STATUS OF SUICIDE IN TENNESSEE

STATUS OF SUICIDE IN TENNESSEE 2010 1

Table of Contents Executive Summary A Brief History of the Tennessee Suicide Prevention Network (TSPN) Overview TSPN and its Intervention Efforts Suicide Prevention Awareness and Educational Events Project Ongoing Challenges The Future of Suicide Prevention in Tennessee Additional Data and Graphics Time Trends Racial and Gender Trends Age Trends Youth Suicide Suicide in Midlife Non-Fatal Suicide Attempts Methods of Suicide Geographical Differences Suicide in Tennessee by the Numbers Bibliography 3 4 5 6 8 9 10 11 12 13 15 16 17 19 20 21 22 24 TSPN s Election 2010 project seeks to establish connections with candidates in this year s governor s race. All major candidates received a questionnaire on their positions on suicide prevention, with responses posted on the Network website. Candidates were also invited to speak at TSPN Advisory Council meetings. At top: former gubernatorial candidate Kim McMillan addresses TSPN s Advisory Council at the Metro Nashville Hermitage Precinct on February 24. Bottom left: Rep. Zach Wamp, candidate for Governor, speaks to Advisory Council members on June 1, during the annual retreat at Montgomery Bell State Park Inn. Bottom right: Candidate Mike McWherter visits the Council on June 2, later on during the retreat.. 2

Executive Summary Tennessee Suicide Prevention Network (TSPN or Network), like most suicide prevention and mental health organizations, is striving to do more with less to fight an ever growing need. This review of suicide in Tennessee contains information on both the problem itself and the steps taken to prevent it. The latest suicide trends within our state contain some surprising information. A collaborative statewide effort has led to a precipitous drop in our state s youth suicide rate. TSPN now plans to reach out to the baby boomers, especially white males, who have suffered the most from the recent recession and have been generally overlooked by the national suicide prevention movement. Suicide is not exclusively the problem of the inner city; in fact, it is more of a problem in rural communities lacking mental health resources and fighting centuries old stigma surrounding mental illness and treatment. A summary of TSPN s multifaceted and multimedia efforts to educate the general public and to save lives is presented in this report. Special mention is made of the statewide Suicide Prevention and Awareness Event project launched in 2009, which showcased the Network s regional structure, its diverse and committed membership, and its ability to engage members of government, education, and the private sector in suicide prevention efforts. I would like extend my sincerest thanks to Governor Phil Bredesen and his office for his commitment to TSPN and its Advisory Council during his term in office. I also wish to acknowledge the Tennessee Department of Mental Health and Developmental Disabilities and Commissioner Virginia Trotter Betts, MSN, RN, JD, FAAN, not just for their patronage but also their enthusiastic endorsement of our suicide prevention mission. Special mention must also be made of the Tennessee Commission on Children and Youth, the Tennessee Department of Education, the Tennessee Department of Health, for their financial contributions and their enduring support of our local and statewide projects. This report is intended to shock, enlighten, and inspire the reader to join the Network in the ongoing quest to save our loved ones, our friends, our colleagues, and maybe even ourselves. The task is formidable and the stakes are high. But we are united, we are prepared, and we are resolute. We can make a difference as witnessed by our activities and success documented in this report. The Network looks forward to having others join in the ongoing struggle of taking the past s painful lessons and the present s knowledge to make a better future for all. Scott Ridgway, MS Executive Director, TSPN 3

Rural West Region Mid-Cumberland Region Upper Cumberland Region Northeast Region East Tennessee Region Memphis/Shelby County Region South Central Region Southeast Region A map of TSPN s eight regional networks. A Brief History of the Tennessee Suicide Prevention Network (TSPN) TSPN has its origins in two landmark events in the field of suicide prevention: the 1998 SPAN-USA National Suicide Prevention Conference in Reno, Nevada, which spurred the development of a statewide suicide prevention movement, and the U.S. Surgeon General s Call to Action to Prevent Suicide in 1999, acknowledging suicide as a major public health problem and provided a framework for strategic action. The movement in Tennessee was spearheaded by Dr. Ken Tullis and his wife Madge, who attended the 1998 Conference. They subsequently launched a campaign to "SPAN the State of Tennessee in 1998." By convening a panel of local mental health and suicide prevention experts, the Tennessee Strategy for Suicide Prevention was developed responding to each of the fifteen points in the Surgeon General's Call to Action. Top left: the cover of the National Strategy for Suicide Prevention issued by the Office of the U.S. Surgeon General in 1999. The Tennessee Suicide Prevention Strategy responds to the goals and objectives outlined in this document. Center left: the cover of the latest version of the Tennessee Suicide Prevention Strategy, frequently distributed at TSPN events. Bottom left: a commemorative medal given to all recipients of TSPN s Pioneer Awards and distinguished guests at a symposium held in 2008, commemorating the 10th anniversary of the foundation of the national suicide prevention movement. At the first statewide Tennessee Suicide Prevention Conference in 1999, the Tennessee Strategy for Suicide Prevention was endorsed by mental health, public health, and social service professionals and presented to state leaders. The foundation of a statewide suicide prevention network was an outgrowth of this conference and the collaborative momentum built there. Eight regional networks were established for local community action on the Tennessee Strategy for Suicide Prevention under the coordination of a statewide Executive Director and a gubernatorially appointed Advisory Council consisting of regional representatives. An Intra-State Departmental Group consisting of representatives from state departments and agencies was established to advise the Network and influence state policy around the Tennessee Strategy for Suicide Prevention. 4

Overview Suicide is a major public health problem on national and state levels. Although suicide is the ninth-leading cause of death overall in Tennessee, for the following age groups, suicide ranks higher: Second-leading cause of death for adults aged 25-34; Third-leading cause of death for youth aged 15-24; and Fourth-leading cause of death for children aged 10-14 and adults aged 35-44. According to the Tennessee Department of Health, Tennessee s age-adjusted suicide rate in 2008 was 15.7 per 100,000 population, translating into 965 reported suicide deaths. This rate and number are the highest recorded in the state since 1981. The latest available comparisons show Tennessee s suicide rate is above the national average. In 2007 Tennessee s suicide rate was 13.7 per 100,000, compared to 11.5 per 100,000 for the nation at large. Compared to other states, Tennessee ranked 20 th out of all 50 states and the District of Columbia. The reframing of suicide as a public health problem has led to the development of interventions saving individual lives and reducing the overall incidence of suicide in general. Prevention strategies, especially those connecting people with effective and appropriate treatment for depression, are an effective weapon in combating suicide, depression and other mental illness. TSPN is the statewide organization responsible for implementing the Tennessee Strategy for Suicide Prevention as defined by the 2001 National Strategy for Suicide Prevention. Following the release of the U.S. Surgeon General s National Strategy for Suicide Prevention in 1999, the Tennessee Department of Mental Health and Developmental Disabilities (TDMHDD) became dedicated to reducing Tennessee s suicide rate. TDMHDD contracts with the Mental Health Association of Middle Tennessee (MHAMT) to provide administrative oversight to TSPN. Established in October 2001, TSPN is a grass-roots network which includes survivors of suicide, suicide attempters, counselors, mental health professionals, physicians, clergy, journalists, social workers, representatives of government, law enforcement personnel and other interested advocates. TSPN works across the state to eliminate the stigma of suicide and educate communities about the warning signs of suicide, with the ultimate intention of reducing suicide rates in Tennessee. TSPN seeks to achieve these objectives by facilitating collaborative suicide prevention projects throughout the state, providing suicide prevention and crisis intervention training to the general public and specific agencies (businesses, churches, mental health facilities, etc.), coordinating suicide prevention trainings and conferences across the state, and conducting postvention sessions for schools and other organizations after suicides occur so they can return to normal operations as quickly as possible. The Network has a gubernatorially appointed Advisory Council and an Intra-State Departmental Group of state employees who advise TSPN on an ex officio basis. But the bulk of TSPN s work is carried out by its 6,000 volunteers across the state, organized into eight regional groups and five county-specific task forces. All members of TSPN are committed to saving lives within their community. TSPN only has two paid staff members no one else, Advisory Council or intra-state departmental group members included, is compensated for their service to the Network. All of TSPN s regular members are motivated by the loss of a friend or a loved one, their own personal struggles against suicidal impulses, or an overall passion to save lives. This commitment drives TSPN and allows this unique grass-roots organization to accomplish so much. TSPN is leaving an indelible legacy in improving the lives of Tennesseans. Our innovative public-private partnerships and joint initiatives have allowed us to mesh with the community infrastructure at multiple levels, creating of lasting solutions to a previously unaddressed community issue. From schools to churches to government to businesses to the military to individuals and family members, these strategies are as varied as the communities they serve. Yet all embrace the overarching priority of addressing one of the most preventable causes of death. Tennessee is well known as the Volunteer State, and TSPN exemplifies communities voluntarily joining together to make a lasting impact. 5

TSPN and its Intervention Efforts TSPN s primary interest is providing suicide prevention and crisis intervention training to the general public. Currently, the Network maintains about 40 certified Question, Persuade, and Refer (QPR) suicide prevention training instructors. This evidence-based curriculum teaches people how to recognize depressed and suicidal people, ask them about their intentions, talk them out of immediate self-harm, and connect them with local mental health and crisis intervention agencies. Participants do not need a formal mental health background or training, and the entire session lasts approximately 90 minutes. On average, TSPN s QPR trainers reach upwards of 2,000 people every quarter. In addition to QPR, TSPN occasionally provides Applied Suicide Intervention Skills Training (ASIST), a more intensive curriculum developed by LivingWorks Education, Inc. This two-day program is designed for mental health and public health professionals, as well as police and school staff. The Network regularly works with social service and mental health agencies to organize postvention activities at schools and workplaces affected by a recent suicide. Postvention helps survivors deal with feelings of grief, insecurity, and helplessness, and to identify and recommend strategies for prevention of future tragedies. Staff members receive information on identifying other potentially suicidal individuals and providing them with the help they need in order to prevent a contagion effect. The Network has long understood the value of the emotional and spiritual support offered by churches and faith-based communities as a protective factor. Hence, the Network takes great care to engage communities of faith in its suicide prevention efforts. TSPN is a regular sponsor of the Suicide Prevention and the Black Church Conference, held semiannually in Memphis, and has helped organize Silencing the Silent Epidemic: the Suicide Prevention and the African American Faith Communities Conference which was held in 2010 in Nashville. Additionally, the Network has published a church bulletin insert listing key facts about suicide in Tennessee, warning signs, and contact information for the National Suicide Prevention Lifeline as well as the Network. Response to the project has far exceeded our expectations; thousands of these inserts have been distributed statewide. TSPN takes on-going steps to remind local media about the need for responsible coverage of suicide. In the past TSPN has held several media conferences featuring community leaders and representatives of local media outlets. Participants received packets containing suicide prevention resources and press coverage guidelines. More recently, TSPN has started responding to individual reports in local newspapers and other media, recognizing them for their efforts to promote the cause of suicide prevention and mental health awareness. Meanwhile, reports and articles including potentially harmful or negative stories receive letters explaining the need for sensitive coverage of suicide incidents and referrals to the American Association of Suicidology press guidelines linked on our website. TSPN routinely provides emergency rooms across the state with brochure holders stocked with the Emergency Department Resource Toolkit, a set of brochures on suicide attempt aftercare for attempt survivors, their loved ones, and the doctors who treat them. Other publications from TSPN and the Lifeline are also included in these brochure holders, which have gone out to dozens of emergency departments throughout Tennessee. Also, our Rural West Region developed a rapid assessment poster featuring common suicide prevention risk factors and distributed it to a number of local doctors offices. We plan to distribute these to offices statewide this fall. Alarmed by high rates of suicide among soldiers and veterans, the Network established contacts within the state s VA centers, consulting with each center s Suicide Prevention Coordinator on the mental health needs of former and current members of the armed forces, as well as the best ways to reach them with information and resources. The Network consulted with a specially commissioned task force regarding the development and implementation of crisis intervention protocols, and developed an original brochure on veteran suicide prevention. Finally, TSPN recruited the Suicide Prevention Program Manager at Fort Campbell to its Intra-State Departmental Group, where he offers regular guidance on outreach efforts and an opening through which the Network can provide materials and information to one of the nation s largest Army bases. 6

TSPN maintains a Web site (www.tspn.org) which is updated daily. All TSPN publications are available for download through the site, which also includes resource lists for advocates and survivors, fact sheets for specific populations, information on the ASIST, QPR, Tennessee Lives Count Project and Jason Foundation training programs, a schedule of all statewide meetings, and contact points for all Advisory Council and Intra-State Department Group members. As of the last quarter (January March 2010), the site was averaging 10,000 hits monthly. The Network also publishes a monthly newsletter, the TSPN Call to Action. The newsletter commonly features information on pending relevant legislation, local and national conferences, information about new suicide prevention and mental health resources, and the latest research in the field of suicidology. The Call to Action has roughly 6,000 readers, many of whom forward it to professional and personal contacts. Ken Tullis, MD, one of the founders of TSPN, moderates the survivor s panel at the 2008 SPAN-USA conference in Washington, DC. It was the first time the conference had featured such a panel. TSPN members and public officials address the crowd at the South Central Suicide Prevention Awareness and Education Event held at Columbia Mall on September 10, 2009. The event was promoted on the mall s outdoor electronic signboard. From left to right: Pam Arnell, then chair of TSPN s South Central Advisory Council; Steve Gregory, Mayor of Hickman County; William E. Gentner, Mayor of Columbia; and James L.. Bailey, Jr., Mayor of Maury County. 7

Suicide Prevention Awareness and Educational Event Project Perhaps the best example of TSPN s statewide public-private partnership is the Suicide Prevention Awareness and Educational Event project run by the Network in 2009. TSPN and its members organized and coordinated eleven events across the state in September, attended by an estimated 1,000 people. Each September, TSPN observes Suicide Prevention Awareness Month in connection with World Suicide Prevention Day. Usually this involves a ceremony including addresses from state officials, a governor s proclamation, testimony from survivors of suicide, and the presentation of awards for contributions to suicide prevention in our state. In 2009 TSPN s Advisory Council opted to stage a coordinated statewide project demonstrating TSPN s active and dynamic presence in the state as well as public support for TSPN and its suicide prevention mission. While regional event agendas varied slightly, each one included the following elements: Dedication of the Love Never Dies Memorial Quilt, an ongoing Network project; Reading of the Suicide Prevention Awareness Month proclamation issued by the Office of the Governor, and announcement of city/county proclamations; Presentation of the Regional Suicide Prevention and the Madge and Ken Tullis Suicide Prevention Awards; A candlelight ceremony in memory of those lost to suicide and in honor of survivors of suicide and suicide attempts; and Acceptance of donations to further local and statewide awareness efforts. Each of TSPN s eight regions was charged with organizing its own Suicide Prevention Awareness and Educational Event. In some instances, regions opted to stage two or three events in different venues to reach key localities and provide the general public with every opportunity for involvement. Most of the events included walks to illustrate the steps we take to raise awareness of the problem of suicide as outlined in the Tennessee Strategy for Suicide Prevention. The walks also demonstrated the steps the general public needs to take to understand the warning signs, learn about area resources, and work to prevent suicides in our communities. These walks also parallel the journey towards healing and recovery taken by all those struggling with suicide loss, suicidal impulses, and mental illness. All event participants received educational materials from the National Suicide Prevention Lifeline (1-800-273-TALK), local mental health agencies, and event sponsors as well as TSPN. Several of the Network s Love Never Dies memorial quilts were on display at the Light of Hope suicide prevention awareness event in Cookeville on September 18, 2009. The quilts, which are part of the Lifekeeper Memorial Quilt Project, help personalize the problem of suicide. Light of Hope is an annual awareness event staged by TSPN s Upper Cumberland Region. The 2009 event was incorporated into the statewide Suicide Prevention Awareness and Education Project. About 75 people attended this event, which was covered by the Cookeville Herald-Citizen (photo courtesy of Linda Moran). 8

Ongoing Challenges Healthy People 2010 and TDMHDD share a common goal is to reduce the age-adjusted suicide rate to 5.0 per 100,000. Given numbers from recent years and based on reports from regional members on local trends, it is a certainty Tennessee will not meet this goal. Tennessee faces three major obstacles in its mission to prevent suicide: The ongoing recession and the related rise in unemployment. Unemployment and related financial difficulties are major suicide risk factors. At the same time, the recession is also creating financial pressures on state and local governments, resulting in cutbacks to vital social service agencies and organizations invested in suicide prevention. Lack of resources in rural communities. Rural areas often lack mental health resources such as clinics, therapists, or hospitals with psychiatric units. Even when these resources exist, people are reluctant to use them. The ongoing stigma attached to suicide and mental illness prevents people from reaching out for help. People are afraid of being labeled or shunned, especially in close-knit communities. Since its foundation, TSPN has made great strides in stigma reduction, proving to both individuals and communities suicide can be prevented and mental illness can be treated. But there are still areas of the state TSPN has not reached effectively. A lack of representation in those areas or logistical issues such as access to these areas and lack of venues for distributing information continue to be challenges for the Network. Resistance to safe storage of firearms. 63.1% of the suicide deaths reported in Tennessee in 2008 involved firearms. Studies show that people who attempt suicide, especially on an impulse, use whatever means are readily available. Safe storage of firearms keeping them locked and unloaded, out of access to children, and temporarily removing them from areas where someone is actively suicidal or severely depressed will prevent suicides. However, firearms are readily available to suicidal individuals, especially in rural areas. TSPN s efforts must focus on safe-storage education. TSPN s regional networks and county task forces meet monthly or bimonthly to develop local suicide prevention and mental health awareness projects. The photo below from a recent meeting of the Mid-Cumberland Region. Above, members of Left Behind By Suicide, a support group headquartered in Centerville, release balloons at the close of the Moment of Remembrance event held in Lyles on November 21, 2009. Attached to each balloon was a memorial tag naming a person lost to suicide and promoting the National Suicide Prevention Lifeline (1-800273-TALK). 9

The Future of Suicide Prevention in Tennessee Last summer the Tennessee Department of Health released figures on suicide for the year 2008, and the numbers suggest the Network is needed now more than ever. In 2008 there were 965 recorded suicide deaths in Tennessee, at a rate of 15.7 per 100,000. Both are record highs for the state. On some level, the increased numbers could be considered the result of better reporting. As TSPN reaches out to public health officials across the state, there is less resistance about recording suicide on death certificates. They are less inclined to recording these deaths as accidents or natural causes at the request of family members. However, the ongoing recession and the stress job loss, job uncertainty, and financial instability inflict on the people of our state is a contributing factor in many of the recorded deaths. Additionally, soldiers returning from combat deployments with post-traumatic stress disorder and traumatic brain injuries will need resources and ongoing access to mental health treatment. Perhaps no organization in the state of Tennessee is working harder to make itself obsolete. Our members are leading trainings, organizing programs, providing information or simply sitting down with people in need, helping them see that suicide is not the answer to their problems. We look forward to the day when everyone will know how to recognize the warning signs of suicide, how to prevent an attempt, have access to readily available and fully funded mental health centers, and not have to worry about paying for treatment or what will happen when the treatment ends. This report is more than the sum of its parts. For all its charts, graphs, and analyses, this document is not about an abstract phenomenon that can be written off as yet another unavoidable social ill. The devotion of public resources towards education and treatment saves lives, keeps families whole, ensures healthy schools and workplaces, heals our communities, and strengthens our state and our nation. We understand this and are working to make sure everyone in Tennessee does as well. We dare to dream of a day when no one has to die a hopeless, lonely death because no one knew what to say or what to do, or because the help they needed was out of reach. Until that day comes, the Tennessee Suicide Prevention Network will be the people s bridge to knowledge, healing, and action. Since 2006, the Network has overseen the development of five Love Never Dies memorial quilts, intended to personalize the tragedy of suicide. The quilts demonstrate to the community at large that suicide is not some abstract concept, but a real problem that affects people of all ages and backgrounds and a heartbreaking loss to many Tennessee families. 10

Recent Notable TSPN Achievements The following is a summary of noteworthy TSPN projects and activities during the last five years: TSPN supports eight regional networks and five county-specific task forces comprised of over 6,000 people, who work together to develop and implement suicide prevention strategies on a local level. In addition, TSPN promotes and provides logistical support to 13 support groups across Tennessee, including groups for survivors of suicide attempts. The Network coordinates statewide connection to the National Hopeline Network (1-800-SUICIDE) and the National Suicide Prevention Lifeline (1-800-273-TALK) through nine local crisis centers across the state. TSPN s monthly newsletter, the TSPN Call to Action, is published and circulated to an estimated 6,500 people each month, not including forwards by readers. Each issue features information on local and national suicide prevention projects, major developments in the field, and late-breaking scientific studies related to suicide and mental health. TSPN has distributed an estimated 46,000 church bulletin inserts to a variety of Tennessee churches; these inserts feature the warning signs of suicide and the National Suicide Prevention Lifeline number (1-800-273-TALK). Additionally, members of the Network have distributed approximately: 16,000 brochures promoting local survivor support groups 16,000 brochures on suicide among older adults (since development in 2007) 20,000 brochures on saving teen and young adult lives (since development in 2007) 68,000 regional/county resource directories (since development in 2007) 3,800 brochures on suicide and veterans (since development in 2009) 2,700 brochures on suicide and substance abuse (since development in 2009) Two other brochures are set to debut later in 2010: one on suicide and bullying; the other on suicide and middle-age. TSPN is responsible for over 200 profiles, appearances, and/or references on local TV and radio stations and newspapers across Tennessee. Also, the Network has sent out 142 media letters in response to articles appearing in Tennessee newspapers. Through an arrangement with the Tennessee Press Service, TSPN monitors news clippings from 95 newspapers across the state. The TSPN website (www.tspn.org) is updated regularly with information on regional meetings, support groups, resources, and information about TSPN projects. The site registered 105,969 hits during 2009, a 44% increase over the previous year. During the past five years, TSPN sponsored over 550 suicide prevention conferences, training sessions and workshops. These events provided information to first responders, public school staff, faith-based communities, as well as members of the media, reaching an estimated 43,000 people within and outside Tennessee. These include the Suicide and the Black Church Conference, which convenes semi-annually in Memphis. TSPN provides materials and logistical assistance to the Tennessee Lives Count (TLC) project, now in its second threeyear grant cycle. TLC provided suicide prevention training to over 18,000 people associated with child-serving agencies between 2006 and 2009, and is now focusing on staff and youth within the juvenile justice system. TSPN cultivates public/private partnerships with agencies across the state to provide awareness and educational opportunities within a wide variety of organizations. These include the Tennessee Department of Health s Commissioner s Council on Injury Prevention, the Tennessee Department of Health s Child Fatality Review Board, the Tennessee Coalition of Mental Health and Substance Abuse Services (TCMHSAS), the Tennessee Conference on Social Welfare (TCSW), the Tennessee Commission on Children and Youth (TCCY), Tennessee Voices for Children, the Statewide System of Care Task Force, and the Association of Tennessee Contact/Crisis Centers. 11

Network members have provided support for approximately 15 major postvention efforts, including technical assistance and onsite debriefings. Many of these occurred at public schools that lost students to suicide. In several cases, the Network staged awareness events or town hall meetings for the general public in the affected areas. Each September, TSPN observes Suicide Prevention Awareness Month in Tennessee through a series of presentations, memorial events, seminars, and educational opportunities across the state. The highlight of each month is the presentation of the Governor s Suicide Prevention Awareness Month proclamation, typically presented at a ceremony at the Tennessee State Capitol. Additionally, 176 Suicide Prevention Awareness Month proclamations have been issued by mayors and county executives across the state over the years. TSPN regularly sends a delegation to the National Awareness Event in Washington, an annual project of the Suicide Prevention Action Network (SPAN-USA). TSPN delegates meet with the state s Congressional delegation and speak with them about the importance of federal funding for suicide prevention and mental health. Over the past several years the Network has promoted and helped organize Out of the Darkness Community Walks at various locations in Tennessee for the benefit of the American Foundation for Suicide Prevention. Suicide prevention advocates in 16 other states have consulted the Network to study its unique public/private suicide prevention partnership. TSPN is regarded as one of the nation s foremost state-supported suicide prevention agencies and is an example of how government entities, professional agencies, and community activists can come together to produce tangible, real-time social change. Fiscal Year 2005-2006 Highlights, 2006-2010 In 2006 the Network instituted the Madge and Ken Tullis Suicide Prevention Award, which recognizes outstanding contributions to the state and national suicide prevention movement. The first Tennessee Memory Quilt made its official debut at the 2006 Suicide Prevention Awareness Day observance at the State Capitol. TSPN members served on the planning committee for the First National Conference for Survivors of Suicide Attempts, Healthcare Professionals, Clergy, and Laity, which took place in Memphis. This was a joint project of the Organization for Attempters and Survivors of Suicide in Interfaith Services (OASSIS) and SPAN-USA. The Network promoted the event heavily at the regional and statewide levels. Ultimately, there were over 100 people from Tennessee in attendance, the largest delegation from any state. The Network helped establish the DeKalb County Suicide Prevention Task Force, which later became a part of the DeKalb County Wellness Commission. During the spring and summer of 2006, the Network coordinated four regional suicide prevention conferences across the state. Fiscal Year 2006-2007 TSPN worked closely with the Tennessee Bar Association and Tennessee Lawyers Assistance Program to help develop a statewide suicide prevention trainer instruction program. TSPN received a $40,000 grant from the Tennessee Department of Health to finance the recruitment and education of additional suicide prevention instructors. TSPN currently has 31 trainers available to provide training sessions to schools, businesses and civic organizations across the state. 12

TSPN joined forces with the Jason Foundation, Inc. to promote the Jason Flatt Act of 2007, which was ultimately passed into law by the Tennessee General Assembly. At the time, this legislation was the most far-reaching public school youth suicide prevention ordinance in the country. The law has served as the basis for similar legislation in California, Louisiana, and Mississippi. The Network s Mid-Cumberland Region created a bookmark featuring the National Suicide Prevention Lifeline number and the warning signs of suicide; 10,000 of these were distributed to area universities, libraries, and churches. Belmont, David Lipscomb, Middle Tennessee State, and Vanderbilt Universities participated in the project. The Network developed two new suicide prevention brochures: one discussing suicide risk among older adults; and another one regarding teens and young adults. Also, most of the regional resource directories were developed during this timeframe. Fiscal Year 2007-2008 SPAN-USA recognized the Network with its Allies for Action Award, the first time this award was presented to a group rather than an individual. In celebration of the ten-year anniversary of the historic Reno conference and ten years of suicide prevention activity in the state of Tennessee, the Network s Advisory Council elected to stage a repeat of the 10-Tenn Challenge event in 2008. Members of each region selected an aspect of the Tennessee Strategy for Suicide Prevention around which they developed a project addressing a specified need which would be implemented over the subsequent year. Some of these projects included outreach to the deaf and hard of hearing (DHH) community, older adults, substance abuse service providers, adult abuse service counselors, and area VA hospitals. One of the regional projects, a rapid assessment poster for primary care physicians, is currently being developed for statewide distribution. TSPN was consulted by the commanding general at Fort Campbell and his staff regarding the development of a suicide prevention task force. The Network continues to provide materials, guidance, and logistical support to the base s Suicide Prevention Program Manager. Partly in response to the needs of Fort Campbell and other military communities, TSPN developed a new suicide prevention brochure designed for veterans and military families. Another new brochure, this one addressing the connection between suicide and substance abuse, was also developed. Finally, the Network staged a two-day statewide symposium at the Millennium Maxwell House Nashville, which was attended by over 300 people. This event hosted several well-regarded figures within the national suicide prevention movement. Fiscal Year 2008-2009 In 2009, the Network staged a series of events across Tennessee as part of its Suicide Prevention Awareness and Educational Events project, reaching over 1,000 people through eleven separate events. (For more information about this project, refer to TSPN in Action: Suicide Prevention Awareness and Educational Events on page 8 of this publication.) The Network established an alliance with the state s Employee Assistance Program; this association led to the ongoing contribution of regular articles on suicide and mental health to reap the Benefits, the EAP newsletter, which reaches 150,000 state employees and contractors monthly. The Network published its Older Adult Suicide Prevention Plan, which offers guidelines on preventing suicide among older adults. 13

The Network began providing and restocking brochure holders containing suicide prevention information to hospital emergency centers in most Tennessee counties. These holders include brochures on suicide attempt aftercare, regional resource directories, and promotional materials from both TSPN and the National Suicide Prevention Lifeline. Fiscal Year 2009-2010 As part of TSPN s Election 2010 project, all major candidates in the state gubernatorial contest received questionnaires asking them to describe their administrations plans for suicide prevention and mental health, as well as invitations to Advisory Council meetings. As of this writing, three candidates have addressed the Council. Responses to the questionnaire were posted on the TSPN website; at present all but one major candidate has responded. The Network established the Davidson County Suicide Prevention Task Force, in collaboration with the Nashville Metro Public Health Department. This group will review suicide trends in the Nashville-Davidson County area and develop targeted suicide prevention projects. TSPN developed two new brochures, one on the interaction between bullying and suicide and another addressing suicide risk within middle age. The Network also developed rapid assessment posters for doctors waiting rooms which include crisis contact points for local mental health centers. TSPN s Advisory Council developed plans to reach out to and train law enforcement units across the state, from city police departments to county sheriff s offices, in various aspects of suicide prevention. This initiative also includes police dispatchers, 911 operators, and others who work closely with law enforcement. TSPN is regularly featured as a sponsored charity at Nashville Sounds baseball games. PSAs promoting suicide prevention and the Network are broadcast, and the Network sets up an exhibit with materials from TSPN and other partner agencies. Here, TSPN volunteers pose at the Network exhibit during a 2009 home game; the TSPN banner is in the background. At the 2008 symposium, guest speakers join members of the TSPN Memphis/Shelby County Region for a photo. Among those pictured are military suicide prevention advocate Carol Graham (fourth from left), Teresa Okwumabua of the University of Memphis, presenter during the educators presentation (second from left), Madge Tullis, chair of the TSPN Advisory Council s Special Activities Committee (fourth from right), and minister Teddy Carr, who sang during both segments of the event (third from right). 14

Additional Data and Graphics Note regarding statistics in this report: All national data is courtesy of the Centers for Disease Control and Prevention; all state data is from the Tennessee Department of Health. Where possible, data from 2008 is used. Some statistical data was available solely from the CDC databases, which at present only extends up to 2007. 15

Time Trends A comparative trend analysis of suicide data for Tennessee and the United States is presented in Figure 1. Tennessee s suicide rates are consistently higher than those of the country at large. Although the overall suicide rate in Tennessee has somewhat fluctuated, it has increased significantly in recent years especially in 2008, where the rate increased roughly 14.6% (from 13.7 per 100,000 in 2007 to 15. 7 in 2008). 18 n tio la u p o p 0,0 0 1 r e p s a te R 16 14 12 10 8 6 TENNESSEE US 4 2 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 Figure 1: Suicide rates per 100,000 in Tennessee and the United States, 2000-2008. (Note: national data not available for the years 2007 and 2008.) 16

Racial and Gender Trends Figure 2 demonstrates racial differences in suicide within Tennessee. Suicide rates for white non-hispanics are generally two times higher than other ethnic groups. According to the United States Census Bureau, non-hispanic whites made up 80.4% of Tennessee s population in 2008 but accounted for 91.2% of all reported suicide deaths in the state that year (880 out of 965). 18 16 14 Rates per 100,000 population 12 10 8 6 4 WHITE BLACK HISPANIC AA/PI NA OTHER 2 0 WHITE BLACK HISPANIC AA/PI NA OTHER Figure 2: Aggregate suicide rates in Tennessee for assorted racial groups for the years, 2001-07. (AA/PI = Asian-American/Pacific Islander; NA = Native American, OTHER = persons of more than one race or race uncertain.) TSPN s Mid-Cumberland Region staged Silencing the Silent Epidemic: the Suicide and the African-American Faith Communities Conference on March 15, 2010 in Nashville. Several agencies and local churches assisted in planning the conference. Select conference organizers and presenters from left to right: Pastor Curtis W. Goodwin, Angie Thompson, Dr. Howard Burley, Gwen Hamer, Pastor Dianne Young, Dr. Donna Barnes, and Bishop William Young (Photo courtesy of Lorene Lambert, TDMHDD). 17

25 Rates per 100,000 population 20 15 10 5 0 MALE FEMALE Figure 3: Average suicide rates in Tennessee by sex, 2003-08. Suicide rates for males are generally four times higher than for females in Tennessee (Figure 3), a trend replicated within each racial group (Figure 4). Generally speaking, females typically use less violent means in attempting suicide, such as drug overdose and suffocation. These methods cause less catastrophic damage than firearms or jumping: means of suicide typically employed by males. The race/sex breakdown in Figure 4 also demonstrates that white males are the most vulnerable group accounting for race and sex. 30 25 Rate per 100,000 population 20 15 10 5 MALES FEMALES Figure 4: Aggregate suicide rates in Tennessee broken down by race and gender, 2001-07. (AA/PI = Asian- American/Pacific Islander; NA = Native American, OTHER = persons of more than one race or race uncertain.) 0 WHITE BLACK HISPANIC AA/PI NA OTHER 18

Age Trends Rates of suicide in Tennessee generally increased with age through the 35-44 age group, with the suicide rate was more than four times the teen rate. Rates dropped somewhat during middle age but then reached a plateau during ages 65-74. It should be noted, however, that rates for Tennesseans in this latter group are still higher than within the 10-19 and 20-24 age groups. 25 Suicide rate per 100,000 population 20 15 10 5 0 10-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Figure 5: Average suicide rates in Tennessee for select age groups, 2003-08. 19

Youth Suicide For young people 10-19 years of age, suicide is the third-leading cause of death. In any given year, more teenagers and young adults die by suicide than from cancer and heart disease combined, and far more than from higher-profile causes of death such as birth defects, HIV infection, and meningitis. While suicide is a tragedy regardless of age, when it involves a child or a young adult, it is especially alarming. Youth suicide gets the most attention from mental health agencies, mass media, and the general public. While TSPN s suicide prevention efforts address suicide across the lifespan, the Network takes a particular interest in the 10-19 age group. TSPN is fortunate to have a strong working relationship with the Jason Foundation, Inc., (www.jasonfoundation.com), a national youth suicide prevention agency headquartered in Hendersonville, Tennessee. TSPN and the Jason Foundation have collaborated on numerous projects, most notably the effort to promote passage of the Jason Flatt Act of 2007, which mandates annual suicide prevention training for all public school teachers in Tennessee. TSPN also works closely with other local child-serving agencies such as Tennessee Voices for Children, the Tennessee Commission on Children and Youth, Youth Villages and all community mental health centers. These organizations and countless others have worked alongside TSPN to provide training and resources to parents, teachers, counselors, coaches, social workers and community members. Our goal has been to educate everyone and anyone who works with young people. The Network is a proud partner of the Tennessee Lives Count (TLC) Project. TLC was established in 2006 through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA) authorized by the Garrett Lee Smith Memorial Act of 2004 administered by TDMHDD. In its first grant cycle concluded in 2009, TLC staff provided youth suicide prevention training to over 18,000 people in schools, mental health clinics, health departments, foster care agencies, and juvenile justice facilities. TLC also has an extensive social marketing campaign partnering with TSPN to provide televised public services announcements, brochures, and other materials to thousands across the state. We believe the combined efforts of all these agencies helped contribute to the 34.2% decline in youth suicide rates recorded between 2004 and 2008, even as the overall suicide rate actually increased by 17.2% within the same timeframe. This development indicates our efforts our successful and demonstrates the power of a concerted collaborative outreach effort. It also inspires us to reach out to other age groups in Tennessee, especially the middleage group driving the current increase. Suicide rate per 100,000 population 8 7 6 5 4 3 2 1 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Figure 6: Suicide rates for the 10-19 age group in Tennessee, 1997-2008. 20

Suicide in Midlife In contrast to the decrease in Tennessee youth, suicide among middle-aged and older adults increased over the last ten years. As Figure 7 illustrates, this is particularly true among the baby boom generation (ages 55-64). Note also the rates for certain senior age groups which have increased steadily over the last several years. As detailed in Figure 7, the proportion of suicides among adults, especially the baby boom generation, has risen steadily over the past few years. In a nationwide study published in a 2008 issue of the American Journal of Preventive Medicine, researchers from Johns Hopkins University discovered an overall increase in suicides by 0.7 percent each year between 1999 and 2005, driven primarily by rising suicide rates among whites aged 40-64. This study argues suicide in midlife needs more attention from public and mental health experts, as well as the general public. These findings along with the current numbers of suicide in this age group suggest the Network s primary suicide prevention priority should be outreach and education among middle-aged adults. 30 25 Suicide rates per 100,000 population 20 15 10 5 10-19 35-44 45-54 55-64 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Figure 7: Suicide as a proportion of total deaths for select age ranges in Tennessee, 1997-2008. 21

Rates per 100,000 population 60 50 40 30 20 10 WHITE MALE WHITE FEMALE BLACK MALE BLACK FEMALE 0 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Figure 8: Average suicide rates for certain sex-race subgroups tracked over select age groups, 2003-08. Figure 8 examines the relationship between age, race and sex. Only whites and blacks were included in this analysis due to unstable numbers within the other racial groups. As discussed previously, white males of any age are at significantly higher suicide risk, especially after age 75. Disparity between white male and other sex-race subgroups analyzed increases substantially beyond the 25-34 age bracket. Suicide among non-white older adults is a relatively rare phenomenon. Stronger familial and social supports may be a possible protective factor for this group. The Tennessee Lives Count (TLC) mousepad is regularly distributed to computer labs in schools across the state, as well as conferences and events where TSPN stages an exhibit. This design is also available as a magnet and a luggage tag. 22

Non-Fatal Suicide Attempts In any given year, over 4,000 people in Tennessee are hospitalized for suicide attempts, which translates to about 11 people a day. Females account for 57% of all suicide hospitalizations in Tennessee, in contrast to only 20% of all suicide deaths. As noted earlier, females generally use suicide methods easier to treat by first responders and emergency department personnel. Non-Hispanic whites represent 89% of all suicide attempts requiring hospitalization in this state. 50% of all suicide hospitalizations involve patients between 30 and 49, at a rate 28% higher than the higher-profile 15-19 age group. Poisoning which may involve prescription drugs, over-the-counter medications, narcotics, alcohol, industrial compounds, toxic gas, or some combination of the above is the leading method involved in non-fatal suicide attempts, accounting for approximately 84% of all such attempts each year. Cutting and piercing ranks second at 11%. The number of poisonings only considers incidents clearly identifiable as suicide attempts. It does not count poisonings of undetermined intent. This is notable given the high rate of prescription drug abuse in this state. If a regular abuser of prescription drugs attempted suicide by overdose, the incident could be incorrectly labeled an accident. The CDC estimates if half of all undetermined-intent poisonings were self-inflicted, the overall number of suicide attempts in Tennessee would be 13% higher. In 2009, the Tennessee Youth Risk Behavior Surveillance System reported 13.6% of Tennessee high school students one in seven seriously considered attempting suicide during the previous 12 months. 11.7% one in eight went so far as to make a suicide plan; 7.1% one in 14 actually attempted suicide during the 12-month period in question; and 2.2% one in 45 required medical attention for injuries related to a suicide attempt. TSPN was a leading supporter of the First National Conference for Survivors of Suicide Attempts, Healthcare Professionals, Clergy, and Laity held in Memphis in October 2005. This gathering, sponsored by the Organization for Attempters and Survivors of Suicide in Interfaith Services (OASSIS) and the Suicide Prevention Action Network (SPAN USA), was the first nationwide conference focusing on the needs of attempt survivors and how healthcare professionals, faith communities, and others can learn from them. Additionally, TSPN supports and promotes three support groups for survivors of suicide attempts. These self-help programs, which are based on the Twelve Step model, provide safe environments for people to share their struggles with suicide and develop strategies for support and healing from the devastating effects of suicidal preoccupation and behavior. More information for these groups as well as support groups for families and friends who have lost a loved one to suicide can be found at www.tspn.org. Support Groups for Survivors of Suicide Attempts These groups are fellowships in which members from a variety of backgrounds share their experiences, strengths, and hopes with each other, that they may solve their common problems, Membership is open to all who want it; the only requirement is a desire to stop living out a pattern of suicidal ideation and behavior. There are no dues or fees for membership; each group is self-supporting through its own contributions. Cookeville Memphis Nashville Suicide Anonymous Suicide Anonymous Survivors of Suicide Attempts Angel Smithers (901) 383-1924 or info@suicideanonymous.org Judith A. Merritt (931) 432-4081 (615) 707-1992 To establish an SA group in your area, contact Dr. Ken Tullis of the Psychological Trauma and Wellness Centers at (901) 767-1469 or via e-mail at kfttenn@ktullis.com. 23

Methods of Suicide Figure 10 demonstrates the leading methods used to die by suicide in Tennessee. Firearms were the most common method. Between 2003 and 2008, almost two-thirds of suicides involved firearms, with poisoning and suffocation also common. While firearms were the most common method of suicide for both sexes and most races, some groups have a higher propensity for them than others. For example, males were more likely to use firearms than females. The second most common method for women was poisoning, while for men it was suffocation. Suffocation was also the second most common mechanism for blacks compared to poisoning for whites. Methods such as jumping, cutting/ piercing, and drowning/submersion were relatively uncommon among Tennesseans compared to the rest of the country. FIREARM (64.7%) SUFFOCATION (15.4%) POISONING (15.1%) CUT/PIERCE (1.1% DROWNING (0.9% FALL (0.9%) OTHER (1.7%) Figure 10: Suicide methods used in recorded Tennessee suicide deaths, 2003-08. (NOTE: The SUFFOCATION category refers to death involving a cutoff of the air supply, including both hanging and suffocation by other means. The FALL category refers to deaths involving intentional jumping from a high place. The OTHER classification includes deaths involving motor vehicle crashes, jumping or lying in front of moving objects, fires, explosions, consequences of self-injury, and suicide deaths by uncertain means.) 24

Geographical Differences Not all Tennessee counties experience the same suicide trends. Suicide is more common in some counties than others. When a single county experiences a spike in suicides or several years above the state average, TSPN may seek to establish a county-specific task force, working with the county health department, the county medical examiner, the mayor s office, mental health professionals, and other advocates to implement intensive suicide prevention projects on the local level. The first task force, the Blount County Mental Health and Suicide Prevention Alliance, was founded in 2002 after county medical examiner David M. Gilliam noticed an unusually large number of suicides in Blount County. He sought out the editor of the Maryville Times, the county s largest newspaper, to draw attention to this phenomenon. TSPN was engaged in the effort and helped concerned citizens organize a county-wide suicide prevention campaign. Their efforts paid off the suicide rate dropped by 38% the following year and by 2005 was down by more than half. Groups in Hickman and Giles counties followed in 2003 and 2005, respectively. Within one year of the beginning of the Hickman County Suicide Prevention Task Force, the local suicide rate dropped 79%. The rate in Giles County fell by half after the Giles County Suicide Prevention Task Force was formed. The July/August 2005 edition of Advancing Suicide Prevention magazine revealed DeKalb County had the fifth-highest suicide rate of all U.S. counties for 1999-2002, and the highest of any county east of the Mississippi River. TSPN helped establish a group in DeKalb County eventually merging with the county s Wellness Commission. In the first year of the group s operation, the local suicide rate dropped by 40%. TSPN is interested in forming additional county task forces and is currently considering options and soliciting contacts in these areas. Each of TSPN s eight regions maintains a display board members set up at local events. The display board for the Rural West Region, which covers twenty western Tennessee counties, is seen here with select TSPN materials. 25