
• Promote cultural and religious orientation so that suicide is considered a "taboo" and not the way out of difficulty.

9. Rapidly detect and limit damage that has occurred.
• Post-intervention programs that emphasize coping strategies to deal with suicide crisis situation.
• Extreme caution in carefully portraying the circumstances around a suicide through the media so that it does not initiate or worsen the contagion suicide.
• "Contagion" is recognized by the CDC as a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide.
• Educate youth to treat suicidal individuals.
• Send suicide survivors to rehabilitation centers.
• Motivational talks to depressed individuals.

10. Initiate immediate and long term reparative actions.
• Intervention programs for attempters.
• Organize program or agency that has trained workers to perform follow-up monitoring and assessments for attempters and their close family and friends.
• Crisis centers and hotlines.
• Social Marketing: Guided laws on media reporting of suicide should be enforced to prevent contagion effects or community or family stigma.

14. References

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