Suicide Across the Lifespan

Transcription

1 New Hampshire s Annual Report on Suicide and Suicidality 1999 through Suicide Across the Lifespan This report was produced by the Youth Suicide Prevention Assembly (YSPA), the State Suicide Prevention Council (SPC) and the National Alliance on Mental Illness (NAMI NH) Any individual or organization may freely copy and distribute this report Electronic copies are available at:

2 Table of Contents Introduction... 3 Primary Partners... 4 Recent Accomplishments Annual Data Report Chart Reading Basics Glossary of Terms Reliability of Rates Recognize the Warning Signs of Suicide Page 2

3 Introduction The 2008 NH Suicide Prevention Annual Report is the result of the collaborative work of many groups, committees and organizations in NH who have dedicated time and resources to study the issue of suicide in our state and to look at prevention and postvention across the lifespan. Efforts have included an in-depth review of individual cases and data; a variety of outreach methods through traditional as well as new electronic media; the joining of state systems, key service providers and communities in an integrated, cohesive approach to prevention; education and training that promotes best practices at all levels of our work and understanding the efficacy of the many direct interventions that occur daily throughout New Hampshire. Our progress is built on the working relationships between all of those affected and all of those able to effect change, including families and those living with mental illness or a loss to suicide; health care providers, media, first responders, law enforcement, military, faith leaders, educators, social service providers, legislators, funeral directors, the Chief Medical Examiner and even gun shop owners and firearms instructors. NH has made great gains in supporting and bringing forward the voices of survivors - those who have lost someone to suicide - to understand and support them and reduce the isolation that often comes with their profound grief. Social capital - demonstrated by the willingness of such diverse groups to work together for a common cause - is the reason for the progress and success of so many suicide prevention initiatives generated out of NH and the reason many other states turn to us for new and demonstrated effective strategies. We still have miles to go before we sleep, but we have many partners walking forward together. Leadership For the Suicide Prevention Council (SPC) James MacKay, Ph.D., Chairman, State Suicide Prevention Council; President, NH Mental Health Council Nancy Rollins, Vice Chairman, State Suicide Prevention Council; Associate Commissioner, Department of Health and Human Services (DHHS) Jo Moncher, Facilitator, State Suicide Prevention Council; Bureau Chief, Community Based Military Programs, DHHS Leadership For The Youth Suicide Prevention Assembly (YSPA) Elizabeth Fenner-Lukaitis, Co-Chairman, Youth Suicide Prevention Assembly; Acute Care Services Coordinator, Division of Behavioral Health, DHHS Elaine Frank, Co-Chairman, Youth Suicide Prevention Assembly Elaine de Mello, Co-Chairman, Youth Suicide Prevention Assembly, Supervisor of Training and Prevention Services, National Alliance on Mental Illness (NAMI NH) Page 3

4 Primary Partners The State Suicide Prevention Council The mission of the State Suicide Prevention Council (SPC) is to reduce the incidence of suicide in New Hampshire by accomplishing the goals of the Suicide Prevention Plan: * Raise public and professional awareness of suicide prevention; * Address the mental health and substance abuse needs of all residents; * Address the needs of those affected by suicide; and * Promote policy change. In 2008, on behalf of the previous State Suicide Prevention Council and with the collaboration of legislative partners, Senator Kathy Sgambati introduced Senate Bill 390 statutorily establishing the Suicide Prevention Council (SPC). The legislation passed and was signed into law by Governor Lynch. This legislation requires the Council to report on its progress to both the Governor and the legislature annually. The official recognition of the Suicide Prevention Council will assist NH in sustaining the attention that suicide prevention efforts should receive given its impact on our residents. Primary Contact: Jo Moncher at jamoncher@dhhs.state.nh.us The Youth Suicide Prevention Assembly (YSPA) Mission: The Youth Suicide Prevention Assembly is dedicated to reducing the occurrence of suicide and suicidal behaviors among New Hampshire's youth and young adults between 10 and 24 years old. This is to be accomplished through a coordinated approach to providing service providers and communities with current information regarding best practices in prevention and postvention strategies and by promoting youth and young adult safety in our communities and organizations. YSPA is an ad hoc committee of individuals and organizations that meets monthly to review the most recent youth suicide deaths and attempts in order to develop strategies for preventing them. Over the years, YSPA and its partners have been involved with a wide range of suicide prevention efforts in the state including but not limited to: collecting and analyzing timely data on suicide deaths and attempts, holding an annual educational conference, creating the original State Suicide Prevention Plan and developing the Frameworks Project which has since been implemented by NAMI NH and renamed Connect. Primary Contact: Elaine de Mello at edemello@naminh.org Page 4

5 The Connect Project of NAMI NH NAMI New Hampshire (The National Alliance on Mental Illness) is dedicated to improving the quality of life of persons of all ages with mental illness/sed (Serious Emotional Disorders) and their families so they may have the opportunity to recover from mental illness, achieve their aspirations and live, work and play in the community of their choice. NAMI NH s Connect Project, is designated as a National Best Practice Program. Connect s community-based approach focuses on prevention (education about early recognition) and intervention (skills for responding to attempts, thoughts, and threats of suicide) and reducing risk and promoting healing after a suicide (postvention). Connect provides consultation, training, technical assistance, and information and referral regarding suicide prevention throughout NH. Our website provides NH specific data, news and events, information and resources and supports to survivors. Primary Contact: Ken Norton at knorton@naminh.org Page 5

6 Recent Accomplishments of Suicide Prevention Efforts in NH Many of our successful efforts are summarized here using the Subcommittees of the Suicide Prevention Council though not all these activities were accomplished directly through the Council in 2008 into early In NH, we pride ourselves on the public/private partnerships and the collaborative nature of our work that focuses more on the activities than on the actors. Communications & Public Education Encouraged news outlets to follow national media recommendations on responsible reporting of suicide through Letters to the Editor, phone calls to reporters and editors, and positive and negative feedback on related stories. Held a screening of the movie Ordinary People at the Red River Theatre in Concord. The screening was followed by a facilitated discussion about the movie and how it portrays the reactions and impact a suicide death has on friends and family. Organized a Press Conference that was held in the Legislative Office Building and focused on the efforts of the SPC and its partners. Developed a two hour program on Responsible Reporting on Suicide and presented it to journalism students at both Keene State College and the University of New Hampshire. Efforts are underway to add this to the UNH curriculum. University of New Hampshire offered a community screening and panel discussion of the film There Ought To Be a Law regarding a mother s efforts at legislative advocacy following the suicide death of her son. SPC members spoke. Keep Sound Minds held a contest for high school students to develop Public Service Announcements (PSA s) on suicide prevention and mental health treatment Data Collection & Analysis Produced this annual NH Suicide Prevention Data Report which provides timely information and statistics on suicide deaths and attempts across all age groups in NH. Developed a glossary of epidemiology terms for the report to assist readers in using the information. Convened representatives of key state programs and agencies to focus specifically on the issue of quality and accessibility of data. Tracked suicide deaths and attempts through collaboration with the Office of the Chief Medical Examiner, the Bureau of Behavioral Health, the Bureau of Emergency Management Services and the Northern New England Poison Center. Shared this information at every Suicide Prevention Council and Youth Suicide Prevention Assembly meeting. Through the University of New Hampshire Survey Center conducted a follow-up survey of NH residents attitudes toward mental health treatment and suicide prevention Page 6

7 Military and Veterans Developed a committee of the Suicide Prevention Council to focus on issues related to the unique suicide prevention needs of active duty, and reserve service members as well as on veterans and their families. Worked collaboratively in supporting, and representing the Manchester VA Medical Center s 3 rd Annual Suicide Prevention & Mental Health Awareness Expo. Work with the National Guard and the Department of Defense on suicide prevention and postvention efforts with military and veterans. Participated in community activities, conferences, and lectures, offering educational material on suicide prevention resources for service members, veterans and their family members including Massachusetts VSO Conference, Annual American Legion Conference, Annual DAV Conference, Annual VFW Conference and others. Presented to Law Enforcement officers, primarily State Troopers about Veterans and Suicide to increase awareness, comfort, and collaboration. In collaboration the Disaster Behavioral Health Response Team (Dept. Of Safety) and NH National Guard offered training for mental health and social service providers in Military Culture. The expansion of the responsibilities of the liaison from the Department of Health and Human Services to the Office of the Chief Medical Examiner allows the National Guard to receive timely information about the suicide deaths of any National Guard service man or woman so that immediate postvention responses can be offered Manchester VA Medical Center hosted a regional training to reduce risk and promote resilience and healing after a suicide. Professional Practice Established a professional practice sub-committee of the Suicide Prevention Council and identified co chairs to provide committee leadership. Reviewed Professional Practice priorities within the State Suicide Prevention Plan and revised several sections to augment other sub-committee s sections. In collaboration with YSPA, held a statewide suicide prevention conference featuring local and national speakers for educators, law enforcement, mental health professionals, health care providers, survivors of suicide, faith leaders and others Participated in recruitment of members representing a multidisciplinary cross-section of professionals. Public Policy Worked with advocates in and outside of the legislature to introduce and support SB 390, which legislatively established the State Suicide Prevention Council. The bill was passed and signed into law by Governor John H. Lynch. The new Council held its first organizational meeting in September At this meeting, a new subcommittee to address Veterans issues was added. The five active subcommittees include: Data Collections and Analysis, Communications and Public Education, Military and Veterans, Professional Education and Public Policy. These five subcommittees meet regularly. If you would like to join any of the subcommittees, please contact Jo Moncher at jamoncher@dhhs.state.nh.us to find out when and where they meet. Page 7

8 In addition to the work of the individual Suicide Prevention Council subcommittees, there are many accomplishments by Council members, YSPA members, NAMI NH and other partner organizations and local coalitions. These include: The NH Suicide Survivor Network The NH Lifekeeper Quilt traveled to 66 locations in the first year after being created in During 2008, eight support groups for survivors of suicide were active, with the development of a ninth group in Nashua. NH survivors gathered at sites around New Hampshire in the Fall of 2008 to raise money for suicide prevention and mental illness awareness including the AFSP Out of Darkness Walks (Portsmouth and Hanover), the NAMI NH Annual Walk and the West Central Behavioral Services annual fundraising events, Paddlepower and Firepower. American Foundation for Suicide Prevention s (AFSP) Tenth Annual National Survivor s of Suicide Day conference on November 22, 2008 was expanded to five New Hampshire locations to join sites around the country and link with the national conference. Connect developed a training for survivors of suicide to speak publicly about their experience. Seven NH survivors completed the training in the spring of 2008 and have since gone on to actively share his/her story with NH audiences through the Connect Postvention Trainings or in response to media inquiries for NH publications and at the NH Annual Suicide Prevention conference. The Survivor Committee continues to publish the Survivors of Suicide Newsletter (8,000 copies were printed and distributed in 2008) and updated materials to expand the survivor resource packet disseminated through the Office of the Chief Medical Examiner. In 2008, Survivor Resource Folders were distributed to all funeral homes in NH as a resources should they respond to a suicide death. Through the joint efforts of NAMI NH, Disaster Behavioral Health Response Team and the Youth Suicide Prevention Assembly technical assistance and supports were provided to schools and communities following high profile suicide deaths. For more information on the Survivor of Suicide Network, contact: Becky McEnany at bmcenany@naminh.org Education and Training Program Initiatives With the support of the Department of Education, Safe and Drug Free Schools, NAMI NH Connect provided suicide prevention and postvention training to over 170 school staff, students and concerned community members and trained 35 trainers in In conjunction with NH Police Standards and Training Council, NAMI NH provided training in mental illness and suicide prevention for both new recruits and certified police officers as part of ongoing training efforts. NAMI NH provided Connect Suicide Prevention and Postvention training to the New Hampshire National Guard and Reserves. Connect staff were invited to present the model at several national military conferences around the U.S. including with the Department of Defense. Trainings conducted in NH were extended to military groups in other states. In 2008 the Connect Postvention Protocols were included in the national Best Practices Registry along with Connect Prevention and Intervention. For additional information on the Best Practices Registry, please visit the SPRC website at Page 8

9 CALM (Counseling on Access to Lethal Means) training was offered to mental health providers; pediatricians, school nurses, hospital staff and others throughout the state as well as at several state and national conferences. Youth Suicide Prevention Assembly (YSPA) provided quarterly professional development opportunities through presentations at monthly YSPA meetings. Local Coalitions Are Growing Stronger Moultonborough: The Moultonborough Suicide Prevention and Mental Health Coalition formed early in 2007 after experiencing the tragic suicides of six residents in the prior year. With the support of funding approved at town meetings this coalition offered public educational events about mental health and suicide prevention, support to survivors and the establishment of mental health services in town for those residents who could not access services at the community mental health offices in other locations. Among other creative strategies, this Coalition developed mental health resource cards which they distributed throughout their community with the contact information of local mental health resources. At their town meeting, they also distributed information kits to every person in attendance that included these resource cards and National Suicide Prevention Lifeline information. Moultonborough hosted a site for the annual survivor of suicide teleconference and purchased survivor packets to have them readily available for any citizens who experienced a loss to suicide. This coalition continues to meet monthly and is looking further into educational programs and services that will benefit the town in preventing and responding to suicide risk of residents Seacoast: The Seacoast Suicide Prevention Coalition was formed in late 2008 after several high profile suicide incidents in the Seacoast area came to the attention of concerned citizens and the media. Recognizing the need for a public health approach to prevention, Reverend Angelo Pappas of St. Nicholas Greek Orthodox Church went to the City of Portsmouth and the Rotary Club and received funds and permission to put Help signs with hotline numbers at high profile locations. Building on a well established network of survivors and with consultation and technical assistance from NAMI NH, the Seacoast region brought together a diverse group of providers, survivors and citizens and established a mission statement, goals around suicide prevention and support to survivors. Through several sources of funding the Coalition is offering numerous trainings, public forums, and plans to establish a survivor support group. Among the results already experienced is that persons contemplating suicide are calling for help from the bridge locations where the signs are posted. Raymond: Over 400 Raymond community members have been trained in the Connect (formerly Frameworks) Suicide Prevention Project and the Raymond Coalition for Youth (RCFY) is now focusing on sustainability in its future efforts around substance abuse and suicide prevention. In 2008, members of the Raymond Coalition presented on their successful implementation of Connect at a workshop at the national AAS conference in Boston. Early in 2009, RCFY received the Systems Change Award from NAMI NH as a model for how communities can effect change and understanding around the issues of mental illness and suicide prevention. Page 9

10 North Country: In 2008, over 25 educators from Groveton, Stark and Stratford were trained in Connect suicide prevention and intervention. Fifteen of these people went on to become trainers and have helped bring the Connect Suicide Prevention Project to the greater Groveton area through a Tillotson grant. In addition to assisting with training of their peers, several trainers have formed a suicide prevention coalition to expand suicide prevention efforts in the North Country and support the implementation of the Connect project. The coalition held its first meeting in August To become involved in any of these coalitions, please visit National Attention on NH Initiatives Expertise and initiatives home grown in NH received national attention through presentations at national conferences and through dissemination to other states. These include: Bereavement Packets sent to next of kin of all suicide deaths (YSPA, Office of Medical Examiner, NH Suicide Survivor Network, BBH). CALM (Counseling on Access to Lethal Means) Training. Connect (formerly Frameworks) Suicide Prevention Program. Working with media including new media and social networking sites. NH National Guard s suicide prevention effort was identified as a national model in the area of postvention (coordination of services after a suicide death) in testimony before the Senate Armed Services Committee. Page 10

11 2008 Annual Data Report SPC/YSPA Data Subcommittee Membership Representation Injury Prevention Center at Dartmouth National Alliance of Mental Illness New Hampshire New Hampshire Army National Guard Northern New England Poison Control Center State of New Hampshire Department of Corrections State of New Hampshire Department of Health and Human Services State of New Hampshire Department of Justice State of New Hampshire Office of the Chief Medical Examiner University of New Hampshire The NH SPC Data Subcommittee Representatives and Primary Contributors to the 2008 Report: Melissa Heinen, New England Poison Control Center Alicia L Esperance: Department of Health and Human Services Primary Contact: Patrick Roberts, National Alliance on Mental Illness: proberts@naminh.org Introduction The data presented in this report are the result of the collaborative efforts of a variety of organizations and people. The data was compiled by the two major collaborative groups for suicide prevention in New Hampshire, the Youth Suicide Prevention Assembly (YSPA) and the Suicide Prevention Council (SPC). YSPA and SPC merged data efforts over the last year, combining historical expertise with emerging methods. YSPA has been collecting and analyzing data about youth and young adult suicide deaths and behavior over the last 15 years. SPC has been analyzing and planning for data capacity improvements for the last 3 years. Key areas of interest and concern for suicidal behavior in New Hampshire are included in this report. A data interpretation and chart reading section has been included at the end of the report. While each suicide is a separate act, aggregate data is presented in this report. Aggregate data helps inform which populations/age groups are most at risk, reveals points of particular vulnerability, and thus leads to determinations of prevention and intervention efforts as well as where to direct program funding. When reading this report it is important to note two primary sources of NH data were used. One main data source is Vital Records data for the State of NH obtained from the Bureau of Health Statistics and Data Management, Division of Public Health Services, DHHS. Another main data source is the Office of Chief Medical Examiner (OCME) for the State of NH. These two key data sources cover similar populations, but small differences in numbers and rates may occur due to differences in how the data is collected. The Vital Records data includes suicide deaths that Page 11

12 occur in NH, as well as the deaths of NH residents that occurred outside of the state. The OCME data includes only suicide deaths that occurred in NH regardless of state residency and does not capture suicide deaths by NH residents that occurred outside of the state. Additional data sources were used for specific purposes that may have varying methods of collection. All of the charts and graphs in this report include citations of data source to prevent confusion. Different data sources also vary regarding how quickly the information is made available, so the time periods covered are also indicated. The Big Picture: Suicide in NH and Nationally Figure 1 displays the 10 leading causes of death for people of different age groups in NH. From , suicide among those aged was the second leading cause of death for NH compared to the third leading cause nationally. Suicide rates were behind deaths due to unintentional injury, including motor vehicle crashes in NH and were also behind homicides nationally. Suicide among all ages was the 10 th leading cause of death for NH but not among the 10 leading causes of death nationally. The vast majority of violent deaths in NH are suicides. For every homicide in NH, there are approximately 8 suicides. This ratio is in sharp contrast to national statistics, which show less than 2 suicides for every homicide. Deaths classified as suicides occur about half as often as deaths classified as unintentional injuries in NH; whereas, nationally approximately 3 deaths are classified as unintentional injuries for every suicide. Therefore, suicide constitutes a larger proportion of traumatic deaths in NH than in the US as a whole. Page 12

13 Figure Leading Causes of Death, New Hampshire, by Age Group, Age Groups Rank < All Ages 1 Congenital Anomalies 72 Unintentional Injury 9 Malignant Neoplasms 15 Unintentional Injury 18 Unintentional Injury 294 Unintentional Injury 223 Unintentional Injury 356 Malignant Neoplasms 1,109 Malignant Neoplasms 2,175 Heart 11,190 Heart 13,171 2 Short Gestation 63 Congenital Anomalies 6 Unintentional Injury 13 Malignant Neoplasms 7 Suicide 89 Suicide 103 Malignant Neoplasms 348 Heart 627 Heart 1,100 Malignant Neoplasms 8,877 Malignant Neoplasms 12,651 3 SIDS 40 Malignant Neoplasms 5 Diabetes Mellitus 1 Suicide 5 Malignant Neoplasms 42 Malignant Neoplasms 72 Heart 196 Unintentional Injury 302 Chronic Low. Respiratory 274 Chronic Low. Respiratory 2,575 Chronic Low. Respiratory 2,941 4 Placenta Cord Membranes 19 Benign Neoplasms 3 Homicide 1 Congenital Anomalies 5 Heart 19 Heart 30 Suicide 159 Suicide 155 Diabetes Mellitus 223 Cerebro- Vascular 2,480 Cerebrovascular 2,740 5 Maternal Pregnancy Comp. 18 Heart 3 Influenza & Pneumonia 1 Chronic Low. Respiratory 2 Homicide 13 Homicide 18 Liver 53 Liver 135 Unintentional Injury 164 Alzheimer's 1,657 Unintentional Injury 2,144 6 Unintentional Injury 15 Homicide 3 Nephritis 1 Heart 2 Congenital Anomalies 10 Congenital Anomalies 12 Diabetes Mellitus 44 Diabetes Mellitus 89 Cerebrovascular 136 Diabetes Mellitus 1,166 Alzheimer's 1,676 7 Respiratory Distress 13 Influenza & Pneumonia 1 Perinatal Period 1 Diabetes Mellitus 1 Cerebrovascular 4 HIV 8 Cerebrovascular 30 Cerebrovascular 78 Suicide 109 Influenza & Pneumonia 1,123 Diabetes Mellitus 1,530 8 Circulatory System 12 Perinatal Period 1 Pneumonitis 1 Homicide 1 Five- Tied 2 Chronic Low. Respiratory 6 HIV 28 Chronic Low. Respiratory 68 Liver 108 Unintentional Injury 750 Influenza & Pneumonia 1,197 9 Bacterial Sepsis 11 Pneumonitis 1 Influenza & Pneumonia 1 Five- Tied 2 Diabetes Mellitus 6 Homicide 18 Viral Hepatitis 34 Septicemia 44 Nephritis 709 Nephritis Intrauterine Hypoxia 10 Septicemia 1 Perinatal Period 1 Five- Tied 2 Cerebro- Vascular 5 Chronic Low. Respiratory 14 Two- Tied 25 Nephritis 44 Parkinson's 393 Suicide 736 WISQARS TM Produced By: Office of Statistics and Programming, National Center for Injury Prevention and Control, Centers for Control and Prevention Data Source: National Center for Health Statistics (NCHS), National Vital Statistics System Page 13

14 The most effective way to compare NH to the US is to look at suicide death rates. Table 1 presents NH and US suicide death rates by age group. Table 1. Crude Suicide Death Rates per 100,000 in NH & US, by age group, ALL AGES YOUTH YOUTH YOUNG ADULTS NH US AGES 25 TO 39 AGES 40 TO 59 AGES 60 TO 74 OVER 75 NH US Source: CDC WISQARS Adults over age 75 had the highest suicide rates of all ages (17.97 NH, US) from Both the NH and the US suicide rates were almost quadrupled between ages (2.55 NH, 2.90 US) to (12.99 NH, US) revealing the transition from middle/late adolescence to late adolescence/early adulthood as a particularly vulnerable time. Youth and Young Adult Suicide in NH In the 10 years from , 191 NH youth and young adults aged have lost their lives to suicide. The table on the following page depicts the most up-to-date information about these youth and young adults as reported by the Office of the Chief Medical Examiner in NH and collected/aggregated by YSPA. Males are the most common youth and young adults who die by suicide in NH (82%) and nationwide. Firearms are used by 43% of youth and young adults who die by suicide in NH, followed closely by 41% who hang themselves. Again, these figures are similar to national data. The five-year sub-totals in Table 2 show a significant decrease in the number of youth and young adult suicides from the period of (23.0 +/- 3.7) to (15.2 +/- 2.2). Each year from had a significantly lower rate of youth suicide than the prior five years. This trend was not seen in 2008, however. Also of note, in 2006 there were no suicides by youth 18 years old or younger. It is unknown if the lower rates in are due to suicide prevention efforts as there is no scientific method to directly make this connection. Figure 2 shows the overall decreasing number of youth suicide deaths Figure 3 shows this as a decrease in male suicides without a decrease in female suicides. The decrease in suicide deaths has been accompanied by an increase in drug overdose deaths among youth and young adults. Drug overdose deaths represent a profound and disturbing level of risk taking. Despite this high disregard for risk, most of these deaths are ruled accidental unless there is direct evidence of suicide intent. Page 14

15 Please note that Table 2 is based on Medical Examiner data. Hanging/Asphyxiation refers to all forms of suffocation (e.g. hanging, bag over the head) and Drugs/Poison refers to all suicide cases of overdoses or ingested poisons. Suicides where carbon monoxide poisoning was the cause of death are reported in the Other section. These categories are slightly different than those used by the Center for Control (CDC), which places suicides by carbon monoxide into the Poison category (e.g., Figure 12). Table 2. NH Youth Suicide Death Trend, by Age and Method, Year Total Male Female < Firearms Hanging/ Asphyxiation Drugs/ Poison Other Sub Total Percent of Sub- Total % 84% 16% 48% 52% 46% 38% 10% 6% * 9* 4 3* * Sub Total Percent of Sub- Total % 78% 22% 37% 63% 40% 46% 5% 9% Total Percent of Total 100% 82% 18% 43% 57% 43% 41% 9% 7% *Does not include one death that was changed from suicide as cause of death to undetermined cause of death Produced by NAMI NH. Data Source: Office of Chief Medical Examiner, NH. Page 15

16 Figure 2. NH youth, ages 10-24, suicide rates decreased significantly Number of Youth Suicides New Hampshire Youth Suicides from 1999 to 2008 Data Source: Office of the Chief Medical Examiner, NH Year Deaths Figure 3. NH male suicide rates decrease significantly , while female rates have fluctuated around a stable rate. Number of Youth Suicides New Hampshire Youth Suicides from 1999 to 2008 by Gender Data Source: Office of the Chief Medical Examiner, NH Males Females Year Page 16

17 Figure 4 shows youth and young adult suicide rates by county in NH. The county youth and young adult suicide death rate chart indicates geographical locations that may be particularly vulnerable to youth and young adult suicide. Due to small numbers, most of these differences are not statistically significant. Further, county limits are neither soundproof nor absolute. A suicide that occurs in one county can have a strong effect on neighboring counties, as well as across the state, due to the mobility of residents. However, Coos County has a higher youth and young adult suicide rate than the average of NH (8.6 per 100,000) and the US (7.1 per 100,000). Figure 4. Coos County: significantly higher youth suicide rate than the NH and US rates. Suicide Across the Lifespan in NH Figures 5 and 6, respectively, display NH resident suicide deaths and suicide death rates by age groups and gender from Rates are expressed as the number of suicide deaths per 100,000 people. Displayed together, these charts reveal how death rates correct for differences in the size of each age group. While the highest numbers of suicide deaths occur in the 40 and 50 year old age groups, the highest rates, or those at the greatest risk, are males over the age of 80, followed by males in their 70 s and early 60 s. Suicide death rates are also important in determining vulnerable age groups and age-related transitions. The suicide death rate in males rises rapidly from ages to and then again from ages to 20-24, pointing to a rise in vulnerability during the transitions from early adolescence to middle adolescence and then middle adolescence to late adolescence/early adulthood. Similarly, male elderly suicide rates increase substantially at years compared to the five previous age groups, indicating another vulnerable time of life for men. Page 17

18 Figure 5. The highest numbers of suicides are seen in males and females in the 40 and 50 year old age groups. Figure 6. Male NH residents over age 80 have the highest rate of suicide deaths, and male youth transition periods see the most significant changes in suicide rates, between ages to and to Page 18

19 Suicide Behavior in NH and Gender: Attempts and Deaths Youth and Gender While nearly 79% of the youth and young adult suicides from represented males, the fact that males die by suicide at a higher rate than females is largely due to males using more lethal means. In fact, females attempt suicide at a higher rate than males do. When examining how many NH youth and young adults were hospitalized and then discharged for self-inflicted injuries from , it is shown that 63% of the 1,098 discharges represent females, while only 37% represent males. Likewise, the 2007 NH YRBS reports approximately two and one half times as many female youth attempt suicide as males each year (7.9% of females and 3.2% of males). Emergency department (ED) use (ambulatory) data reveals the same gender ratio, based on self-inflicted injury rates 1. Female youth are less likely to die by suicide, since ED data shows many more less severe injuries during suicide attempts (self-inflicted injuries) (Fig. 11). Therefore, although male youth and young adults in NH complete suicide about 4 times as often as females, female youth and young adults in NH attempt suicide or deliberately harm themselves about twice as often as males. Figure 7. A greater percentage of male than female NH residents ages died by suicide Classifying an injury as self-inflicted is another way of stating that the injury was an instance of deliberate selfharm. Not all self-inflicted injuries necessarily represent suicide attempts. Analysis of these injuries, however, is the best current available data for approximating attempts. Page 19

20 Figure 8. A greater percentage of female than male NH residents ages attempted suicide, as seen in inpatient self-inflicted injuries Figure 9. A greater percentage of female than male NH residents ages attempted suicide, as seen in ambulatory self-inflicted injuries Age, Gender, and Self-inflicted Injury When rates of NH resident inpatient hospitalizations/discharges and emergency department use for self-inflicted injuries are examined by gender and age group, the variability can be seen (Fig. 10 and 11). These data refer to number of visits; therefore, individuals may be counted more than once if they were admitted or seen more than once. Page 20

21 Female NH residents have a higher overall rate of inpatient hospitalizations/discharges for selfinflicted injuries, yet for ages 80 and up males may, with some uncertainty, have a greater rate of self-inflicted injuries. For those females aged 15-19, the rate of those being discharged from inpatient care (Figure 10) is close to 150/100,000, 2 times the rate for males of the same age. The peak age for males is between 20 and 24 for self-inflicted injuries requiring hospitalizations. Again, emergency department (ambulatory Figure 11) use rates point to females aged as a population particularly vulnerable to self-injury and/or suicide attempts, with a rate over 750/100,000, about 188 times the suicide death rate for this population. Males also peak in selfinjury in this age group, though their rates are much lower. Also of note, the total number of youth and young adult ED visits (5,123) is 4.6 times greater than the number of inpatient discharges. Since less severe injuries are more common among self-inflicted youth injuries, there are many more attempts than deaths. It s also likely that there are many more attempts than are recorded as ED visits or hospitalizations. This data reinforces transition from middle adolescence to late adolescence/early adulthood is a time of great risk for suicidal thinking, self-harm and suicide attempts. Figure 10. Female NH residents ages and show the highest rates of suicide attempts, higher than males of any age group. Figure 11. Female NH residents ages show the highest rates of suicide attempts, but male rates also peak at this age. Page 21

22 According to inpatient admissions/discharges and ED/ambulatory use data across all ages in NH, there are approximately 18 suicide attempts for every suicide death. This number does not include attempts that go unreported, unrecognized, or without a hospital or ED visit which required medical intervention. Further, the rates of attempts for young people and females create an even greater ratio of suicide attempts to deaths. Based solely on hospital self-injury data, it is estimated well over 400 youth and young adults attempt suicide each year in New Hampshire. However, the above data which is based on cases where medical intervention is required is contrasted by the results of the Youth Risk Behavior Survey (YRBS). From 2007, there were over 1,600 high school students who reported having attempted suicide at least one time over the previous year. Based on these estimates, over 5,000 youth in NH may attempt suicide each year. The YRBS reports may account for some attempts not included in hospital self-injury data. This could be the case for any attempts with relatively non-lethal means where medical assistance was not sought. Of particular concern for this data is the likelihood that in many of these cases, the youth never sought help or disclosed the attempt to any adult. While a great majority of self-inflicted injuries are not fatal, they affect a substantially greater number of people than do fatalities, directly and indirectly. In fact, a significant risk factor for suicide is a previous attempt: in one study 21-33% of people who die by suicide have made a previous attempt (Shaffer & Gould, 1987). Any suicide attempt, regardless of its lethality, must be taken seriously as it signals an individual s effort to reduce their pain. If not addressed, it could lead to additional attempts; therefore, once an individual has made an attempt, secondary prevention is necessary. Suicide in NH: Suicide Methods The gender difference in suicide deaths/attempts may be explained by the fact that males, in general, use more lethal means. Of NH male youth and young adults who died by suicide between 2002 and 2006, 46% used firearms compared to 25% of females (Fig. 12 and 13). This gender disparity in firearm use becomes even greater as residents enter their late 20 s, 30 s, and 40 s. Male rates remain relatively constant, while the proportion of female deaths from firearms decreases (CDC WISQARS, ). Figure 12. Nearly half of male year old suicide deaths are from firearms, Page 22

23 Figure 13. Only a fourth of female year old suicide deaths are from firearms, Suicide attempt methods have varying lethality. Figure 14 compares firearms, hanging, poisoning, and cutting/piercing in terms of the percentage of various outcomes (emergency department visit, inpatient admission, death) for each method. Almost 90% of self-injuries using a firearm result in death (Fig. 14). Among youth and young adults, suicide is a highly impulsive act and poor impulse control is a significant risk factor for suicide. Therefore, intervention efforts that reduce youth and young adult access to firearms and other highly lethal means may be effective to reduce suicide, particularly among those found at risk for suicide and those who have poor impulse control. Firearms remain the most commonly used method of suicide throughout the lifespan in NH. In fact, the percentage of suicide deaths due to a firearm increases to close to 70% for those ages 60+. The use of suffocation as a suicide method peaks in early adolescence, and decreases steadily throughout the lifespan (Fig.15). Figure 14. Lethality of means used for suicidal behavior in NH, Page 23

24 Figure 15. Suicide methods used in NH vary by age group, as seen in Figure 16. Poisoning is the most frequent method of suicide attempt, as seen in hospital discharge data Although suicide attempts employing poison do not account for as many deaths in NH as either firearms or hangings, intentional poisonings account for the overwhelming majority of inpatient and emergency department admissions for suicide attempts (Fig. 16). Figure 17 presents the prevalence of the five most common substances used in suspected suicide attempts in NH as collected by the Northern New England Poison Center (NNEPC), the top two being benzodiazepines (e.g. valium) and antidepressants. 2 Page 24

25 Figure 17. Benzodiazepines and Antidepressants were the top substances used in suspected NH suicide attempts in Reducing Access to Lethal Means There has been a decrease in both the number and the proportion of youth and young adult suicides where firearms are being used. From 1999 to 2003, there were 53 firearm suicides among those less than 24 years of age, accounting for 46% of the total suicide deaths. Between 2004 and 2008, the number dropped to 30 representing only 40% of the total suicides. Interestingly, the reduction in the number of firearm suicides (23 fewer deaths) accounts for a substantial portion of the total reduction in deaths from During the same period, there were 8 fewer poison suicides and 8 fewer hanging deaths. The deaths from other causes remained constant. Reducing access to lethal means is part of many suicide prevention goals and protocols, including the National Strategy for Suicide Prevention, NH s State Suicide Prevention Plan, NH Firearm Safety Coalition, Connect, and the Counseling on Access to Lethal Means (CALM) Project. It has not been conclusively demonstrated that the efforts being undertaken in NH and nationally to reduce access to lethal means are responsible for the reductions in suicides using firearms and poisons. However, these reductions and the accompanying overall decline in suicide deaths suggest that when access to a highly lethal means is reduced, there is little means substitution (seeking a different method of killing oneself). Costs of Suicide and Suicidal Behavior There were between 24,824 and 28,343 years of potential life lost to suicide from in NH (CDC WISQARS). Suicide s most obvious cost is the loss of individuals and their potential contribution to their loved ones and to society. For each suicide death, there are many survivors of suicide (the family and close friends of someone who died by suicide) who are then at higher Page 25

26 risk for depression and suicide themselves. In addition, many others are affected, including those who provide emergency care to the victims and others who feel they should have seen the warning signs and did not do all they could to prevent the death. In NH, the attempts and suicide deaths treated in acute care hospitals alone represented an estimated $6.2 million in health care costs in This does not include the costs associated with mental health services on an inpatient or outpatient basis. [Bureau of Health Statistics and Data Management, New Hampshire Department of Health and Human Service (BHSDM NH DHHS), 2003] Harder to measure is the cost to employers of lower or lost productivity due to suicidal behavior by employees or their loved ones. NH Baseline Survey on Attitudes In 2006, YSPA, SPC and NAMI Connect collaborated with the UNH Survey Center on a survey of NH residents about their attitudes toward suicide prevention and mental illness. The survey included 500 NH households representative of the state as a whole. The survey was repeated in 2008 to determine if there had been any change in public perceptions. In fact, no statistically significant differences were found between the answers given during the Spring 2006 Granite State Poll and the Fall 2008 Granite State Poll. The 2008 results are summarized below: Three-quarters of New Hampshire adults (75%) agree suicide is preventable (45% strongly and 30% somewhat), 6% are neutral, 9% somewhat disagree, 6% strongly disagree and 5% do not know. New Hampshire adults 18 to 29 years old, who have never been married, and who have lived in New Hampshire for less than 2 years or 6 to 10 years are most likely to agree that suicide is preventable. Most New Hampshire adults (90%) agree that mental healthcare is useful for those who might be thinking about, threatening, or had attempted suicide (73% strongly and 17% somewhat), 3% are neutral, 2% somewhat disagree, 2% strongly disagree, and 3% do not know. Only about one in ten New Hampshire adults (12%) agree they would feel uncomfortable getting mental health care because of what some people might think if they found out (5% strongly and 7% somewhat), 4% are neutral, 15% somewhat disagree, 68% strongly disagree, and 2% do not know. A substantial majority of New Hampshire adults (81%) agree that if someone were thinking about, threatening, or had attempted suicide, they would know how to find help (52% strongly and 29% somewhat), 2% are neutral, 9% somewhat disagree, 5% strongly disagree, and 3% do not know. The vast majority of New Hampshire adults (97%) agree if they became aware that a young person was thinking about or had attempted suicide, they would feel that they had a responsibility to do something to help (87% strongly and 10% somewhat), 1% are neutral, 1% somewhat disagree, and 1% do not know. A little less than a third of New Hampshire adults (29%) think firearms are the most frequent method of suicide used in New Hampshire, followed by poisoning (22%), drugs or overdosing (12%), hanging (10%), knives (1%), some other method (4%), and 23% do not know. In fact, firearms are used in over 50% of the suicide deaths in NH. This highlights the need for education about the tie-in between firearms and suicide. Page 26

27 Although it is not possible to determine exactly how these results translate into actual behavior, they do indicate that progress has been made in the battle against overt stigma towards mental health services. They also show the vast majority of NH residents feel that suicide prevention is a shared responsibility. These conclusions are important reinforcers for collaborative efforts to reduce suicide deaths and attempts. Data from the NH Department of Corrections In 2007, the NH Department of Corrections had a total population of 2,595 males and 191 females at its facilities. (Note: this does not reflect the populations in County or local facilities) Each of those men and women were screened by trained correctional staff for suicidality upon their entry into the prison facilities. After this immediate screen, mental health staff met with the individual within 14 days of entry into the system to complete an individual mental health assessment which includes further screening for suicidality. Data available from 2007 show that at intake more than 16% of males indicated past suicidal ideation and more than 12% indicated a past suicide attempt. Figure 21 displays the percentage of intakes indicating suicidal ideation and/or attempts by quarter. Figure 21. Percentage of individuals entering NH prisons in 2007 indicating past suicidal ideation and/or attempts by quarter % 20.00% 15.00% 10.00% 5.00% Past Suicidal Ideation Past Suicide Attempt(s) 0.00% Quarter 1 (January March) Quarter 2 (April June) Quarter 3 (July September) Quarter 4 (October December) *An average of 282 intakes are conducted h t Suicide Rates in NH: Moving in a Better Direction Recent data suggests that rates of youth and young adult suicide and suicidality overall in NH may be on a downward trend. It is nearly impossible to firmly establish causality for this trend, although there are several variables that likely contribute. Recent statewide collaborative prevention efforts, including the work of YSPA, SPC, implementation of the State Suicide Prevention Plan, the Connect Project, Garrett Lee Smith funding through the Substance Abuse and Mental Health Services Administration (SAMHSA), CALM and the work of many community partners undoubtedly play a role. Finally, the increased focus on resiliency as well as identification and treatment of depression and other mental illnesses has certainly contributed as well. Page 27

28 Figure 18 presents NH suicide death rates for youth and young adults aged in rolling 3- year intervals from 1999 to There is a significant difference between years and 99-01, 00-02, and Youth and young adult suicide rates appear to have significantly decreased over the last 10 years in NH. Figure 19 shows that the suicide death rate for people of all ages in NH has remained relatively constant over the last 10 years. Figure 20 indicates results of the NH Youth Risk Behavior Survey (YRBS) from 1993, 2003, 2005 and The percentage of high school youth in NH who seriously considered a suicide attempt in the past year and the percentage of those who made a suicide plan in the past year both decreased by about 50% from 1993 to However, in 2007, 1 in 7 youth surveyed still seriously considered attempting suicide in the past year, while 1 in 18 actually made an attempt. Although these final charts represent what may, in fact, be good news for NH youth and young adults, what outcomes and rates are ideal for suicides in NH? While suicidal thinking and attempts are decreasing among NH high school students, they still affect a large proportion of the student body. NH youth suicide death rates, as well as rates for all of the NH YRBS survey items related to suicidal behavior, are steadily dropping. They fall even more as the public and private and military and civilian sectors continue to pool their efforts and resources to respond to the challenge of suicide prevention in an integrated and collaborative manner. Figure 18. Suicide rates among year old NH residents are deceasing, as seen Page 28

29 Figure 19. Suicide rates among NH residents of all ages are not changing, as seen Figure 20. Depression among high school youth remains at about a fourth of the population despite decreases in suicide attempts and suicidal ideation Page 29